Adrenal lacerations in child abuse: a marker of severe trauma

There are few reports of adrenal injuries complicating inflicted pediatric trauma. All child-abuse cases at the New York City Medical Examiner's Office over a 7-year period were reviewed. Of these 121 homicides, 50 sustained severe injuries to the torso. Five infants (10.0%) had adrenal laceration, a marker of major blunt-force injury. Accepted: 21 January 1999     

Excitatory amino acid concentrations in ventricular cerebrospinal fluid after severe traumatic brain injury in infants and children: the role of child abuse

BACKGROUND: Excitotoxicity is an important mechanism in secondary neuronal injury after traumatic brain injury (TBI). Excitatory amino acids (EAAs) are increased in cerebrospinal fluid (CSF) in adults after TBI; however, studies in pediatric head trauma are lacking. We hypothesized that CSF glutamate, aspartate, and glycine would be increased after TBI in children and that these increases would be associated with age, child abuse, poor outcome, and cerebral ischemia. METHODS: EAAs were measured in 66 CSF samples from 18 children after severe TBI. Control samples were obtained from 19 children who received lumbar punctures to rule out meningitis. RESULTS: Peak and mean CSF glycine and peak CSF glutamate levels were increased versus control values. Subgroups of patients with TBI were compared by using univariate regression analysis. Massive increases in CSF glutamate were found in children <4 years old and in child abuse victims. Increased CSF glutamate and glycine were associated with poor outcome. A trend toward an association between high glutamate concentration and ischemic blood flow was observed. CONCLUSIONS: CSF EAAs are increased in infants and children with severe TBI. Young age and child abuse were associated with extremely high CSF glutamate concentrations after TBI. A possible role for excitotoxicity after pediatric TBI is supported.     

Future role of the pediatrician in child abuse and neglect

This article reviews the recent history of responses to child abuse and the present roles of pediatricians. It outlines actions that are needed to protect children, recognizes the difficulties in effecting intervention, and concludes that pediatricians cannot afford to stand by while children continue to suffer harm.     

Fatal child abuse: a two-decade review

The purpose of the present study was to identify demographic variables and medical causes of death associated with child deaths, secondary to abuse, at one pediatric hospital. Abuse and neglect reporting forms, social service records, and autopsy reports were reviewed. A total of 72 known deaths occurred between 1965 and 1984. The majority of children were under two years of age, and the most common cause of death was head trauma. Less than one half of the children who died presented to the emergency department with visible signs of injury. Male abusers outnumbered females; boyfriends of the victims' mothers were the most frequent perpetrators. Emergency department personnel should have a high index of suspicion about abuse in cases of inadequately explained conditions in children. All cases of children who die unexpectedly, or from inadequately explained conditions, should be referred to the coroner, and autopsies should be performed.     

Funding of child abuse evaluations: survey of child abuse evaluation programs

This article delineates the current fiscal management and reimbursement for child abuse examinations. These financial issues are high priority for child abuse programs because most programs lack the revenues to meet the demands for service, education, advocacy and research. Programs may share medical protocols and standards but have yet to share management solutions. The authors present the administrative details of 75 child abuse evaluation programs and highlight innovative approaches to increase funding and stabilize the funding for the programs. They present information on billing, contracts, costs of care, and state-based initiatives that can be reproduced by other programs and states.     

Child abuse consultations initiated by child protective services: the role of expert opinions

ObjectiveTo describe consultations provided by child abuse pediatricians for cases referred by child protective services (CPS); compare the opinions of the likelihood of child maltreatment of the initial physician, CPS, and the child abuse pediatrician; and examine predictors of the experts’ opinions.MethodsCases were referred by CPS for consultations between March 1, 1998, and June 30, 2005, to 2 child abuse pediatricians at Yale–New Haven Children’s Hospital. We abstracted demographic and clinical information and the opinions of the initial physician, CPS, and the child abuse expert, each coded using a 5-point scale from definite maltreatment to definite benign cause (eg, accident).ResultsOf 187 cases, 50.3% occurred in children younger than 1 year of age. Children’s most serious injuries were fractures (50.8%), burns (16.6%), and bruises/abrasions (15.0%). The child abuse experts’ opinions were 47.6% definite or probable maltreatment, 8.6% uncertain, and 43.9% definite or probable benign. Of the 119 cases with opinions from all 3 assessors, the expert agreed with the physician in 57.1% of cases (κ = 0.34) and with CPS in 64.7% (κ = 0.42). The best predictor of the expert’s opinion that the injury was due to maltreatment was agreement between the physician and CPS that maltreatment had occurred.ConclusionsLevels of agreement were fair to poor between the child abuse expert and either the physician or CPS. Child abuse experts’ opinions have important value in selected cases to confirm previous assessments by the physician and/or CPS, or to change the opinion of the case.     

The role of a child life specialist in a pediatric radiology department

Child life programming is predominantly developed in inpatient areas throughout major pediatric hospitals. However, the trend toward outpatient services has increased the need for facilities to develop child life positions to assist in the teaching demands of patients and families coming in for routine hospital visits. Since radiology is often the first experience for families, but not the last, it is essential to involve them in a positive experience. Imaging facilities serving pediatric patients are currently developing or considering child life programs. A certified child life specialist (CCLS) is committed to developing programming that enhances the child's understanding and involvement in their medical experience. This paper provides an outline of the responsibilities and areas of expertise of the CCLS in a pediatric radiology department. The reviewed program is based on, but not limited, to fluoroscopy.     

Multiple personality disorder: a risk indicator, diagnostic marker and psychiatric outcome for severe child abuse

Recent studies suggest that multiple personality disorder (MPD) is not as rare as previously believed. Indeed, it may represent a relatively common (as many as 25% of cases) outcome of severe physical and sexual abuse of children. Because diagnosis and treatment offer the best prognosis, it is important for the pediatric clinician to become familiar with both the at risk situations (such as cult practices and multigenerational sexual abuse) as well as the more unusual behavioral presentations of this disorder.     

Bite marks, oral and facial injuries--harbingers of severe child abuse?

Bite mark evidence has been admitted in a vast number of cases in courts throughout the United States, as well as other countries. Because there is variation in the dentition of humans, if bite marks are noted in a victim, it is possible in many cases to determine the identity of the perpetrator depending on the quality of the bite mark, its age, lack of distortion and documentation. In other cases, facial injuries, including damage to the frenum and teeth in addition to the face, may point to nonaccidental injury if the history corroborates this condition.     

Disclosure, reactions, and social support: findings from a sample of adult victims of child sexual abuse

Information about abuse characteristics, disclosure, and current social support was collected through semistructured interviews and questionnaires from 122 adult women reporting exposure to child sexual abuse by someone close. Women who used an active disclosure strategy in childhood reported more physical and violent abuse. Moreover, women who reported more severe abuse had more often received negative reactions from the social network. Furthermore, a relation was found between current social support and positive-but not negative-reactions.     

Cutaneous mimickers of child abuse: a primer for pediatricians

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.     

Differential diagnosis of child physical abuse: conditions that may be mistaken for child abuse

Child protection is one of the most difficult aspects of paediatric practice. Physical abuse is the commonest form of maltreatment identified by clinicians. Suspicious injuries are rarely accompanied by an admission of inflicted harm, even when this is the cause. Clinicians therefore must have a high index of suspicion and where injuries appear consistent with physical abuse or are inadequately explained they must follow safeguarding procedures. However, as for any clinical problem, there is a differential diagnosis to consider. Medical conditions can sometimes mimic signs suggestive of physical abuse. Other conditions can increase a child's vulnerability to specific injuries. In this article we discuss the differential diagnosis of bruising, fractures and head injuries which are the three commonest presenting features of physical abuse. Awareness of the differential diagnosis and appropriate assessment of the injured child can assist in reaching the correct diagnosis and therefore protect children from harm.     

The role of the nursing team caring for a child approaching the end of life

In a general paediatric department, nurses may have to care for children suffering from severe life-threatening illnesses. When supporting the child and his/her parents, sometimes until the end of life, they must learn to manage their emotions and adopt a position which is both sympathetic and professional.     

Severe child abuse: a study of cases reported to the police

AIM: To investigate the characteristics of severe abuse of children and possible differences in comparison with less severe abuse. METHOD: Cases of abuse reported to the police within a single police district (n=142) in Sweden were studied. The severe cases were compared to all the remaining cases. RESULTS: Severe abuse constituted 14% of the total cases and was reported by agencies to a greater degree than minor cases. The suspected perpetrators were socially disadvantaged people in both groups. Half of the most serious cases led to conviction in the courts, compared to 8% in the reference group. The children who had been subjected to abuse were often already known to social services and reports of child abuse had frequently been made. CONCLUSION: In comparison between cases of severe and minor child abuse reported to the police, the results did not show any crucial differences except the pattern of reporting and a higher occurrence of prosecution/conviction in the severe cases. This finding places a responsibility on agencies outside of the justice system to consider all cases of reported abuse as serious warning signals and to make independent evaluations to identify risks and the possible need for child protection.