Impact of Child Abuse Clinical Pathways on Skeletal Survey Performance in High-Risk Infants

ObjectiveWe sought: 1) to examine the association between the presence of a child abuse pathway and the odds of skeletal survey performance in infants with injuries associated with high risk of abuse and 2) to determine whether pathway presence decreased disparities in skeletal survey performance.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬MethodsIn this retrospective study of children <1 year diagnosed with injuries associated with high risk of abuse at hospitals in the Pediatric Hospital Information System, information regarding the presence of a child abuse pathway was collected via survey. We examined whether the presence of a child abuse pathway was associated with the odds of obtaining a skeletal survey, adjusting for patient-level factors.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ResultsAmong 2085 included cases 55% were male, 69% had public insurance, and 64% were white. Fifty-eight percent presented to a hospital when a pathway was present. Skeletal surveys were performed in 86% of children between 0 and 5 months and 73% of children 6–11 months. In our regression model, adjusted for covariates (age, race, insurance, injury) the presence of a child abuse pathway in a hospital was associated with greater odds of skeletal survey performance (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.02–2.08). Children with public insurance had greater odds of receiving a skeletal survey (OR 2.75, 95% CI 2.11–3.52) despite presence of pathway.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ConclusionsWhen a child abuse clinical pathway was present, children with injuries associated with a high risk of abuse had a greater odds of receiving a skeletal survey. Differences in skeletal survey performance exist between infants with public vs. private insurance regardless of a pathway.     

Association of externalizing behavior disorder symptoms and injury among fifth graders

ObjectiveInjury is the leading cause of death among American youth, killing more 11-year-olds than all other causes combined. Children with symptoms of externalizing behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) may have increased risk. Our aims were to determine: (1) whether increasing symptoms of ADHD and CD associate positively with injuries among a community sample of fifth graders; and (2) whether symptoms of ADHD and CD have a multiplicative rather than additive association with injuries among the sample.MethodsData were collected from 4745 fifth graders and their primary caregivers participating in Healthy Passages, a multisite, community-based study of pediatric health risk behaviors and health outcomes. The primary outcome was injury frequency. Primary independent variables were ADHD and CD symptoms. Additional covariates included gender, race/ethnicity, and household income. Ordinal logistic regression examined correlates of injury frequency. The interaction between ADHD and CD symptoms also was examined.ResultsIn bivariate analyses, the odds of injury increased as ADHD symptoms (odds ratio [OR] 1.29; 95% confidence interval [95% CI] 1.18–1.41) and CD symptoms (OR 1.18; 95% CI 1.07–1.31) increased. However, in multivariate analysis, only ADHD symptoms were significantly associated with injury (OR 1.22; 95% CI 1.10–1.35). There was no statistically significant interaction between ADHD and CD symptoms.ConclusionsADHD symptoms are associated with increased odds of injury in fifth graders. Findings have implications for potential injury prevention strategies for mental health practitioners (for example, cognitive training with at-risk youth), pediatricians (ADHD screening), and parents (improved supervision).     

Less anticipatory guidance is associated with more subsequent injury visits among infants.

OBJECTIVE: To describe clinician delivery of injury prevention anticipatory guidance and injury visits in a birth cohort, and to describe the association of injury prevention anticipatory guidance with subsequent injury visits. METHODS: We performed a prospective cohort study of 2610 infants born from July 1, 1998 to June 30, 1999, at an urban safety-net hospital and seen subsequently for well child care (WCC, visits = 10558) and/or injury by 16 months of age. Injury guidance was defined as the proportion of recommended injury prevention anticipatory guidance items delivered to those expected, given the WCC visits the child attended. The outcome was a first injury visit to a clinic, emergency department, or hospital. RESULTS: The injury prevention items most discussed were car seats (84%-95% of all WCC visits) and rolling over at the 2-month WCC visit (80%). Other items were addressed at 36%-69% of visits. A total of 1931 (74%) of children received > or = 50% expected injury guidance. A total of 277 children (11%) had an injury visit, primarily for minor injuries. In unadjusted analysis, children receiving < 25% expected injury guidance were more likely to have a subsequent injury visit (unadjusted odds ratio 6.2; 95% confidence interval [95% CI] 3.2-9.7). In adjusted analysis, children who received < 25% and 25%-49% expected injury guidance were more likely to have a subsequent injury visits (adjusted odds ratio [AOR] 6.6; 95% CI 3.8-11.2; and AOR 2.9, 95% CI 2.0-4.3, respectively). CONCLUSIONS: Disadvantaged children whose families received less injury guidance than other children in their cohort were more likely to have a subsequent injury visit. Further studies are needed to determine whether increased injury prevention counseling reduces injury visits.     

A randomized controlled trial testing an HIV prevention intervention for Latino youth

OBJECTIVE: To test the efficacy of a prevention intervention to reduce sexual risk behavior among Latino adolescents. DESIGN: Randomized controlled trial from April 2000 through March 2003, with data collection before and after intervention and at 3, 6, and 12 months. SETTING: Northeast Philadelphia schools. PARTICIPANTS: Latinos aged 13 through 18 years (249 males and 304 females); 81.6% retained at 12-month follow-up. INTERVENTIONS: The HIV and health-promotion control interventions consisted of six 50-minute modules delivered by adult facilitators to small, mixed-gender groups in English or Spanish.Main Outcome Measure Self-reported sexual behavior. RESULTS: Analyses using generalized estimation equations over the follow-up period revealed that adolescents in the HIV intervention were less likely to report sexual intercourse (odds ratio, 0.66; 95% confidence interval [CI], 0.46-0.96), multiple partners (odds ratio, 0.53; 95% CI, 0.31-0.90), and days of unprotected intercourse (relative risk, 0.47; 95% CI, 0.26-0.84) and more likely to report using condoms consistently (odds ratio, 1.91; 95% CI, 1.24-2.93). Baseline sexual experience and language use moderated intervention efficacy. Adolescents assigned to the HIV intervention who were sexually inexperienced at baseline reported fewer days of unprotected sex (relative risk, 0.22; 95% CI, 0.08-0.63); Spanish speakers were more likely to have used a condom at last intercourse (odds ratio, 4.73; 95% CI, 1.72-12.97) and had a greater proportion of protected sex (mean difference, 0.35; P<.01) compared with similar adolescents in the health-promotion intervention. CONCLUSION: Results provide evidence for the efficacy of HIV intervention in decreasing sexual activity and increasing condom use among Latino adolescents.     

Controlled evaluation of a community based injury prevention program in Australia

OBJECTIVE: To evaluate the effects of a community based, all age, all injury prevention program, the Safe Living Program, on injury risk and injury rates. DESIGN: A quasiexperimental population based evaluation using an intervention and comparison community design. SETTING: The intervention community (Shire of Bulla, n = 37,257) is an outer metropolitan area of Melbourne, Australia. The demographically matched comparison community (Shire of Melton, n=33,592) is located nearby. SUBJECTS AND METHODS: The Safe Living Program in the Shire of Bulla targeted injury reduction in all settings with a focus on high risk groups. Strategies included program publicity, education and training, injury hazard reduction, and environmental change. Baseline and follow up measures of program reach, risk factors, and injury rates in both communities were used to evaluate program process, impact, and outcome. RESULTS: Increase in program awareness was moderate and similar to other community based programs. The program achieved injury hazard reduction on the road, in schools, and, to a more limited extent, in the home. Other changes in injury risk factors could not necessarily be attributed to the program as similar changes were observed in the comparison community. No significant changes were found in rates of injury deaths, hospitalisations, or emergency department presentations in the Shire of Bulla after six years. Self reported household injuries, mostly minor, were reduced in the intervention community, but had been higher at program launch than in the comparison community. CONCLUSIONS: The Safe Living Program was unable to replicate the significant reductions in injuries reported in other community based interventions. Replication of apparently successful community based injury prevention programs in different settings and populations requires evidence based interventions, sustained and effective program penetration, reliable data systems to measure change, at least one control community, and sufficient budget and time for effects to be observable.     

Prevalence of Abusive Injuries in Siblings and Household Contacts of Physically Abused Children

OBJECTIVE: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. METHODS: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were <5 years old, physical examination and skeletal survey (SS) if they were <24 months old, and physical examination, SS, and neuroimaging if they were <6 months old. RESULTS: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9). CONCLUSIONS: SS should be obtained in the contacts of injured, abused children for contacts who are <24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts.     

Sensory deficit and the risk of pedestrian injury.

OBJECTIVES: To examine the association between sensory deficit and the risk of child pedestrian-motor vehicle collisions. SETTING: The Auckland region of New Zealand. METHODS: A community based case-control study was conducted. Cases (n = 190) were all children (< 15 years) killed or hospitalised as a result of a pedestrian injury occurring on a public road between 1 January 1992 and 1 March 1994. Controls (n = 479) were a random sample of the child population. RESULTS: The risk of pedestrian injury for children whose parents reported abnormal vision was over four times that of children with reported normal vision (odds ratio = 4.25, 95% confidence interval 1.68 to 10.8). The risk of injury for children whose parents reported abnormal hearing was close to twice that of children with reported normal hearing (odds ratio = 1.73, 95% confidence interval 0.83 to 3.61). CONCLUSIONS: Children with sensory deficits constitute a high risk group for pedestrian injuries. Paediatricians caring for children with sensory impairments should be aware of this increased risk.     

Comparison of urban and rural non-fatal injury: the results of a statewide survey.

OBJECTIVES: This study compared the epidemiology of non-fatal injury among urban and rural residents of Colorado. DESIGN: A stratified probability sample with random digit dial methods was used to survey Colorado residents by telephone regarding injuries experienced in the last 12 months. Questions on the cause of the injury, the activity at the time of the injury, and the place of injury were based on the Nordic Medico Statistical Committee's (NOMESCO) classification of external causes of injuries. SUBJECTS: A total of 1425 urban and 1275 rural Colorado residents aged 18 and older were interviewed. RESULTS: Age, gender, marital status, and rural residency were found to increase the odds of self reported injury. The adjusted odds ratio for self reported injury was 1.3 (95% confidence interval (CI) 1.01 to 1.68) for rural compared with urban residents. Rural residence (odds ratio 1.02, 95% CI 0.51 to 7.01) was not a risk factor for injury among the highest risk group, those who were single and never married. No differences in injury characteristics were found by urban-rural status. CONCLUSIONS: The increased odds of self reported injury among rural residents were not explained by differences in the causes of injury or other injury characteristics. The differences in the importance of rural residence in increased odds of injury by marital status warrants further understanding and may be important in the development of injury prevention programs. Based on comparison with a similar survey, the NOMESCO coding system appears to be a viable alternative survey tool for gathering information on injury characteristics.     

Family characteristics and pedestrian injury risk in Mexican children

BACKGROUND: Family characteristics have been described as risk factors for child pedestrian and motor vehicle collision. Research results come mainly from developed countries, where family relationships could be different than in developing ones. OBJECTIVE: To examine family characteristics as risk factors for pedestrian injury in children living in Guadalajara City, Mexico. METHODS: Case-control study of injuries among children 1-14 years of age involved in pedestrian-motor vehicle collisions. Cases resulting in death or injuries that required hospitalization or medical attention were included and identified through police reports and/or emergency room registries. Two neighborhood matched controls were selected randomly and compared with cases to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Significant risk factors were: male (OR 2.3, 95% CI 1.2 to 4.4), number of siblings in household (two siblings, OR 3.2, 95% CI 1.4 to 6.6; three siblings, OR 4.5, 95% CI 1.9 to 11.0; four or more siblings, OR 3.7, 95% CI 1.1 to 12.9), and number of non-siblings/non-parents in household (four or more, OR 6.2, 95% CI 1.5 to 26.6). Children of a sole mother, working mother, or grandmother living in house did not show increased risk after adjusting for socioeconomic conditions. CONCLUSION: Household size has implications for child pedestrian and motor vehicle collision prevention efforts and is relatively easy to identify. Also, the lack of risk association with working mothers may indicate that grandmothers are not part of the social support network that cares for children of working mothers.     

Disability and risk of school related injury

OBJECTIVE: Approximately six million children with disabilities attend school in the United States. Cognitive and physical limitations may compromise their ability to handle environmental hazards and hence increase their risk for injury. The objective of this study was to describe the epidemiology of school related injury among children enrolled in 17 special education schools in one large, urban school district. DESIGN: Altogether 6769 schoolchildren with disabilities were followed up from 1994-98. Injury and population data were collected from pupil accident reports and existing school records. Associations were estimated through generalized estimating equations. RESULTS: A total of 697 injuries were reported for a rate of 4.7/100 students per year. Children with multiple disabilities had a 70% increased odds of injury compared with the developmentally disabled (odds ratio (OR) 1.7, 95% confidence interval (CI) 1.3 to 2.3). The physically disabled (OR 1.4, 95% CI 1.0 to 1.9) had a modest increased odds of injury. Cuts, bruises, and abrasions composed almost three fourths of all injuries; almost half of these injuries were to the face. Falls (34%) and insults by other students (31%) were the most common external causes. More than a fourth of injuries were sports related, and 21% occurred on the playground/athletic field. Injury patterns differed across disabilities. CONCLUSIONS: Although limited to one school district, the population studied is the largest cohort thus far of schoolchildren with disabilities. With this large study base, potentially high risk groups were identified and circumstances of injury described. This information is imperative for developing and improving school based injury prevention measures.     

Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers

OBJECTIVE: To evaluate the effectiveness of mechanical patient lifts in reducing musculoskeletal symptoms, injuries, lost workday injuries, and workers' compensation costs in workers at a community hospital. DESIGN: Pre-post intervention study. SETTING: Three nursing units of a small community hospital.Patients or SUBJECTS: Nursing personnel. INTERVENTIONS: Mechanical patient lifts were made available and nursing staff trained in their use between August 2000 and January 2001. MAIN OUTCOME MEASURES: Workers completed symptom surveys at baseline and six months after lift training. Pre-intervention and post-intervention rates of injuries and lost workday injuries using Occupational Safety and Health Administration logs of the three study units, from the period July 1999 through March 2003 were analyzed. Injuries potentially related to lifting patients were included in the analyses. Using workers' compensation data from the same time period, the compensation paid ($ per full time equivalent [FTE]) due to injuries during the pre-intervention and post-intervention period was calculated. RESULTS: Sixty one staff members were surveyed pre-intervention; 36 (59%) completed follow up surveys. Statistically significant improvements in musculoskeletal comfort (p<0.05) were reported for all body parts, including shoulders, lower back, and knees. Injury rates decreased post-intervention, with a relative risk (RR) of 0.37 (95% confidence interval (CI) 0.16 to 0.88); decreased injury rates persisted after adjustment for temporal trends in injury rates on non-intervention units of the study hospital (RR = 0.50, 95% CI 0.20 to 1.26). Adjusted lost day injury rates also decreased (RR = 0.35, 95% CI 0.10 to 1.16). Annual workers' compensation costs averaged $484 per FTE pre-intervention and $151 per FTE post-intervention. CONCLUSION: Reductions were observed in injury rates, lost workday injury rates, workers' compensation costs, and musculoskeletal symptoms after deployment of mechanical patient lifts. Strengths of this study include the community hospital setting and the inclusion of a variety of different outcomes. Limitations include the pre-post study design and the small sample size.     

Long term effects of a home visit to prevent childhood injury: three year follow up of a randomized trial

OBJECTIVE: To assess the long term effect of a home safety visit on the rate of home injury. DESIGN: Telephone survey conducted 36 months after participation in a randomized controlled trial of a home safety intervention. A structured interview assessed participant knowledge, beliefs, or practices around injury prevention and the number of injuries requiring medical attention. SETTING: Five pediatric teaching hospitals in four Canadian urban centres. PARTICIPANTS: Children less than 8 years of age presenting to an emergency department with a targeted home injury (fall, scald, burn, poisoning or ingestion, choking, or head injury while riding a bicycle), a non-targeted injury, or a medical illness. RESULTS: We contacted 774 (66%) of the 1172 original participants. A higher proportion of participants in the intervention group (63%) reported that home visits changed their knowledge, beliefs, or practices around the prevention of home injuries compared with those in the non-intervention group (43%; p<0.001). Over the 36 month follow up period the rate of injury visits to the doctor was significantly less for the intervention group (rate ratio = 0.74; 95% CI 0.63 to 0.87), consistent with the original (12 month) study results (rate ratio = 0.69; 95% CI 0.54 to 0.88). However, the effectiveness of the intervention appears to be diminishing with time (rate ratio for the 12-36 month study interval = 0.80; 95% CI 0.64 to 1.00). CONCLUSIONS: A home safety visit was able to demonstrate sustained, but modest, effectiveness of an intervention aimed at improving home safety and reducing injury. This study reinforces the need of home safety programs to focus on passive intervention and a simple well defined message.     

Assessment of suspicion of abuse in the primary care setting.

OBJECTIVES: To describe the primary care practitioner's assessment of the likelihood that an injury was caused by physical abuse. The hypotheses were 1) practitioners face great uncertainty as to the possibility that an injury may have been caused by abuse; a measure that assigns variable degrees of suspicion to childhood injuries can be developed that will reveal this uncertainty; and 2) practitioner factors and patient factors influence this suspicion. METHODS: Primary care practitioners in a regional practice-based research network prospectively collected information about each consecutive office encounter during a 4-week study period. For injury-related visits, the practitioner described injury type, reported cause and severity, and the practitioner's assessment of the cause of injury. Practitioners also used a 5-point Suspicion Scale to identify their level of suspicion that the injury was caused by abuse, with 1 equating to impossible and 5 equating to virtually certain. A subset of practitioners gave information about child and family risk factors. The practitioner's reporting activity was not studied. RESULTS: Participating practitioners (n = 85) in 17 practices collected information about 12 510 office encounters, including 659 injuries. Although the practitioners assessed no injuries as "caused by abuse," they rated 21% of the injuries as having "some suspicion" of abuse. Practitioners were more likely to have "some suspicion" of abuse for those children who were Hispanic or African-American (vs. White) (P =.001, chi(2)) and for those children whose mothers had no college education (P =.018, chi(2)). In multivariate logistic regression modeling, "some suspicion" of abuse was associated with higher injury severity (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.7, 7.0), age <6 years (OR 2.9, 95% CI 1.5, 5.6), Medicaid or self-pay health care (OR 1.4, 95% CI 1.4, 5.3), practitioner identification of family risk factors (OR 4.8, 95% CI 1.6, 14.6), and more recent practitioner education about child abuse (OR 2.9, 95% CI 1.4, 5.8). CONCLUSION: Primary care practitioners reported some degree of suspicion that 21% of injuries they evaluated were caused by abuse. Patient factors and practitioner factors influenced their suspicion.     

Helmet use and the risk of neck or cervical spine injury among users of motorized two-wheel vehicles

OBJECTIVE: To quantify the effects of wearing a helmet on head and facial injury among users of motorized two-wheel vehicles and to determine if helmet use increases the risk of neck and cervical spine injury. DESIGN/METHOD: A population-based study involving injured riders from the Rh?ne Road Trauma Registry from 1996 to 2005. Victims were only included if they had an injury to a body region other than (or in addition to) the head, face, neck, or cervical spine. Thus, inclusion was not affected by helmet use by the rider. The risk of head, face, neck, and cervical spine injury was assessed, with helmet use as the exposure of interest using logistic regression analyses. Adjusted odds ratios and corresponding confidence intervals were calculated. RESULTS: Helmet use significantly decreased the risk of head and facial injuries. The adjusted odds ratios for non-helmeted riders were 2.43 (95% CI 2.05 to 2.87) and 3.02 (95% CI 2.48 to 3.67), respectively. There was no association between helmet use and the occurrence of neck or cervical spine injuries. The adjusted odds ratios for non-helmeted riders were 0.86 (95% CI 0.60 to 1.23) and 1.04 (95% CI 0.78 to 1.39), respectively. CONCLUSION: Helmets protect users of motorized two-wheel vehicles against head and facial injury without increasing the risk of neck or cervical spine injury.     

Prevention of agricultural injuries: an evaluation of an education-based intervention

OBJECTIVE: To evaluate the effectiveness of an agricultural health and safety program in reducing risks of injury. DESIGN: Cross-sectional survey. SETTING: 50 rural municipalities in the Province of Saskatchewan, Canada. INTERVENTION: The Agricultural Health and Safety Network (AHSN), a mainly educational program that administered 112 farm safety interventions over 19 years. SUBJECTS: 5292 farm people associated with 2392 Saskatchewan farms. Farms and associated farm people were categorized into three groups according to years of participation in the AHSN. MAIN MEASURES: Impact: self-reported prevalence of: (1) farm safety practices; (2) physical farm hazards. Outcome: (1) self-reported agricultural injuries. RESULTS: After adjustment for group imbalances and clustering at the rural municipality level, the prevalence of all impact and outcome measures was not significantly different on farms grouped according to years of AHSN participation. To illustrate, the adjusted relative risk of reporting no rollover protection on tractors among farms with none (0 years) versus high (>8 years) levels of AHSN participation was 0.95 (95% CI 0.69 to 1.30). The adjusted relative risk for agricultural injuries (all types) reported for the year before the survey was 0.99 (95% CI 0.74 to 1.32). CONCLUSIONS: Educational interventions delivered via the AHSN program were not associated with observable differences in farm safety practices, physical farm hazards, or farm-related injury outcomes. There is a need for the agricultural sector to extend the scope of its injury prevention initiatives to include the full public health model of education, engineering, and regulation.     

A population based case-control study of agricultural injuries in children.

OBJECTIVES: To identify preventable risk factors related to agricultural injuries occurring to children on family farms. SETTING: A geographically defined central region of Wisconsin, USA with nearly 1800 family dairy farms. METHODS: A two year, population based incidence study of occupational injuries among farm residents was conducted. For cases, trained staff abstracted information on the nature, severity, and treatment of the injury from the patient's medical record. Staff also administered a telephone questionnaire to cases and controls, usually answered by parents. RESULTS: There were 60 cases of farm residents younger than 18 years who sought care for acute agriculture related injuries. Farms on which uninjured children lived served as controls (n = 102). Multivariate analyses of 16 different variables revealed three significantly related to injuries to children: hours worked per week (odds ratio (OR) = 1.05; 95% confidence interval (CI) = 1.01 to 1.08); presence of disabled safety device (OR = 2.64; 95% CI = 1.10 to 6.35); and feeding cows by grazing (OR = 0.22; 95% CI = 0.06 to 8.83). CONCLUSIONS: Interventions designed to reduce the risk of agricultural injuries to farm children should acknowledge the participation of children as productive workers on the farm. Although education has been the standard method for encouraging safe practices in farm work, additional approaches, such as limiting the number of hours a child works, avoiding the disabling of safety devices, and using specific methods of managing cows, should also be adopted to minimize injury risks to farm children.     

Adverse Childhood Experiences: Translating Knowledge into Identification of Children at Risk for Poor Outcomes

ObjectiveTo pilot test a tool to screen for adverse childhood experiences (ACE), and to explore the ability of this tool to distinguish early child outcomes among lower- and higher-risk children.MethodsThis cross-sectional study used data collected of 102 children between the ages of 4 and 5 years presenting for well-child visits at an urban federally qualified health center. Logistic regression analyses adjusted for child sex, ethnicity, and birth weight were used to test the association between each dichotomized child outcome and risk exposure based on a 6-item (maltreatment suspected, domestic violence, substance use, mental illness, criminal behavior, single parent) and 7-item (plus maternal education) Child ACE tool.ResultsEffect sizes were generally similar for the 6-item and 7-item Child ACE tools, with the exception of 2 subscales measuring development. The adjusted odds of behavior problems was higher for children with a higher compared to a lower 7-item Child ACE score (adjusted odds ratio [aOR] 3.12, 95% confidence interval [CI] 1.34–7.22), as was the odds of developmental delay (aOR 3.66, 95% CI 1.10–12.17), and injury visits (aOR 5.65, 95% CI 1.13–28.24), but lower for obesity (aOR 0.32, 95% CI 0.11–0.92).ConclusionsBrief tools can be used to screen for ACE and identify specific early child outcomes associated with ACE. We suggest that follow-up studies test the incorporation of the 7-item Child ACE tool into practice and track rates of child behavior problems, developmental delays, and injuries.     

Injury prevention programmes in primary care: a high risk group or a whole population approach?

OBJECTIVE: To examine the relationship between risk factors for childhood unintentional injury and injury outcome and to assess the feasibility of using risk factors to identify children at high risk of injury. SETTING: One general practice in Nottingham, UK. METHOD: A postal questionnaire survey to all parents of children registered with the practice (n = 771) to obtain data on risk and sociodemographic factors. All children still registered with the practice one year later were followed up for occurrence of a medically attended injury. RESULTS: The response rate was 78%. The injury rate over the follow up year was 246 injuries per 1000 children. Previous medically attended injury was associated with each of the injury outcomes (odds ratio (confidence interval) for all attendances, 2.33 (1.37 to 4.05); for accident and emergency attendances, 2.27 (1.15 to 4.4); and for primary health care team attendances, 2.58 (1.33 to 5.0)). Male sex was associated only with accident and emergency department attendance (odds ratio 2.13 (1.06 to 4.2)). Maternal age and previous injury were associated with a higher number of injuries in the subsequent year on univariate and multivariate analyses. The sensitivity and positive predictive value of the risk factors were low, except for previous injury and male sex. The number of children needing an injury prevention intervention to prevent one injury as identified by the risk factors was not significantly different from that required if a whole population approach were to be used. CONCLUSION: Primary care based injury prevention programmes, at present, should not be targeted at children identified as being at 'high risk' of injury. Nevertheless, a larger study using a wider cross section of the population is needed to address this issue further.     

Sole parenthood and the risk of child pedestrian injury

Children of sole parents have the worst mortality record of all social groups. Road vehicle related injuries account for a large part of their excess mortality. In this case-control study the association between sole parent status and the risk of child pedestrian injury was examined. Cases (n= 258) were children killed or hospitalized as a result of a pedestrian injury in the Auckland region over a period of 2 years and 2 months. Controls were a random sample of the child population. The children of sole parents were at a significantly increased risk of injury (odds ratio = 1.57; 95% confidence interval (CI) 1.09, 2.27). However, there was a striking difference in the effect of sole parent status according to ethnic group. Among European families, sole parenthood was associated with a greatly increased risk of injury (OR = 3.13; 95%CI 1.84, 5.31), whereas in Pacific Island families sole parenthood was associated with a significant protective effect (OR = 0.40; 95%CI 0.18, 0.89). The protective effect of sole parent stalus in Pacific Island families may reflect the beneficial effects of the social support provided by extended family networks. Children of sole parents in the context of the nuclear family may be particularly vulnerable.     

Disturbed sleep: effects of sociocultural factors and illness

To assess the prevalence of sleep disturbance and associated risk factors, sleep patterns were analysed in 14,372 English and Scottish children. Approximately 4% of children aged 5 experienced disturbed sleep more than once a week, but this decreased to 1% from age 9. Less than 25% of the parents with an affected child consulted a doctor. Sleep disturbance was associated with persistent wheezing compared to non-wheezing children (odds ratio 4.42; 95% confidence interval (CI) 3.17 to 6.13), and more frequent in children of Indian subcontinent descent than in white children (odds ratio 2.20; 95% CI 1.34 to 3.60), and in children whose mother reached no more than primary education compared with those with higher education (odds ratio 2.41; 95% CI 1.51 to 3.84). Sociocultural factors associated with ethnicity and respiratory illness are important risk factors for sleeping disorders in childhood.