Given location and relative rarity, anogenital injuries in children often prompt concern for maltreatment. We present a case of localized intravascular coagulopathy as a complication of venous malformation, which mimicked abusive trauma leading to an evaluation for maltreatment. Comprehensive assessment identified the underlying medical cause. This case represents an example of the importance of objective assessment in unusual case presentations to ensure diagnostic accuracy, and appropriate direction of medical and child protection resources.
Amidst the opioid crisis, acute pain management in pediatric trauma is complicated by the fact that children respond differently to pain than adults. This is largely due to incomplete development of neural networks and immature mechanisms in verbalizing distress. Much of the literature emphasizes that adequate and timely analgesic relief in pediatric patients is necessary to avoid complications of chronic pain. This article analyzes current strategies in nonpharmacologic and pharmacologic alternatives to opioid management in the setting of pediatric trauma. We also acknowledge that, albeit having a lower incidence than in the adult population, opioid use disorders (OUD) are a serious consequence of narcotic prescriptions in adolescent patients, and emergency and primary care providers must remain vigilant of the signs and symptoms of OUD.
When a child presents to the emergency department with injuries concerning for abuse, a complete evaluation must look beyond the patient's physical exam to identify potential sources of harm as well as protective factors in the family's psychosocial environment. Here we discuss a structured, evidence-based assessment tool designed by our research team for use in its complete form by social workers (when available), or in its abbreviated form by licensed independent practitioners. Even amidst the controlled chaos of the acute care setting, providers can utilize trauma-informed communication strategies to effectively and efficiently elicit an unbiased narrative of relevant historical information and key psychosocial risk factors in the patient's home environment. Without understanding the contributory role of each component to the child's overall risk of abusive injury, it remains difficult to address the root cause of the problem, and the door is thus left open for ongoing harm.
The COVID-19 pandemic has created conditions which heighten risk for child abuse. As key players in times of crisis, pediatric emergency medicine providers must be equipped with the tools to recognize, respond to, and mitigate risk of child abuse. An exploration of the scientific literature, stakeholder organization reports and lay press was undertaken to understand the impact of large-scale U.S. crises, including infectious disease, financial downturn, natural disaster, and violence, on child abuse risk and inform prevention strategies. Review of the literature suggests a relationship between crises and child abuse risk, though gaps in the research remain. We outline the role of pediatric emergency medicine providers in partnering with communities in organizing and advocating for systems that better protect children and strengthen families.
Bruising is a common finding in children presenting to emergency departments and can result from either accidental or abusive trauma. In physically abused children, bruising often precedes other, more severe injuries. Key features can help distinguish normal childhood bruising from bruising concerning for physical abuse, which can guide an appropriate medical workup and help ensure child safety. This review will cover bruising features associated with physical abuse. A child's age and developmental capabilities relate to the likelihood of bruising being due to physical abuse. Features specific to the bruising itself are also significant. Bruising location, as well as the pattern and number of bruises are relevant in assessing injury plausibility. A careful medical assessment with consideration of alternate diagnoses is critical in thoroughly evaluating the likelihood of abuse. Laboratory and radiographic studies can help identify potentially contributory underlying medical conditions as well as injuries that may not be apparent on physical examination.
In this case report, we present an 8-day-old female with failure of midline fusion, also known as perineal groove, that was mistaken for trauma from acute sexual assault and provide a review of the literature to improve the recognition and management of this condition. Failure of midline fusion is a rare congenital anomaly that has not been well studied and may mimic trauma from sexual assault. Therefore, a thorough understanding of the characteristics and clinical presentation of this entity may help medical providers differentiate failure of midline fusion from injury. Clinical awareness of failure of midline fusion needs to be improved through further study of its incidence, prevalence, pathogenesis, natural history, work-up, and treatment.
Abusive head trauma is a specific type of child maltreatment associated with high morbidity and mortality rates that can be challenging to diagnose as there is often no history or a fabricated one. Including the diagnosis in a differential requires a high level of suspicion from frontline providers especially when the clinical presentation is subtle as signs and symptoms can mimic other common conditions in pediatrics. This may result in a delayed or missed diagnosis. A thorough and comprehensive history and physical exam and complete documentation are essential for timely diagnosis. Consultation with a child abuse pediatrician is recommended if available. This article reviews current knowledge of the epidemiology, presenting signs and symptoms, clinical findings, and differential diagnosis of abusive head trauma with a focus on relevant information for the emergency department care provider.
The Ann & Robert H. Lurie Children's Hospital of Chicago identified issues with team communication, consistency of services provided, and continuity of care within the sexual abuse and assault program in the emergency department (ED) which necessitated improvement efforts. The aim of this project was to engage an interdisciplinary team to define and delineate roles and streamline clinical workflows from ED presentation to nonacute follow-up. An interdisciplinary team was convened and utilized quality improvement methodology to complete a current state analysis, develop a future state design, and prioritize interventions for improvement. The project team focused on four interventions: (1) establish a team approach with delineated roles and responsibilities; (2) develop and implement consistent workflows to reduce unwarranted variation in care; (3) expand education on the sexual assault nurse examiner (SANE) program more broadly to the care teams in the ED; and (4) implement clinical decision support (CDS) tools to streamline the continuum of sexual assault services provided. Three of the interventions (all but education) were carried out as a comprehensive care guideline for patients presenting to the ED for evaluation. The ED implemented this care guideline in August 2019. The utilization of quality improvement methodology was effective in ensuring an organized, interdisciplinary team response for the evaluation of pediatric and adolescent sexual abuse and assault in the ED. It enabled strong buy-in from team members and ownership of the process with anticipated improvements in patient care and experiences.
Child abuse is a common and morbid condition that is frequently identified in the emergency department, but emergency departments far outnumber specialized child abuse pediatricians. The small size and slow growth of child abuse as a specialty requires innovative approaches to ensure that specialized services are available to all children who may have been abused. This review covers the history and core concepts of telemedicine in child abuse pediatrics, highlighting services including live patient visits, advice and consultation, and retrospective peer review. We describe a deliberate approach to establishing a telemedicine program. Training and practice help establish new competencies in this form of medicine. Evaluation and sound business planning lead to sustainable and positive change. We also discuss challenges unique to child abuse telemedicine including confidentiality, security, provider engagement, and specialized training. Child abuse is a common and pervasive problem whereas child abuse pediatricians are both few and far between. Telemedicine may provide a solution to problems of availability and distribution within our specialty.
Cannabis is the most commonly used illicit drug in the world. The use of cannabis continues to evolve, as it is available in a growing variety of forms and changing potencies. At the time of this writing, eleven states and the District of Columbia have legalized recreational cannabis use for adults. Studies of pediatric cannabis exposure after legalization have demonstrated an increase in related emergency department visits. Here we review some of the ways that pediatric cannabis exposure may present to the emergency care clinician, including accidental exposure, intentional exposure, drug facilitated sexual assault, commercial sexual exploitation of children, and caregiver use and impairment. We also review the ways in which substance abuse and child maltreatment intersect and illustrate how these examples of pediatric cannabis exposure should prompt consideration of child maltreatment.
Childhood fractures are a common reason for presentation to the emergency department. Fractures are also an important manifestation of child maltreatment. Therefore, it is critical that healthcare providers understand historical, biomechanical, physical examination, and psychosocial factors that can help differentiate abusive skeletal trauma from accidental injuries and recognize other contributors such as metabolic bone disease. As fractures may not be apparent based on history and examination alone, medical providers with concern for abusive injury in young children should understand when and how to evaluate for occult skeletal and other injuries. While no fracture location is pathognomonic for abuse, certain fracture types have high specificity for abuse and therefore knowledge of their radiologic appearance, mechanism of injury, and association with maltreatment is essential. This article will review current knowledge on the topic of child abuse considerations when children present with fractures.
While injury is the leading cause of death for children, unlike many other fatal disease states injury is also particularly amenable to prevention efforts to decrease its morbidity and mortality. Pediatric emergency medicine physicians have a particularly important vantage point from which to craft and deliver injury prevention interventions. Here we interviewed successful physician advocates in order to summarize collective wisdom for those interested in increasing their own advocacy work or simply wanting to best support those who are. Key themes included the importance of each of the following; clinical experience informing advocacy efforts, use of multiple streams of data to drive research, frequent reassessments of efforts, overcoming funding obstacles, combined interventions, building trust in the community, and learning from previous successes. In addition, experts offered specific advice for advocacy at the individual, community, and national level. All physicians should seek to include advocacy, or the support of advocacy efforts, in their own practice. By seeking out the wisdom of experts we can identify the methods most likely to be effective in changing behaviors and ultimately decrease the impact of injury on our pediatric patients.
Transgender and gender-expansive (TGE) youth represent a diverse population with unique health needs. Inadequate education and training in gender-related health hamper pediatric emergency medical providers' ability to offer affirming care to TGE youth. Increasing staff education and competency and advocating for welcoming spaces and inclusive practices are ways that emergency medical care providers can offer culturally affirming clinical care to patients and families. Additionally, emergency medical providers can play key roles in advocating for improved health care for TGE youth both within and outside of their health organization.
Neglect is the most prevalent form of child maltreatment. Neglect can lead to serious medical issues requiring emergency department care including injuries, ingestions, decompensation of chronic illnesses, and urgent behavioral health concerns. Knowledge of different types of neglect, and of how each type could result in an emergency department (ED) visit could help clinicians to recognize and respond to neglect. This review will outline supervisory, medical, dental, emotional, and physical neglect. Children could also present to the ED for evaluation after a substantiated report for neglect. Therefore, this review also covers important elements of medical evaluations for children who have experienced neglect. Neglect is the most common reason for foster care placement, and considerations for emergency medicine providers caring for children in foster care are outlined. Avenues for prevention of neglect in the ED setting are also discussed.
Advocacy is a vitally important activity as it applies to all aspects and settings where pediatric care is provided. Advocacy also offers a forum for scholarship, professional and layperson education, mentorship and research. In this issue of Clinical Pediatric Emergency Medicine we explore different topics in pediatric emergency medicine, and examine how we can use our patient care experiences and our position as health care providers to advocate for the well-being of children both inside and outside of the hospital.
More than 80% of pediatric patients who seek emergency care in the United States are seen in general emergency departments. Yet, emergency care systems evolved to address time-sensitive adult-focused conditions such as trauma, stroke, and myocardial infarction, not pediatric-specific needs. Yet, children with emergency conditions also experience significant morbidity and mortality when not managed safely and effectively. This article details the development of emergency care systems and the impact of advocacy efforts on pediatric emergency care, including authorization of the Emergency Medical Services for Children Program. Although significant strides have been made to ensure every emergency department has the infrastructure and competency to care for pediatric patients, high-quality pediatric emergency care depends on the advocacy efforts of clinicians, researchers, educators, and families.
Human trafficking is a pervasive problem throughout the world and is largely underreported, particularly within the pediatric population. Signs of trafficking can be subtle, and it is important for clinicians to be familiar with red flags and how to advocate for children whom they suspect of being trafficked. This article provides a brief overview of pediatric human trafficking and methods of successfully advocating for pediatric victims.
