H3026- Section on Child Abuse and Neglect Program

How To Survive Identifying and Reporting Child Maltreatment

Topic: Child Abuse/Neglect

Sponsors: Section on Child Abuse & Neglect (SOCAN)

Monday, October 24
8:00AM - 12:00PM
Moscone West, 2022/2024

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It has been recognized that child maltreatment is an important toxic stress that can have lasting physical and mental health effects on a child (Adverse Childhood Experiences Study). Child maltreatment needs to be identified and recognized early to minimize the impact of this toxic stress. It is challenging, however, for busy physicians to efficiently and effectively address this issue. Physicians need an approach to identification of injuries in childhood and navigating the additional responsibilities of reporting, expert witness testimony, and self-care.

Moderator: Nancy Harper, MD
8:00AM The Abused Child
Rachel Berger, MD, FAAP
8:45AM Confrontation, Distrust, and Burn-out
Matthew Cox, MD, FAAP
9:30AM Promoting Resilience Within
Gena Castro Rodriguez, PsyD, LMFT
10:00AM Question & Answer Session
10:30AM Business Meeting and Award Presentation
11:00AM Scientific Abstract Poster Session
12:00PM Adjourn

Rachel Berger, MD, FAAP

Chief, Division of Child Advocacy, Children's Hospital of Pittsburgh of UPMC
Pittsburgh , Pennsylvania

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Gena Castro Rodriguez, Psy.D., LMFT

Chief of Victim Services and Parallel Justice Programs
San Francisco District Attorney's Office
San Francisco, California

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Matthew Cox, MD, FAAP

Child Abuse Pediatrician
St. Luke's Health Center
Boise, Idaho

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Faculty

Matthew Cox, MD, FAAP

Child Abuse Pediatrician
St. Luke's Health Center
Boise, Idaho

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1- Child Welfare Professionals’ Determination of When Certain Unsafe Activities and Lack of Child Protection Constitutes Child Neglect

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Purpose: Although laws provide guidelines for the evaluation of possible child abuse and neglect cases, the language and substance of child safety laws and guidelines varies greatly among states. The objective of this study was to identify factors that influence the determination of child neglect by child welfare experts, and develop some consensus regarding what constitutes child neglect with respect to child safety issues.
Methods: A survey was developed and distributed to members of the American Academy of Pediatrics Section on Child Abuse and Neglect (SOCAN). Respondents were requested to decide whether a particular scenario was child neglect with varying age of the child involved, and then with alterations in the scenario regarding the presence of injury to the child and the legality of the situation.
Results: Of 523 members, 152 have completed surveys to date. In a child left at home alone scenario, respondents were significantly more likely to declare child neglect for those 8-14 years of age if the child had been injured. In addition, for 10-14 year olds, SOCAN members were significantly more likely to declare child neglect if leaving that aged child at home alone was against the law. In a scenario where a loaded firearm was allowed to be accessible to children, the legality of the situation significantly affected the determination of child neglect for every age category. For a child who had possession of a loaded firearm in their home’s yard, 100% of the experts believed the situation constituted child neglect for those 4-8 years of age, and over 85% thought it was child neglect for children 10-14 years. No significant differences in child neglect determination were seen by sex, age, ethnicity, or child abuse and neglect certification possession.
Conclusion: Age of the child, presence of injury, and the legality of a situation affect how experts view a case of potential child neglect. This suggests that such cases may be evaluated differently across the nation due to varying state child safety laws, even though the risk to the child is the same. Moreover, a vast majority of experts indicated certain scenarios warranted child neglect designation, even when no current state laws regulated those particular situations. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and to better protect the safety of children.

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2- Garlic Poisoning: An Atypical Presentation of Non Accidental Trauma

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Introduction:
Over 650,000 children in the United States are subject to abuse and neglect each year with 4,500 children requiring hospitalization. Despite the prevalence of abuse, many cases are misdiagnosed or underreported. One possible reason for this is that the presenting signs and symptoms may be clouded by the clinical presentation. Several animal studies have shown that garlic extracts inhibits platelet aggregation. We describe a case of abuse with clinical manifestations secondary to forced garlic ingestion.

Case Report:
An 8-year-old previously healthy female presented to the emergency room secondary to becoming unresponsive at her home. On examination she was hypothermic with a temperature of 89°F and cachectic with profound ecchymosis throughout her body. Laboratory evaluation was significant for a platelet count of 14,000, hemoglobin 7.6, and INR 12.2. Serum glucose was 57, albumin 2.2, prealbumin 10, AST 66, and ALT 78. PT and PTT were within normal limits.

The patient revealed that she had been force-fed garlic and water as punishment for bedwetting. Poison Control was contacted and reported that though literature based on human trials is limited, animal studies indicate that garlic toxicity could cause the laboratory derangements observed with the patient. The caregivers later confessed to this and were subsequently taken into police custody.

Discussion:
Nonaccidental trauma (NAT) is form of child abuse with a mortality rate of 30%. Physicians may initially misdiagnose non-accidental trauma due to an unclear history pertaining to the child’s clinical manifestations. When presented with a history that appears inconsistent with the extent of a child's injuries, a physician should be suspicious for abuse. The diagnosis of NAT is based on a comprehensive clinical assessment including history, physical examination, and laboratory and radiographic evaluation. Management should be multidisciplinary with the aim of correcting the underlying organ dysfunction and rehabilitation.

Garlic is part of the Allium species that contains compounds when, taken in excess, cause oxidative hemolysis. This in turn inhibits platelet aggregation through direct interaction with fibrinogen receptors of platelets. The literature of garlic toxicity is limited though studies by both Bordia et al. and Mohammed et al. with human and dog subjects respectively showed significant inhibition of platelet aggregation with 10-25 mg of garlic extract. Furthermore in animal studies garlic toxicity has been shown to manifest in hypoglycemia, hypotension, and transaminitis through loss of liver proteins.

Conclusion:
Physicians play an important role in the recognition and management of NAT. This includes having a high suspicion for abuse especially when the clinical picture does not match the reported history. Our case highlights that child abuse can present in many forms though with continued education and awareness, the goal remains to prevent future cases of abuse from occurring.

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3- Nervous System Dysregulation and Its Association with Traumatic Events

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Background: Medically unexplained symptoms commonly present to pediatricians with no apparent cause following extensive investigations. Such patients frequently present with multiple chronic symptoms including memory problems, insomnia, dizziness, digestive problems and variable somatic complaints such as headache and muscle pain.
Objective: This study aims to characterize the symptom profile of children presenting with multiple medically unexplained symptoms. We hypothesize that these symptoms reflect a maladaptive stress response and dysregulated nervous system due to chronic stress following a trauma event.
Methods: Study patients were identified from a university-based weekly outpatient Child Neurology clinic between June to September 2015. Patients were included if they were >2 years of age, with >/= 4 medically unexplained symptoms. Children with developmental delay were excluded. Symptoms were grouped under the following categories: 1) executive dysfunction, 2) sleep disturbance, 3) autonomic dysfunction, 4) somatization, 5) digestive problems, and 6) emotional dysregulation. Trauma history was obtained from a detailed social history in all patients.
Results: Out of 100 consecutive patients, 17 were included; 12 females, median age 14 years (range 5-17 years). All patients experienced at least one symptom in each of the following categories: sleep disturbance, autonomic dysfunction, somatization and emotional dysregulation, while 82% exhibited executive dysfunction, and 59% had digestive problems. Fifteen patients (88%) disclosed a history of trauma including domestic violence, parental substance abuse, physical or sexual abuse, bullying, or medical trauma, compared to 17% of controls (p < 0.0001).
Conclusions: In a consecutive cohort of patients from a university-based outpatient Child Neurology clinic, children with multiple medically unexplained symptoms accounted for 17% of the clinic population. We propose the term “nervous system dysregulation” to describe children with multiple medically unexplained symptoms involving at least one symptom in each category of 1) sleep disruption, 2) autonomic dysfunction, 3) somatization, and 4) emotional dysregulation. Children with this symptom profile are likely to have a history of traumatic events, suggesting that symptoms may arise from chronic activation of the physiological stress response system. Nervous system dysregulation should alert the physician to a possible history of psychological trauma as a cause for symptoms to reduce the morbidity associated with unnecessary medical procedures, and pursue appropriate therapy.

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4- Non-accidental Trauma Presenting as Esotropia in a 6 Month Old Infant

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Introduction
A 6-month-old male presented to the Emergency Department (ED) due to left sided esotropia that was discovered 5 days prior. Family sources reported that the patient had experienced trauma 13 days before after an older sibling had fallen during a diaper change and struck him on the head. The patient was found to have bilateral 6th nerve palsy, subacute subdural hemorrhage in the right frontal lobe, and multiple healing fractures. The case was ruled as a non-accidental head trauma and demonstrates the importance of conducting a thorough workup for any abnormal neurological findings.
Case Report
The patient is a 6-month-old male who presented to the Emergency Department with concern due to left eye crossing. The left eye esotropia had occurred 5 days ago. Family reported that 13 days prior, an older sibling had fallen during a diaper change and struck the 6 month old in the head. However, at the time, the family claims there was no trauma to the patient's left eye. They also denied any changes in behavior, lethargy, vomiting, or seizures. They reported the in turning of the left eye had occurred 8 days after the trauma incident. Physical exam findings consisted of esotropia of the left eye, poor response to light, pupils unequal, and poor eye tracking. Ophthalmology was soon consulted and reported bilateral abduction deficits and left eye esotropia. The abduction deficits were likely due to bilateral 6th nerve palsy. Ophthalmic exam also expressed optic neuropathy and vitreous hemorrhage of the left eye, as well as retinal hemorrhage of the right eye.
A head CT and facial bone workup revealed a subacute subdural hemorrhage in the right frontal lobe. A skeletal survey was conducted that revealed subacute, healing fractures of the bilateral proximal tibias and fibulas, as well as a healing right distal radial buckle fracture.
An MRI revealed bilateral subdural hematomas of mixed ages. Due to the multiple findings of unaccidental trauma present, the patient was discharged in Department of Human Services (DHS) custody.
Discussion
Esotropia is the inward deviation of one or both eyes toward the nose. Only 1-2% of estotropia in infants is congenital, termed infantile esotropia. Most conditions of esotropia in infants are due to a 6th cranial nerve palsy. The most common cause of 6th cranial nerve palsy in children is due to trauma.
Conclusion
Obtaining a thorough history and conducting a thorough exam is the most important factor when dealing with 6th cranial nerve palsies. Cranial nerve palsies can present as the first sign of serious conditions such as brain tumors, vascular disorders, or non-accidental trauma as seen in this case. Non-accidental trauma should be considered in non-ambulatory children with signs and symptoms of conditions related to trauma.

Left Sided Esotropia
6 month old with acute onset of left sided esotropia of unknown etiology.

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5- Jacobi, Smith, Caffey, Fontana: A History of Child Abuse Pediatrics in New York City

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Background: The history of child abuse pediatrics in New York City reflects the development of medicine as a profession influenced by social movements reacting to poverty, economic exploitation, and child maltreatment. As physicians began to specialize in caring for children, they recognized that children were a vulnerable class affected by special medical problems and diseases, but even more affected by poor social conditions which were sometimes confounded by abuse and neglect from their parents and caregivers. As the magnitude of social problems became apparent, physicians began to actively speak out and to advocate for entire vulnerable populations, using their wisdom in science and their public stature to more effectively shape societal responses based on evidence and the child’s perspective.
Hypothesis/Objectives: We sought to identify and describe the physicians who addressed child maltreatment in New York City and who developed multidisciplinary responses to protect children before the development of the specialty of Child Abuse Pediatrics. Our objectives were to learn more about: (1) the personal and professional characteristics of our “Founding Fathers”, (2) the development of the specialty, and (3) how the work of child abuse pediatricians has been integrated into the community response to child abuse and neglect.
Methods: We reviewed primary and secondary historical sources at the NY Society for the Prevention of Cruelty to Children, the New York Academy of Medicine, the NYU School of Medicine Archives, the American Board of Pediatrics, and the American Academy of Pediatrics. We constructed biographies and timelines showing the interplay their careers with newsworthy child abuse cases, social movements, and policy changes affecting children and child abuse physicians in New York City.
Results/Conclusions: Abraham Jacobi, Job Lewis Smith, John Caffey and Vincent Fontana each made distinct contributions to our understanding of child abuse and neglect, and each had personal and professional characteristics which can inform future generations of child advocates and child abuse pediatricians. Jacobi and Smith were Founding Fathers for Pediatrics; Caffey is the father of Pediatric Radiology, and Fontana lead the integration of medicine into the foster care and child welfare systems. Each interacted differently with their community and faced the unique challenges presented by New York City in different ways. These physicians rose to these challenges to make major contributions to the development of pediatrics and child abuse pediatrics in New York City and the world.

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6- Pediatricians Preventing Child Abuse

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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BACKGROUND: In 2010, the American Academy of Pediatrics (AAP) published a clinical report titled “The Pediatrician's Role in Child Maltreatment Prevention,” which outlines what the pediatrician can do to assist in preventing child abuse. The report addresses how pediatricians can recognize risk factors and provide anticipatory guidance with regards to child abuse and its related topics.
OBJECTIVE: To survey how many pediatricians are providing education to caregivers regarding child abuse prevention, including topics of physical abuse, infant crying, intimate partner violence (IPV), depression, discipline, and sexual abuse.
DESIGN/METHODS: Survey questions were created to address most of the topics listed under the “Guidance for the Pediatrician” section of the article. The Georgia Chapter of the AAP sent email invitations to its members requesting their participation. An email was also sent to the Emory University School of Medicine pediatric residents. There were a total of 74 participants. A link to the AAP clinical report was provided at the end of the survey.
RESULTS: The majority of pediatricians who completed the survey were general pediatricians who have been in practice for more than 10 years. Although most pediatricians were only slightly familiar with the AAP clinical report, they agreed that focusing on topics related to child abuse, relative to other topics, was very important. Eighty-one percent of respondents reported feeling prepared to discuss child abuse issues with caregivers. However, most (70%) stated that additional training was needed. There were risk factors that pediatricians routinely addressed, including inquiring about a support system, toilet training expectations, effective forms of discipline, and safe/unsafe touch. Pediatricians asked about a family history of physical abuse, sexual abuse, substance abuse, and infant crying when a need was perceived. Although pediatricians selectively inquired about IPV and maternal depression, the majority of pediatricians knew how to respond to reports of each (74% and 88% respectively).
CONCLUSIONS: There are a variety of barriers that pediatricians face in regards to providing anticipatory guidance in practice. Increased knowledge and training may help to resolve certain issues and empower physicians to ask difficult questions related to child abuse.

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7- Systematic Review of Pediatric Health Outcomes Associated with Adverse Childhood Experiences (aces)

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Purpose
When children are exposed to Adverse Childhood Experiences (ACEs), their biological stress response is chronically triggered, altering brain architecture and causing long-term harm to their developing bodies. Left unaddressed, this toxic stress response can have serious long-term health effects on children as well as impact educational, social, and economic outcomes. Early detection, therefore, has powerful potential to improve the health and wellbeing of children. Identification and diagnosis are currently limited, however, by gaps in understanding of the clinical response to ACEs in children. A systematic review of pediatric health outcomes associated with ACEs was conducted to help develop a clinical risk profile of children affected by toxic stress.

Methods
PubMed, PsychINFO, and CINAHL were searched for full text studies investigating adverse childhood experiences published in English between January 2001 and December 2015. The terms “early life”, “adolescent”, “child”, “infant”, “youth”, “childhood”, “prenatal”, “in utero” were used in conjunction with “divorce”, “parental incarceration,” “parental depression,” “abuse,” “neglect,” “adversity,” “maltreatment,” “toxic stress,” “allostatic load,” and “adverse childhood experience.”

Abstracts were reviewed to identify articles investigating the relationship between exposure to ACEs and biological or health outcomes. Articles were excluded if they were not in English, if the study was on animals, if the article was a case report/series, if exposure was not an ACE, if the abstract was not available, if the exposure was in utero only, if the study only had mental or behavioral health outcomes, if the study did not have relevant biological or health outcomes, if the study investigated the direct effect of the ACEs (e.g., abusive head trauma), if the study investigated the indirect effect of the ACE (e.g., ACEs moderating the effect of genetic predisposition to mental health outcome), if the study was qualitative, or if the article was a review.

Results
Of 19,230 non-duplicated articles, 1216 articles were identified that investigated the relationship between ACE exposure and biological or health outcomes. Of these, 393 had outcomes in children. Biological changes in children were primarily neurological (e.g., gray matter volume) and hormonal (e.g., cortisol). Clinical outcomes were primarily neurologic (e.g., executive function).

Conclusion
Children affected by ACEs manifest alterations in biology and health in distinct ways. A standardized pediatric risk profile would allow for more precise diagnosis and effective treatment of children affected by ACEs.

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8- The Effects of Abuse and Substance Use on Emergency Department Visits and Hospital Admissions Among Child and Adolescent Patients

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Purpose: Psychosocial factors, stressors, and life events have been shown to affect medical and mental health outcomes among children and adolescents. The purpose of this study was to determine which factors had the strongest association with increased psychiatric emergency department (ED) visits and admissions for children and adolescents.

Methods: 600 charts of patients 18 and under, seen in the psychiatric ED from January 2014 through December 2014, were retrospectively reviewed. 571 charts had complete data sets and were used for analysis. Sociodemographics, family composition, education, social history, diagnoses, ED visits and inpatient admissions was collected. Descriptive statistics, chi-square tests and independent t-test analyses were utilized to examine differences in the sample to determine which factors affected ED visits and admissions.

Results: The sample was 50% female, 35.2% self-identified black, and had a mean age of 13 years. The majority, 85%, went to public school and 17% were in special education. Attention Deficit Hyperactivity Disorder 132(23%) was the most common admitting diagnosis. Most patients came from single parent household 305 (53%). The mean ages for sexually active patients, patients with legal issues, and patients reporting marijuana substance abuse were 15, 14.35, and 15 years respectively. Patients from two biological parent households had significantly fewer ED visits (1.2 vs. 1.7, p < 0.01) and admissions (0.09 vs. 0.26, p < 0.01). Among social factors, those who reported sexual, physical or emotional abuse had a significantly greater number of ED visits (2.1 vs. 1.5, p < 0.01) and admissions (0.61 vs. 0.14, p < 0.01) than those who did not. Patients that were sexually active or had legal issues or substance abuse with marijuana had a significantly greater number of admissions (0.43 vs. 0.17, p < 0.01), (0.54 vs. .18, p < 0.01) and (0.46 vs. 0.18, p < 0.01) respectively.

Conclusion: This data supports that a two parent home is stable. Dual parenting can create a safe space in which a child can develop; this is shown by the decrease in psychiatric ED visits and admissions in patients from two parent households. This highlights the psychological protective role of a two parent household. Abuse is traumatic and triggering, and can exacerbate existing psychiatric illness or initiate the onset of new disease. Substance abuse and legal issues result in early induction to the criminal system. This causes an increase in frequency of visits and severity of symptoms. Only marijuana was found to correlate with higher incidence of psychiatric ED visits; other illicit substances, while reported, did not have similar correlation. This may speak to the psychotropic nature of tetrahydrocannabinols and their role in mental illness. This study demonstrates the psychosocial factors that lead to increased ED visits and admissions in children and adolescents.

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9- Preparing to Interact with the Legal System Using Game-based Learning

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Purpose:

Child maltreatment (CM) is a widespread problem in children and youth. Pediatricians and health professionals involved may be required to interact with child welfare authorities and the court system; arenas in which they may be unfamiliar. Professionals often have little experience in reporting suspected CM and frequently don’t feel prepared to provide court testimony. Even for those specializing in CM, stress surrounding court appearances is reported. Exposure to and familiarity with this element of practice could increase comfort and competence.

Games are an established and effective teaching method. However, evidence for game-based learning among health professionals is limited. Our objective was to assess the satisfaction with and perceived learning from a game-based tool designed to assist with preparation for court.

Methods:

A board game with content developed by an expert CM group was created. Game content, in the form of questions and tasks, reflected knowledge and skills required by the court system. Attendees at a session on ‘preparing for court’ at a national Child Maltreatment Symposium played the game for one hour. An anonymous post-session survey was completed to assess participants’ satisfaction and perceived learning. Responses to questions on a 5-point Likert scale were coded and analyzed using descriptive statistics. Qualitative comments were analyzed and grouped by emerging themes. Subgroup analysis was completed using participant demographic factors.

Results:

Forty-three of the 58 players completed a survey yielding a response rate of 75%. Thirty-four respondents (79%) self-identified as a pediatrician or Child Abuse pediatrician, 9% (n=4) were trainees and 12% (n=5) were allied health practitioners. Over half of the respondents were between the ages of 25-45 (n=22). The mean number of years in practice was 19 (range; 2-46). Respondents most often “agreed” that the game was: useful for learning (88%), helped link knowledge to practice (56%) and met their educational needs (68%). The vast majority of respondents “agreed” or “strongly agreed” (70%) they would participate in a similar session in the future. When asked to compare the game experience to prior educational sessions about court, respondents most often “agreed” or “strongly agreed” (81%) that the game held their attention better. Qualitative feedback, in the form of exemplar quotes also supported respondents’ satisfaction with the game as a learning tool. The impact of the game experience varied by some sub-factors related to overall professional experience and experience with child maltreatment pediatrics.


Conclusion:

These results suggest that game-based learning is an effective and positively accepted method of learning about court. Similar game based interactive sessions may be useful for education in other areas with limited preparation options and opportunities for practical experience.

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10- Influence of Weather Severity and Other Risk Factors on the Incidence of Nonaccidental Trauma

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Purpose:
To identify the demographic, situational, socioeconomic, and meteorological factors that characterize patients presenting to the ER with suspected NAT. Furthermore, to utilize this data to develop a standardized intake assessment tool to identify at risk families and facilitate focused intervention/prevention.

Methods:
Data on patient demographics, situational factors, socio-economic factors and weather patterns at the time of injury were gathered from medical records of 277 patients evaluated for possible NAT from 2007 to 2014. Chi-square and Fisher’s exact test were used to examine possible associations between these factors and the presence of NAT.

Results:
Patient age had a significant impact on the likelihood of NAT (p = 0.022) – almost 64% of children older than two years old who were evaluated were actually found to have NAT. The mechanism of injury significantly correlated with a case being found to be NAT (p = 0.000) -- 58.1% of cases with an unknown or unclear history were determined to be NAT, and the vast majority (90 to 100%) of thoracic, intraabdominal, and eye injuries (retinal hemorrhage, retinoschisis, and subconjunctival hemorrhage) were deemed NAT. The person in whose custody the injury occurred strongly correlated with the diagnosis of NAT (p = 0.000). A case was more likely to be NAT when the injury occurred while in the care of an unrelated adult: 74.0% (37 of 50) compared to only 39.6% of children in the care of a related adult (78 of 197). There were fewer cases of NAT seen in patients living with both parents compared to those with a single parent (33.9% and 53%, respectively), p = 0.010. Patients with mothers under the age of 25 represented a greater proportion of NAT cases when compared to patients with mothers older than 25 (70.2% vs. 43.8%), p = 0.014. Overall, February had the highest number and greatest proportion of cases deemed to be NAT, while July had the lowest, p = 0.044. On average, February also corresponded with the month that had the greatest number of days with snowfall and days of significant snow depth on the ground (16 days and 79 days, respectively).

Conclusion:
Our study’s findings identified several NAT potential risk factors: patient age, biologic relationship of caregiver at time of injury, mechanism of injury, and maternal age less than < 25 years. The month of the year at the time of injury also correlated with NAT, although a definitive link between the two remains to be found. These risk factors for NAT that might be incorporated into a standardized assessment as a means of identifying those at-risk families in need of preventative intervention.

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11- Are Supracondylar Fractures of the Elbow in Children Caused by Child Abuse?

Monday, October 24
11:00AM - 12:00PM
Moscone West, 2022/2024

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Purpose: Previous authors have reported that skull, rib, and corner fractures, and fractures in young children who have not started walking are highly associated with abuse. The purpose of this study is to determine the epidemiology, etiology, and relationship of supracondylar elbow fractures with child abuse.
Methods: 75 consecutive displaced supracondylar elbow fractures were reviewed to determine specific information about the manner in which the injury occurred. Medical records and radiographs were analyzed for demographic and injury data.
Results: 42 males and 33 females were studied. The average age was 6 years (range: 1 year 4 months - 12 years 4 months). 2 patients were 12 years of age, 3 were 23 years of age, and 70 were older than 3. The left elbow was fractured in 60% of cases. 87% were right hand dominant, 9% were left hand dominant, and 4% were too young to determine handedness. 58% injured the non-dominant arm. 31% were Gartland Type 2 and 69% were Gartland Type 3 fractures. 1 fracture was open. 11% presented with a pucker sign, 11% presented with a nerve palsy, and 5% presented without a pulse. 9% presented with an additional ipsilateral distal radius fracture. 85% were transferred from 27 different outside hospitals in 17 counties, while 15% presented directly to the ED. 47% of fractures occurred at home, 40% on the school grounds, 5% in a gymnasium, 5% in a park, 1% at a farm show, and 1% in a parking lot. 24 fractures were treated between midnight and 8am, 15 were treated between 8am and 5pm, and 33 were treated between 5pm and midnight. All fractures stemmed from a fall: 39% from playground equipment, 13% off furniture, 11% from standing, 8% playing sports, 4% down stairs, 4% from a bicycle, and 32% were miscellaneous (i.e. sled, bounce-house, ATV, go-cart, etc.). The average time from injury to a call for transfer: 3 hours 5 minutes; transfer acceptance to arrival in ED: 2 hours 1 min; arrival in ED to OR: 5 hours 14 min; injury to OR: 10 hours 20 min; time to discharge: 16 hours 39 min. Multiple medical professionals including outside ED physicians and orthopaedic surgeons, local ED physicians and orthopaedic surgeons, residents, and nurses evaluated each patient. Only 1 patient, the youngest patient in the cohort at 1 year 4 months, injured from a fall at home, was reported for possible abuse and the evaluation was negative.
Conclusion: Pediatric supracondylar elbow fractures occur from accidental falls while children are at play. The mechanism involves a fall on the outstretched hand, hyperextension of the elbow, and fracture of the humeral cortex at the supracondylar location. In this population, child abuse was rarely associated with supracondylar elbow fractures.

Mechanism of Supracondylar Elbow Fracture
Illustration of the etiologies of how each supracondylar elbow fracture occurred in this 75 patient cohort. "Other" includes falls from a toy ball, sled, tree, wagon, fence, bounce house, mini-van, deck, battery-powered toy car, and go-cart.

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Andrea Ali-Panzarella, DO, MPH, FAAP

Fellow, Child Abuse Pediatrics
Emory University School of Medicine
Atlanta, GA

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Jerome Anyalebechi

Case Western Reserve University School of Medicine
Cleveland Heights, OH

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Jorina Elbers, MD, MS

Assistant Professor of Neurology
Stanford Children's Health
Palo Alto, CA

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Anil George, MD

Resident Physician
University of Kentucky, Department of Pediatrics
Willowbrook, IL

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Debora Oh, MSc, Phd

Research Associate
Center for Youth Wellness
San Francisco, California

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Vincent Palusci, MD, MS

Professor of Pediatrics
NYU School of Medicine
New York, New York

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Paige Pasquali, BS

Medical Student-third year
The University of Oklahoma College of Medicine
University of Oklahoma College of Medicine
Oklahoma City, OK

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John Rinaldi, BS

Medical Student
Penn State Hershey College of Medicine
Pittsburgh, PA

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Laura Stymiest, MD

PGY2
Dalhousie University
Halifax, NS, Canada

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Lalanthica Yogendran, MD

Resident
Richmond University Medical Center
New York, NY

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Bianca Batista

Stanford Children's Health
Palo Alto, CA

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Ryan Brown, MD

Associate Clinical Professor
University of Okalhoma College of Medicine/The Children's Hospital at OU Medical Center
Moore, Oklahoma

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Erin Evans, BS

University of Iowa Carver College of Medicine
Iowa City, IA

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Manassa Hany, MD

Richmond University Medical Center
Staten Island, NY

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Petra Jerman, PhD, MPH

Center for Youth Wellness
San Francisco, California

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Karen Lidsky, MD

Department of Pediatrics, Rainbow Babies and Children’s Hospital – University Hospitals
Cleveland, OH

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Margaret McHugh, MD, MPH

Associate Professor
NYU School of Medicine
New York, NY

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Amy Ornstein, MDCM, FRCPC, MSC

IWK Health Centre, Dalhousie University
Halifax, NS, Canada

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Asha Shenoi, MD

Assistant Professor
Department of Pediatrics, Division of Pediatric Critical Care
Lexington, KY

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Benjamin Chaucer

St. George's University SOM
Staten Island, NY

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Alycia Karsjens, MSW, LMSW

University of Iowa Hospitals and Clinics
Iowa City, IA

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Lolita McDavid, MD

Department of Pediatrics, Rainbow Babies and Children’s Hospital – University Hospitals
Cleveland, OH

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Robyn McLaughlin, MD, FRCPC

IWK Health Centre, Dalhousie University
Halifax, NS, Canada

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Sara Silvério Marques, DrPH, MPH

Director of Policy
Center for Youth Wellness
CA, CA

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Michael Dingeldein, MD

Department of Pediatric Surgery, Rainbow Babies and Children’s Hospital – University Hospitals
Cleveland, OH

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Kadiatou Koita, MD, MSc

Research Assistant
Center for Youth Wellness
San Francisco, California

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Resmiye Oral, MD

University of Iowa Department of Pediatrics
Iowa City, Iowa

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Saira Pasha, MD

Richmond University Medical Center
Staten Island, ND

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Edward Barksdale, MD

Department of Pediatric Surgery, Rainbow Babies and Children’s Hospital – University Hospitals
Cleveland, OH

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Allison Ipsen

Center For Youth Wellness
San Francisco, CA

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Simar Kaur, MD

Richmond University Medical Center
Staten Island, NY

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Christopher Janusz, MD

Richmond University Medical Center
Staten Island, NY

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Anne Kim, MD, MPH

Department of Pediatric Surgery, Rainbow Babies and Children’s Hospital – University Hospitals
Cleveland, OH

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Sukhdip Purewal, MPH

Research Associate
Center for Youth Wellness
San Francisco, CA

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Monica Bucci, MD

Director of Research
Center for Youth Wellness
San Francisco, California

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