Kirsten Bechtel

Utility of hepatic transaminases to recognize abuse in children.

OBJECTIVE: Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. PATIENTS AND METHODS: This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken. RESULTS: Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4–4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. CONCLUSIONS: In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.

Relationship of Serum S100B Levels and Intracranial Injury in Children With Closed Head Trauma

OBJECTIVE: To determine if serum levels of S100B are higher in children with CHT and ICI as detected by cranial CT and if long bone fractures affect the level of S100B in children with CHT and skeletal injury. METHODS: Children <18 years of age who presented to an urban pediatric emergency department or were transferred from a referral hospital within 6 hours after accidental closed head trauma and who underwent cranial computed tomography were enrolled prospectively. Mean serum S100B levels for children with or without intracranial injury (ICI) and long-bone fractures were evaluated through analysis of covariance. RESULTS: One hundred fifty-two children, 24 with ICI and 128 without ICI, were enrolled prospectively. Twenty-five children had long-bone fractures. Children with ICI were significantly younger than those without ICI (6.9 vs 9.8 years; P = .01). The time of venipuncture after injury was significantly later in children with ICI (P = .03). Mean S100B levels were significantly greater for children with ICI (212.9 vs 84.4 ng/L; P = .001), children with long-bone fractures (P = .008), and nonwhite children (P = .03). After controlling for time of venipuncture, long-bone fractures, and race, mean S100B levels were still greater for children with ICI (409 vs 118 ng/L; P = .001). The ability of serum S100B measurements to detect ICI, determined as the area under the curve, was 0.67. CONCLUSIONS: After controlling for time of venipuncture, long-bone fractures, and race, S100B levels were still higher in children with ICI than in those without ICI. However, the ability of serum S100B measurements to detect ICI was poor.

Impact of sexual assault nurse examiners on the evaluation of sexual assault in a pediatric emergency department.

Background: Nearly 44% of sexual assault victims in the United States are younger than 18 years. These victims often present to emergency departments for care after the assault. To date, the effectiveness of sexual assault nurse examiners (SANEs) on the evaluation and management of pediatric and adolescent sexual assault victims in a pediatric emergency department (PED) has not been evaluated. Objective: To evaluate whether the use of SANEs in a PED improves the medical care of pediatric and adolescent sexual assault victims. Design/Methods: Medical records of patients who presented to an urban PED with a history of sexual assault and required forensic evaluation (rape kit) from December 2004 to December 2006 were reviewed in a retrospective, blinded fashion for the following documentation: (1) the genitourinary (GU) examination and if a GU injury was present; (2) evaluation for sexually transmitted infections (STIs) (Neisseria gonorrhoeae and Chlamydia trachomatis), and serologies for hepatitis B and C, HIV, and VDRL; (3) prescription of prophylaxis for STIs, HIV, and pregnancy; (4) evaluation by a PED social worker; and (5) referral to sexual assault crisis services. Patients were grouped as to whether a SANE had been involved in their care. The assignment of a patient to a SANE was random, as SANEs in the PED of this institution do not take call from home and are present in the PED as part of their routine nursing shift. To examine the differences between groups, &khgr;2 analysis or Fisher exact test was used. Results: Of the 114 patients whose medical records were reviewed, 60 had been evaluated by a SANE (SANE+), and 54 patients had not (SANE−); 98% of patients were girls. There were no differences between the 2 patient groups with respect to time of day when they presented to the PED, time after assault to presentation to the PED, sex, age, or race. All medical records had the history of the sexual assault documented in the medical record. Patients evaluated by a SANE were more likely to have the GU examination documented (71% vs 41%; P < 0.001) and to have GU injury documented (21% vs 0%; P = 0.024). Eligible patients were more likely to have testing for N. gonorrhoeae and C. trachomatis (98% vs 76%; P ≤ 0. 001), and serologies for hepatitis B and C (95% vs 80%%; P = 0.03) and HIV (93% vs 72%; P = 0.03) when a SANE had been involved in their care. There were no significant differences between groups with respect to obtaining serology for VDRL. There were no significant differences between groups with respect to provision of prophylaxis for N. gonorrhoeae, C. trachomatis, or HIV. Significantly more patients were prescribed prophylaxis for pregnancy by a SANE (85% vs 64%; P = 0.025). Although there were no significant differences between groups with respect to an evaluation by a PED social worker, significantly more patients in the SANE+ group were referred to the Rape Crisis Center for support and counseling (98% vs 30%; P < 0.001). Conclusions: Many more patients who had been sexually assaulted received STI testing, pregnancy prophylaxis, and referrals to the Rape Crisis Center when a SANE was present for the evaluation in the PED. Even with a SANE providing medical care, not all eligible patients had medical record documentation of the GU examination or that they received appropriate STI testing or STI and HIV prophylaxis. Ongoing quality assurance in programs that use SANEs is needed to ensure optimal medical evaluation of children and adolescents with sexual assault.

Recognizing victims of human trafficking in the pediatric emergency department.

Abstract Human trafficking is a form of modern-day slavery that is rapidly expanding in the United States and throughout the world. It is a crime under both the United States and international law. The child and adult victims of human trafficking are denied their basic human rights and subjected to unspeakable physical and emotional harm. Traffickers exert complete control over their victims and are proficient at hiding their condition from authorities. Healthcare practitioners may be the only professionals who come into contact with victims if they present for medical care. This article will describe human trafficking and its potential victims, as well as guide medical management and access to services that will ensure their safety and restore their freedom.

Acute mental status change due to acute confusional migraine.

Pediatric patients frequently present to the emergency department (ED) with the chief complaint of headache. Migraine headache is responsible for many of these cases. Acute confusional migraine headache can also cause acute mental status changes in children, as illustrated in the following 2 cases. CASE 1 An 11-year-old girl presented to the ED after awakening from sleep with vomiting and headache. She was well before going to bed that evening, and there had been no changes in her appetite or behavior that day. Upon awakening, the patient vomited several times and was disoriented, not recognizing her mother or her surroundings. Her mother then called 911, and paramedics transported her to the ED at Yale-New Haven Children’s Hospital. The patient’s past medical history was significant for a fall down a flight of steps in which she struck her head 4 months earlier. A computed tomography scan of the brain was conducted and was normal. She also was being treated for conjunctivitis with a topical ophthalmic antibiotic ointment. The patient’s mother had depression and was currently taking an antidepressant of which none was missing. The patient’s mother and grandmother had migraine headaches, but neither was treated for such at the time. On arrival to the ED, the patient was somnolent but responsive to verbal command. She was able to speak but was dysarthric. She was not oriented to person, place, or time. Her vital signs were as follows: temperature, 37.68C; heart rate, 128 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 119/69 mm Hg. Examination of the head, ears, oropharynx, neck, chest, abdomen, and skin were normal. Her pupils were equal, round, and reactive to light, and her extraocular muscle movements were normal. No nystagmus was noted. Her optic disc margins were sharp, and there were no abnormalities of the retinal vessels. Her face was symmetric, her tongue was at midline, and her palate elevated symmetrically. Deep tendon reflexes were brisk and symmetric in both the upper and lower extremities. Babinski reflexes were plantar bilaterally. No pronator drift was noted. Upper and lower extremity muscle strength was 5+ and symmetric. Sensation to touch and pinprick was intact and symmetric. She did not follow 1-step commands and was dysarthric. She could not consistently name simple objects such as a pen or a piece of paper. She could not recall the names of family members or their ages. In the ED, laboratory studies were obtained, including serum electrolytes, blood urea nitrogen, creatinine, glucose, and ammonia,

Duodenal hematoma after upper endoscopy and biopsy in a 4-year-old girl.

Abstract: We describe a 4-year-old girl who developed a duodenal hematoma after upper endoscopy and biopsy. Although rare, duodenal hematoma formation can occur after upper endoscopy and biopsy in otherwise healthy children. A young child presenting with a duodenal hematoma in the absence of a clear mechanism of either previous gastrointestinal procedures or injury to the abdomen should have an extensive evaluation to exclude child abuse. A thorough evaluation for other medical causes, such as a coagulopathy, should be performed simultaneously.

Barriers and facilitators to recognition and reporting of child abuse by prehospital providers

Abstract Background: Prehospital care providers are in a unique position to provide initial unadulterated information about the scene where a child is abusively injured or neglected. However, they receive minimal training with respect to detection of Child Abuse and Neglect (CAN) and make few reports of suspected CAN to child protective services. Aims: To explore barriers and facilitators to the recognition and reporting of CAN by prehospital care providers. Design/Methods: Twenty-eight prehospital care providers participated in a simulated case of infant abusive head trauma prior to participating in one-on-one semi-structured qualitative debriefs. Researchers independently coded transcripts from the debriefing and then collectively refined codes and created themes. Data collection and analysis continued past the point of thematic saturation. Results: Providers described 3 key tasks when caring for a patient thought to be maltreated: (1) Medically managing the patient, which included assessment of the patients airway, breathing, and circulation and management of the chief complaint, followed by evaluation for CAN; (2) Evaluating the scene and family interactions for signs suggestive of CAN, which included gathering information on the presence of elicit substances and observing how the child behaves in the presence of caregivers; and (3) Creating a safety plan, which included, calling police for support, avoiding confrontation with the caregivers and sharing suspicion of CAN with hospital providers and child protective services. Reported barriers to recognizing CAN included discomfort with pediatric patients; uncertainty related to CAN (accepting parental story about alternative diagnosis and difficulty distinguishing between accidental and intentional injuries); a focus on the chief complaint; and limited opportunity for evaluation. Barriers to reporting included fear of being wrong; fear of caregiver reactions; and working in a fast-paced setting. In contrast, facilitators to reporting included understanding of the mandated reporter role; sharing thought processes with peers; and supervisor support. Conclusions: Prehospital care providers have a unique vantage point in detecting CAN, but limited resources and knowledge related to this topic. Focused education on recognition of signs of physical abuse; increased training on scene safety; real-time decision support; and increased follow-up related to cases of CAN may improve their detection of CAN.

Sudden Unexpected Infant Death Differentiating Natural From Abusive Causes in the Emergency Department

Abstract Sudden unexpected infant deaths (SUIDs) are deaths in infants younger than 12 months that occur suddenly, unexpectedly, and without obvious cause in the emergency department (ED). Sudden infant death syndrome, the leading cause of SUID in the United States, is much more common, but fatal child abuse and neglect have been sometimes mistaken for sudden infant death syndrome. The distinction between these 2 entities can only be made after a thorough investigation of the scene, interview of caregivers, and a complete forensic autopsy. Development of ED guidelines for the reporting and evaluation of SUID, in collaboration with the local medical examiner and child death review teams, will enable ED practitioners to collect important information in a compassionate manner that will be valuable to the investigating personnel.

Prevention of Pediatric Abusive Head Trauma: Time to Rethink Interventions and Reframe Messages

approved the voluntary fortification of corn masa flour in an effort to increase folic acid intake,13 particularly among Hispanic women,furthereffortstoaddressdisparitiesintheuseoffolicacid supplementsarewarranted.However,evenwithinthesubgroups of women who have the highest rates of supplementation, the proportion of women who follow the recommendation is relatively low. For example, among women with intended pregnancies, less than half took a daily folic acid supplement in the month prior to pregnancy.12 Hence, there is considerable room for improvement in the use of folic acid supplements across the population of reproductive-age women. The major challenges to increasing the proportion of women who take a daily folic acid supplement are not new: behavioral change is hard; the reproductive period is long; and messages about the health of hypothetical future child often do not resonate with the target audience. However, there have been changes since the initial folic acid awareness campaigns of the 1990s that provide new opportunities to address these challenges. For example,wearabledevicesandsmartphone-basedself-trackersprovide new approaches for disseminating information on folic acid supplementation (eg, as a component of menstruation and ovulation trackers) as well as for self-monitoring of supplement use (eg, using pill reminders and medication trackers) and are well suited to the development of messages and approaches that are targeted to specific subgroups of women. In addition, a national effort to promote preconception health, the National Preconception Health and Healthcare Initiative,14 has the potential to drive broad system changes that will increase women’s awareness of and receptiveness to health-related information, including the USPSTF recommendation on folic acid supplements. While identification of the causal link between folic acid and neural tube defects and the subsequent reduction in the prevalence of these conditions via folic acid fortification are remarkable public health successes, the current USPSTF recommendation provides an important reminder that we have yet to achieve the full benefit of these successes. Consequently, the current recommendation statement should serve as a catalyst for renewed efforts to develop and deliver folic acid messages that will translate into further reductions in the population prevalence of neural tube defects.

Hepatosplenomegaly and reticulocytopenia as prominent features of atypical hemolytic uremic syndrome.

This is a case of atypical hemolytic uremic syndrome (HUS) due to invasive pneumococcal disease in which the prominent clinical features were reticulocytopenia and hepatosplenomegaly, leading to the incorrect initial diagnosis of acute leukemia. Delayed diagnosis of HUS, especially in atypical cases, can lead to increased morbidity and mortality. Atypical HUS must be part of the differential diagnosis of children who present with clinical characteristics suggestive of a hematologic malignancy with associated renal injury.