Philip V. Scribano

Abusive Head Trauma During a Time of Increased Unemployment: A Multicenter Analysis

OBJECTIVE: To evaluate the rate of abusive head trauma (AHT) in 3 regions of the United States before and during an economic recession and assess whether there is a relationship between the rate of AHT and county-level unemployment rates. METHODS: Clinical data were collected for AHT cases diagnosed in children younger than 5 years from January 1, 2004 until June 30, 2009, by hospital-based child protection teams within 3 geographic regions. The recession was defined as December 1, 2007 through June 30, 2009. Quarterly unemployment rates were collected for every county in which an AHT case occurred. RESULTS: During the 5½-year study period, a total of 422 children were diagnosed with AHT in a 74-county region. The overall rate of AHT increased from 8.9 in 100 000 (95% confidence interval [CI]: 7.8–10.0) before the recession to 14.7 in 100 000 (95% CI: 12.5–16.9) during the recession (P < .001). There was no difference in the clinical characteristics of subjects in the prerecession versus recession period. There was no relationship between the rate of AHT and county-level unemployment rates. CONCLUSIONS: The rate of AHT increased significantly in 3 distinct geographic regions during the 19 months of an economic recession compared with the 47 months before the recession. This finding is consistent with our understanding of the effect of stress on violence. Given the high morbidity and mortality rates for children with AHT, these results are concerning and suggest that prevention efforts might need to be increased significantly during times of economic hardship.

Use of an observation unit by a pediatric emergency department for common pediatric illnesses.

Objective To describe the use of a pediatric observation unit (OU), including relapse rates for common pediatric illnesses, and to assess effectiveness of OU utilization. Design Retrospective, cohort of all emergency department (ED) visits, OU and inpatient unit (IU) admissions. Setting Tertiary care children’s hospital. Participants All children evaluated in the ED and subsequently admitted to either the OU or IU over a 2-year period. Main Outcome Measure Rates with 95% confidence intervals (CI) for OU use and need for subsequent IU admission from OU, and odds ratios (OR) with 95% CI for use of the OU for specific pediatric disorders. Results During 10/1/96–9/30/98, there were 44,459 ED visits, 1798 (4.0%) OU admissions, and 3241 (7.3%) inpatient admissions (IA) from the ED. OU mean length of stay was 15.6 ± 6.1 hours; mean age was 6 ± 5.3 years with 31% under 2 years of age. Of the total admissions (IU and OU), diagnoses with high OU utilization were: asthma 274/575, 48%; croup 76/125, 61%; enteritis/dehydration 284/470, 60%; poisonings 82/118, 70%; and seizures 80/204, 39%. The likelihood of an OU admission for these illnesses versus IU (adjusted for subsequent need for IU admission) was: asthma OR 1.3 (1.1, 1.5), P < 0.005; croup OR 2.3 (1.6, 3.3), <0.001; enteritis/ dehydration OR 2.8 (2.1, 3.0), P < 0.001; poisonings OR 3.8 (2.5, 5.7), P < 0.001; and seizures OR 0.8 (0.6, 1.2), P = 0.28. For these diagnoses, OU admissions resulting in IU admission occurred for asthma 45/274, 16.4%; croup 7/76, 9.2%; enteritis/ dehydration 13/284, 4.6%; poisonings 3/82, 3.7%; and seizures 15/80, 18.8%, resulting in an overall need for further hospitalization to the IU for these diagnoses of 83/796, 10.4%, (95% CI 8.3, 12.6). Conclusion Admissions to the observation unit comprised over one third of all admissions from a pediatric ED. Certain pediatric illnesses appear to be well suited for admission to the observation unit, with low likelihood of the need for subsequent admission to the inpatient unit. Given the current trends in third-party payer reimbursements for short (<24 hours) admissions, observation unit use provides a more attractive alternative to inpatient admission for many pediatric patients.

Risk Factors for Mortality in Children with Abusive Head Trauma

OBJECTIVE We sought to identify risk factors for mortality in a large clinical cohort of children with abusive head trauma. STUDY DESIGN Bivariate analysis and multivariable logistic regression models identified demographic, physical examination, and radiologic findings associated with in-hospital mortality of children with abusive head trauma at 4 pediatric centers. An initial Glasgow Coma Scale (GCS) ≤ 8 defined severe abusive head trauma. Data are shown as OR (95% CI). RESULTS Analysis included 386 children with abusive head trauma. Multivariable analysis showed children with initial GCS either 3 or 4-5 had increased mortality vs children with GCS 12-15 (OR = 57.8; 95% CI, 12.1-277.6 and OR = 15.6; 95% CI, 2.6-95.1, respectively, P < .001). Additionally, retinal hemorrhage (RH), intraparenchymal hemorrhage, and cerebral edema were independently associated with mortality. In the subgroup with severe abusive head trauma and RH (n = 117), cerebral edema and initial GCS of 3 or 4-5 were independently associated with mortality. Chronic subdural hematoma was independently associated with survival. CONCLUSIONS Low initial GCS score, RH, intraparenchymal hemorrhage, and cerebral edema are independently associated with mortality in abusive head trauma. Knowledge of these risk factors may enable researchers and clinicians to improve the care of these vulnerable children.

Factors influencing termination of resuscitative efforts in children: A comparison of pediatric emergency medicine and adult emergency medicine physicians

Objectives: To examine factors that influence termination of resuscitative efforts (TORE) and compare pediatric emergency medicine (PEM) and general emergency medicine (GEM) physicians regarding TORE in children. Design: Cross-sectional survey. Participants: All physicians board-certified in PEM as of November 1993 and a random sample of board-certified GEM physicians listed in the 1993 American College of Emergency Physicians directory. Interventions: Self-administered questionnaires were mailed to participants who were asked about experience providing pediatric cardiopulmonary resuscitation (CPR) and demographic information. We posed a series of management questions eliciting factors that influence TORE decision-making in single context and case scenario format. Specific emphasis was placed on the influence of time and epinephrine dosing. Results: One hundred and sixty (70%) PEM and 127 (62%) GEM responded. These groups differed significantly in years of experience (PEM 8.2, GEM 11.8), urban practice setting (PEM 84%, GEM 32%) and number of pediatric cardiopulmonary resuscitations per year (PEM 10.6, GEM 4.8), P<0.001 for all. There were no significant differences between groups regarding features pathognomonic of death. PEM were more likely to consider low blood pH and iatrogenic causes of arrest as factors influencing TORE; GEM were more likely to consider co-morbid conditions (P<0.05 for all). Medians for time estimates of minimum minutes of pulselessness that influence TORE were: PEM 26 to 30 minutes, GEM 31 to 35 minutes for both prehospital and emergency department settings (P<0.05 for each). Approximately 20% of all respondents did not place a strict limit on time of pulselessness when determining TORE. No difference was observed between groups regarding maximum doses of epinephrine used prior to TORE. However, fewer GEM (50%) than PEM (75%) utilize “high dose” epinephrine according to current Pediatric Advanced Life Support (PALS) guidelines (P<0.05). PEM physicians were more than two times more likely to terminate resuscitative efforts if return of spontaneous circulation was not achieved by 25 minutes compared to GEM physicians for both prehospital time of pulselessness [odds ratio 2.1,95% confidence interval (1.01,4.5)] and emergency department time of pulselessness [odds ratio 2.2, confidence interval (1.1,4.6)]. Conclusions: 1) Several laboratory and clinical factors significantly influence physician’s decisions regarding TORE; 2) regardless of setting, time of pulselessness does appear to be an influential factor in determining when to terminate resuscitation in children for most physicians; 3) PEM physicians are more likely to terminate resuscitative efforts than are GEM physicians if return of spontaneous circulation is not achieved by 25 minutes; 4) a significant number of PEM and GEM physicians do not use high dose epinephrine in accordance with current PALS recommendations.

Forensic Evidence Collection and DNA Identification in Acute Child Sexual Assault

OBJECTIVE: To describe forensic evidence findings and reevaluate previous recommendations with respect to timing of evidence collection in acute child sexual assault and to identify factors associated with yield of DNA. METHODS: This was a retrospective review of medical and legal records of patients aged 0 to 20 years who required forensic evidence collection. RESULTS: Ninety-seven of 388 (25%) processed evidence-collection kits were positive and 63 (65%) of them produced identifiable DNA. There were 20 positive samples obtained from children younger than 10 years; 17 of these samples were obtained from children seen within 24 hours of the assault. Three children had positive body samples beyond 24 hours after the assault, including 1 child positive for salivary amylase in the underwear and on the thighs 54 hours after the assault. DNA was found in 11 children aged younger than 10 years, including the child seen 54 hours after the assault. Collection of evidence within 24 hours of the assault was identified as an independent predictor of DNA detection. CONCLUSIONS: Identifiable DNA was collected from a childs body despite cases in which: evidence collection was performed >24 hours beyond the assault; the child had a normal/nonacute anogenital examination; there was no reported history of ejaculation; and the victim had bathed and/or changed clothes before evidence collection. Failure to conduct evidence collection on prepubertal children beyond 24 hours after the assault will result in rare missed opportunities to identify forensic evidence, including identification of DNA.

Predicting need for hospitalization in acute pediatric asthma.

Objectives: To develop and validate predictive models to determine the need for hospitalization in children treated for acute asthma in the emergency department (ED). Methods: Prospective cohort study of children aged 2 years and older treated at 2 pediatric EDs for acute asthma. The primary outcome was successful ED discharge, defined as actual discharge from the ED and no readmission for asthma within 7 days, versus need for extended care. Among those defined as requiring extended care, a secondary outcome of inpatient care (>24 hours) or short-stay care (<24 hours) was defined. Logistic regression and recursive partitioning were used to create predictive models based on historical and clinical data from the ED visit. Models were developed with data from 1 ED and validated in the other. Results There were 852 subjects in the derivation group and 369 in the validation group. A model including clinical score (Pediatric Asthma Severity Score) and number of albuterol treatments in the ED distinguished successful discharge from need for extended care with an area under the receiver-operator characteristic curve of 0.89 (95% confidence interval [CI], 0.87-0.92) in the derivation group and 0.92 (95% CI, 0.89-0.95) in the validation group. Using a score of 5 or more as a cutoff, the likelihood ratio positive was 5.2 (95% CI, 4.2-6.5), and the likelihood ratio negative was 0.22 (95% CI, 0.17-0.28). Among those predicted to need extended care, a classification tree using number of treatments in the ED, clinical score at end of ED treatment, and initial pulse oximetry correctly classified 63% (95% CI, 56-70) of the derivation group as short stay or inpatient, and 62% (95% CI, 55-68) of the validation group. Conclusions Successful discharge from the ED for children with acute asthma can be predicted accurately using a simple clinical model, potentially improving disposition decisions. However, predicting correct placement of patients requiring extended care is problematic.

Observation units : The role of an outpatient extended treatment site in pediatric care

This article explores the role of extended outpatient treatment in pediatric care, presents important considerations when planning and implementing an outpatient extended treatment site (OETS), discusses operations of a recently opened unit, and examines the research and teaching potential of an OETS.

Barriers to Successful Treatment Completion in Child Sexual Abuse Survivors

Child sexual abuse (CSA) often requires psychological treatment to address the symptoms of victim trauma. Barriers to entry and completion of counseling services can compromise long-term well-being. An integrated medical and mental health evaluation and treatment model of a child advocacy center (CAC) has the potential to reduce barriers to mental health treatment. Objective: (a) to describe characteristics between CSA patients who engage versus those who do not engage in mental health treatment and (b) to identify factors associated with successful completion of mental health treatment goals. For design/setting, a retrospective cohort study was conducted of CSA patients (ages 3-16 years) referred to mental health services following a CAC assessment. Outcome variables included linkage with treatment and completion of treatment. Independent variables included demographics, abuse characteristics, and therapist characteristics. Data were abstracted from the CAC and billing databases. Results: Four hundred ninety subjects were evaluated. Subjects were as follows: predominately female (74%), White (60%), and more than half received Medicaid (56%). Mean age was 8.4 years. About 52% linked with mental health services and 39% of patients that successfully linked with mental health services completed therapy. Successful linkage was independently associated with referrals to other counseling services (AOR 8.4 [2.5, 27.7]). Successful completion of therapy was independently associated with caregiver participation in therapy (AOR 3.2 [1.8, 6.0]) and if the patient was referred to other counseling services (AOR 4.1 [1.9, 8.5]). There were no differences between subjects that linked and/or completed therapy and those that did not with regard to demographic characteristics or abuse severity. Conclusion: In contrast to previous reports, efforts at our CAC seem to overcome linkage barriers in this population. However, there remain challenges in achieving successful completion of treatment goals in this population. Engaging caregivers’ involvement in therapy services had a positive effect with successfully achieving treatment goals.

Yield of Retinal Examination in Suspected Physical Abuse With Normal Neuroimaging

OBJECTIVE: In some centers, dedicated ophthalmologic examination is performed for all children who are evaluated for potential physical abuse. Although retinal hemorrhages have been reported in rare cases of abused children with normal neuroimaging results, the utility of ophthalmologic examination in this group is currently unknown. The objective of this study was to determine the prevalence of retinal hemorrhages in children younger than 2 years who were evaluated for physical abuse and who had no evidence of traumatic brain injury (TBI) on neuroimaging. PATIENTS AND METHODS: We performed retrospective analysis of data obtained from 1676 children younger than 5 years who were evaluated for potential physical abuse as a part of the Using Liver Transaminases to Recognize Abuse research network. We reviewed results of dedicated ophthalmologic examination in all children younger than 2 years with no evidence of TBI on neuroimaging. RESULTS: Among 282 children who met inclusion criteria, only 2 (0.7% [95% confidence interval: 0.1%–2.5%]) had retinal hemorrhages considered “characteristic” of abuse. Seven other children (2.5% [95% confidence interval: 1.0%–5.1%]) had a nonspecific pattern of retinal hemorrhages. Both children with characteristic retinal hemorrhages in the absence of TBI showed evidence of head or facial injury on physical examination and/or altered mental status. CONCLUSIONS: In children younger than 2 years being evaluated for physical abuse without radiographic evidence of brain injury, retinal hemorrhages are rare. Dedicated ophthalmologic examination should not be considered mandatory in this population.

Prior opportunities to identify abuse in children with abusive head trauma

Infants with minor abusive injuries are at risk for more serious abusive injury, including abusive head trauma (AHT). Our study objective was to determine if children with AHT had prior opportunities to detect abuse and to describe the opportunities. All AHT cases from 7/1/2009 to 12/31/2011 at four tertiary care childrens hospitals were included. A prior opportunity was defined as prior evaluation by either a medical or child protective services (CPS) professional when the symptoms and/or referral could be consistent with abuse but the diagnosis was not made and/or an alternate explanation was given and accepted. Two-hundred-thirty-two children with AHT were identified; median age (IQR) was 5.40 (3.30, 14.60) months. Ten percent (22/232) died. Of the 232 patients diagnosed with AHT, 31% (n=73) had a total of 120 prior opportunities. Fifty-nine children (25%) had at least one prior opportunity to identify abuse in a medical setting, representing 98 prior opportunities. An additional 14 (6%) children had 22 prior opportunities through previous CPS involvement. There were no differences between those with and without a prior opportunity based on age, gender, race, insurance, mortality, or institution. Children with prior opportunities in a medical setting were more likely to have chronic subdural hemorrhage (48 vs. 17%, p<0.01) and healing fractures (31 vs. 19%, p=0.05). The most common prior opportunities included vomiting 31.6% (38/120), prior CPS contact 20% (24/120), and bruising 11.7% (14/120). Improvements in earlier recognition of AHT and subsequent intervention might prevent additional injuries and reduce mortality.