Sandeep K. Narang

Derivation of a clinical prediction rule for pediatric abusive head trauma

Objectives: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that—if validated—can inform pediatric intensivists’ early decisions to launch (or forego) an evaluation for abuse. Design: Prospective, multicenter, cross-sectional, observational. Setting: Fourteen PICUs. Patients: Acutely head-injured children less than 3 years old admitted for intensive care. Interventions: None. Measurements and Main Results: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity—to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. Conclusions: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform—not dictate—their early decisions to launch (or forego) an evaluation for abuse.

Abusive Head Trauma Past, Present, and Future

Abusive head trauma has a robust and interesting scientific history. Recently, the American Academy of Pediatrics has endorsed a change in terminology to a term that is more general in describing the vast array of abusive mechanisms that can result in pediatric head injury. Simply defined, abusive head trauma is “child physical abuse that results in injury to the head or brain.” Abusive head trauma is a relatively common cause of childhood neurotrauma, with an estimated incidence of 16 to 33 cases per 100 000 children per year in the first 2 years of life. Clinical findings are variable; AHT should be considered in all children with neurologic signs and symptoms, especially if no or only mild trauma is described. Subdural and retinal hemorrhages are the most common findings. The current best evidence-based literature has identified some features—apnea and severe retinal hemorrhages—that reliably discriminate abusive from accidental injury. Longitudinal studies of outcomes in abusive head trauma patients demonstrate that approximately one-third of the children are severely disabled, one third of them are moderately disabled, and one third have no or only mild symptoms. Abusive head trauma cases are complex cases that require a rigorous, multidisciplinary team approach. The clinician can establish this diagnosis with confidence if he/she maintains a high index of suspicion for the diagnosis, has knowledge of the signs, symptoms, and risk factors of abusive head trauma, and reasonably excludes other etiologies on the differential diagnosis.

A case series of marijuana exposures in pediatric patients less than 5 years of age

Marijuana refers to the dried materials of the hemp plant Cannabis sativa and herbal preparations contain over 400 compounds, including over 60 cannabinoids. The most potent psychoactive cannabinoid compound is 9-tetrahydrocannabinol (THC). Effects include psychological euphoric effects, dose-related tachycardia associated with vasodilatation and conjunctiva injection, and appetite stimulation (Asthon, 2001). In Colorado, there has been a large increase in medical marijuana dispensaries and licenses for the use of medical marijuana over the past year. The Department of Medical Marijuana Enforcement Division was recently created by legislation passed in July 2010. In August 2010, they received 818 applications for medical marijuana business licenses, 321 applications for infused product business licenses, and 1,237 applications for optional premises cultivation (grow) business licenses (www.colorado.gov). This is a retrospective case series of marijuana exposures that have presented to the emergency department (ED) in children less than 6 years of age.

Lynøe et al. – #theRestoftheStory

Lynøe et al. is an adjunct to a larger report by the Swedish Agency For Health Technology Assessment And Assessment Of Social Services (‘SBU’) entitled ‘Traumatic shaking – The role of the triad in medical investigations of suspected traumatic shaking’ (1). Lynøe et al. purport to rigorously, objectively and transparently examine the evidence-based medical literature on shaken baby syndrome (SBS) under well-established guidelines of systematic reviews (2). And, having done so, it concludes that there is ‘very low’ scientific evidence supporting the premise that the ‘triad’ implies that an infant has been violently shaken, and ‘low’ scientific evidence supporting the assumption that shaking an infant causes the ‘triad’ (3). Despite a number of high-quality systematic reviews on the diagnosis of abusive head trauma (AHT), another rigorous review of the published literature would be a welcome addition to the growing body of literature on the condition. Unfortunately, there are significant concerns about the methodology, objectivity and transparency of this study.

Acceptance of Shaken Baby Syndrome and Abusive Head Trauma as Medical Diagnoses

OBJECTIVE To assess the current general acceptance within the medical community of shaken baby syndrome (SBS), abusive head trauma (AHT), and several alternative explanations for findings commonly seen in abused children. STUDY DESIGN This was a survey of physicians frequently involved in the evaluation of injured children at 10 leading childrens hospitals. Physicians were asked to estimate the likelihood that subdural hematoma, severe retinal hemorrhages, and coma or death would result from several proposed mechanisms. RESULTS Of the 1378 physicians surveyed, 682 (49.5%) responded, and 628 were included in the final sample. A large majority of respondents felt that shaking with or without impact would be likely or highly likely to result in subdural hematoma, severe retinal hemorrhages, and coma or death, and that none of the alternative theories except motor vehicle collision would result in these 3 findings. SBS and AHT were comsidered valid diagnoses by 88% and 93% of the respondents, respectively. CONCLUSIONS Our empirical data confirm that SBS and AHT are still generally accepted by physicians who frequently encounter suspected child abuse cases, and are considered likely sources of subdural hematoma, severe retinal hemorrhages, and coma or death in young children. Other than a high-velocity motor vehicle collision, no alternative theories of causation for these findings are generally accepted.

Breastfeeding Practices in Military Families: A 12-Month Prospective Population-Based Study in the National Capital Region

Breastfeeding practices in military families have not been widely investigated. The objective of this study was to measure the prevalence and duration of breastfeeding among uniformed families and identify factors associated with breastfeeding. We conducted a prospective study of 253 mothers of new infants from July to December 2004. Initial information gathered included demographic data, feeding choices, and intended duration of breastfeeding. Follow-up surveys were conducted until 12 months postpartum. 51% of mothers were breastfeeding at 6 months and 25% at 1 year. Mothers on active duty were equally likely to breastfeed than non-active duty mothers. Officer mothers were 3 times more likely to breastfeed compared to enlisted mothers (p = 0.005). Mothers with higher education were twice as likely to breastfeed longer (p = 0.015). Families participating in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were 2.5 times less likely to breastfed at 1 year (p < 0.001). Our study shows a higher percentage of women initiating and maintaining breastfeeding compared to national data, but still less than current American Academy of Pediatrics guidelines. Our study suggests that to improve breastfeeding rates among uniformed families, more attention may need to be directed to younger, enlisted mothers and those families in a lower socioeconomic status or receiving WIC assistance.

Expert Witness Participation in Civil and Criminal Proceedings

The interests of the public and both the medical and legal professions are best served when scientifically sound and unbiased expert witness testimony is readily available in civil and criminal proceedings. As members of the medical community, patient advocates, and private citizens, pediatricians have ethical and professional obligations to assist in the civil and criminal judicial processes. This technical report explains how the role of the expert witness differs in civil and criminal proceedings, legal and ethical standards for expert witnesses, and strategies that have been employed to deter unscientific and irresponsible testimony. A companion policy statement offers recommendations on advocacy, education, research, qualifications, standards, and ethical business practices all aimed at improving expert testimony.

Disclosure of adverse events in pediatrics

Despite increasing attention to issues of patient safety, preventable adverse events (AEs) continue to occur, causing direct and consequential injuries to patients, families, and health care providers. Pediatricians generally agree that there is an ethical obligation to inform patients and families about preventable AEs and medical errors. Nonetheless, barriers, such as fear of liability, interfere with disclosure regarding preventable AEs. Changes to the legal system, improved communications skills, and carefully developed disclosure policies and programs can improve the quality and frequency of appropriate AE disclosure communications.

Legal Issues in Child Maltreatment

The most common medicolegal issues include reporting child maltreatment, the presentation of ethical and effective expert testimony, informed consent in child maltreatment cases, and various liability risks related to child maltreatment cases. The health care professional who remains knowledgeable about the laws within their jurisdiction, the mandates of their professional society and state medical board, and the local resources (eg, child abuse pediatrician and hospital counsel) available to them minimizes medicolegal risk.

Racial and Ethnic Disparities and Bias in the Evaluation and Reporting of Abusive Head Trauma

Objective To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. Study design Aggregate and site‐specific analysis of the cross‐sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non‐Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. Results In the PediBIRN study sample of 500 young, acutely head‐injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non‐Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non‐AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of ≤25% (P < .001 [aOR, 4.1] and P < .001 [aOR, 2.8]). Similar site‐specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. Conclusion Significant race/ethnicity‐based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians’ implicit bias.