A case-control study comparing rates and diagnoses of hospital readmission in infants affected by neonatal abstinence syndrome.

OBJECTIVE: Rates of neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS), a withdrawal syndrome from opioids and other substances resulting from intrauterine exposure, have been increasing exponentially in the U.S. To improve health outcomes, it is important to understand population health risks, including rehospitalization and related diagnoses, using current data. This study will compare and describe the rates of rehospitalization, the demographic characteristics and the rehospitalization diagnoses and age at diagnosis between the infants affected by NAS/NOWS to those sampled who were unaffected. This study will also describe the frequency of NAS/NOWS births per year along with a yearly comparison of readmissions in those affected by NAS/NOWS to those who were not (2016-2020). METHODS: Health claims data were used to conduct a case/control study. Diagnosis codes for neonatal withdrawal syndrome/NAS/NOWS (P04.49 or P96.1 and P96.1 alone) from 1 October 2015 to 1 June 2021 were extracted, and controls were case-matched based on month/year of birth. Rehospitalizations following birth and the related diagnoses were described and grouped using the Agency of Healthcare Research Quality Clinical Classifications Software Refined Frequency distribution. The chi-square test of association and generalized estimating equation modeling were used for data analysis. RESULTS: Infants affected by NAS/NOWS are 2.7 times more likely to have a rehospitalization. White, non-Hispanic neonates (OR = 1.5; p = .007) and those infants residing in rural areas (OR = 1.9; p < .001) were disproportionately affected. We identified a host of admission diagnoses with increased prevalence in infants affected by NAS/NOWS when compared to those who were not affected (e.g. infectious diseases, feeding disorders). CONCLUSIONS: Infants with NAS/NOWS are at increased risk of rehospitalization with a host of diagnoses, and specific demographic groups (White, rural) are more highly affected.

Caregiver and Clinician Experience With Virtual Services for Children and Youth With Complex Needs During COVID-19.

INTRODUCTION: During the COVID-19 pandemic, support services for children and youth quickly shifted to virtual means. To continue delivering essential, trauma-informed, specialized services, the center transitioned to providing most services by phone/video conference. METHOD: A quality improvement project using survey methods was conducted to determine if virtual delivery was timely and satisfactory for inpatient and outpatient care. RESULTS: Findings indicated services were timely. Caregivers appreciated the support, felt a personal connection with staff, and confirmed services met their goals and expectations. However, challenges faced by staff included engaging the child/youth by phone/video, loss of collaboration with colleagues, and concerns about fulfilling their role through virtual means. DISCUSSION: Understanding stakeholder experiences illuminated the path of quality improvement during this major shift in service delivery. Benefits were shown for a blended model of in-person and virtual services on the basis of clinical judgment and the unique needs of clients and families in considering future service model options.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics.

Importance: Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. Objective: To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. Design, Setting, and Participants: This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. Exposures: Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures: Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. Results: A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). Conclusions and Relevance: In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.

Characteristics of rib fractures in young abused children.

BACKGROUND: The presumed mechanism of rib fractures in abuse is violent grasping of the torso causing anterior-posterior chest compression. We hypothesized an asymmetrical distribution of rib fractures in abused infants given the greater incidence of right-hand dominance within the general population. OBJECTIVE: The objective of this study was to characterize rib fractures in abused children, particularly sidedness; additionally, we evaluated the sidedness of other abusive skeletal fractures. MATERIALS AND METHODS: We reviewed medical records from abused children (0-18 months old) with rib fractures. We also retrospectively reviewed their radiographs to determine characteristics of rib fractures (number, side, rib region, level, acuity) and other skeletal fractures (number, side, location), as well as differences in the distribution of rib and other skeletal fractures. RESULTS: A total of 360 rib fractures were identified on 273 individual ribs involving 78 abused children. Sixty-three children (81%) had multiple rib fractures. There was a significantly greater number of left-side rib fractures (67%) than right-side fractures (P<0.001). Fractures were most often identified in the posterior and lateral regions and mid level of the ribcage (Ribs 5 through 8). Fifty-four percent of subjects had other skeletal fractures; these non-rib fractures were also predominantly on the left side (P=0.006). CONCLUSION: In our study of abused children, there was a higher incidence of rib fractures in the posterior, lateral and mid-level locations. Additionally, we found a predominance of left-side rib and other skeletal fractures. Further research is needed to understand whether factors such as perpetrator handedness are associated with these unequal distributions of fractures in abused children.

Retraction Note to: Radiographic characteristics that delineate abusive from accidental skull fractures, including the significance of fracture extension to sutures.

The authors have retracted the abstract #029 "Radiographic characteristics that delineate abusive from accidental skull fractures, including the significance of fracture extension to sutures".

Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental Injury.

OBJECTIVE: To compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries. STUDY DESIGN: Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4 years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver's relationship with his/her partner. RESULTS: Of 1615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR 3.31, 95% CI 2.38-4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR 169.2, 95% CI 61.3-614.0). Severe or fatal injuries also were more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR 0.25, 95% CI 0.17-0.37) with the exception of a female babysitter (OR 3.87, 95% CI 2.15-7.01). Caregiving arrangements that were different than usual and caregiver relationships <1 year were also associated with an increased risk of abuse. CONCLUSIONS: We identified caregiver features associated with physical abuse. In clinical practice, questions regarding caregiver features may improve recognition of the abused child. This information may also inform future abuse prevention strategies.

(Unpacking) father involvement in the context of childhood neurodisability research: a scoping review.

BACKGROUND: In the past thirty years, theoretical and empirical scholarship on father involvement has emerged and firmly established itself. Efforts to define, measure, and explore outcomes related to father involvement in the context of childhood neurodisability are evident but less well established. The purpose of this study was to systematically map empirical studies on father involvement in the context of childhood neurodisability in order to delineate the current state of research and to highlight profitable directions for future research. METHODS: A rigorous scoping review method was used to select and analyze empirical studies published between the years 1988 and 2016 in order to systematically map research findings about fathers' affective, behavioral, and cognitive involvement. RESULTS: Fifty-four (n = 54) studies (quantitative n = 47 and qualitative n = 7) met inclusion criteria associated with three levels of review. Four main trends emerged: (a) paternal "stress" is a main concept of interest; (b) comparison of mothers and fathers on affective and cognitive involvement; (c) lack of a focus on fathers' behavioral involvement, and (d) the absence of research designs that allow for examination of fathers' unique perspectives. CONCLUSIONS: Fathers are generally underrepresented in research in the context of childhood neurodisability. While there is a lack of depth in this area of research, granular analyses revealed important and unique differences about fathers' parenting experiences. Recommendations for research and practice are provided. Implications for rehabilitation Fathers are underrepresented in the parenting in childhood neurodisability literature. Fathers who report feeling competent in parenting and connected to their child also report less parenting distress and more satisfaction in their couple relationship and family environment. Rehabilitation and allied health professionals should include fathers in parenting/family assessments. Manifestation of distress may differ among family members. Rehabilitation and allied health professionals should offer individualized care that is attuned to the needs of all family members.

Child and parent engagement in the mental health intervention process: a motivational framework.

BACKGROUND: This article proposes a conceptual model of child and parent engagement in the mental health intervention process. METHOD: A scoping review was performed of articles on predictors of engagement in mental health interventions, the effectiveness of engagement interventions, and interpersonal aspects of care. A comprehensive search of PsycINFO and PsycARTICLES was performed for literature published in English from 2000 to 2012. RESULTS: Based on the review, a motivational framework is proposed in which engagement is defined as a state comprised of a hopeful stance, conviction, and confidence, brought about when therapists optimize engagement processes of receptiveness, willingness, and self-efficacy. CONCLUSIONS: Implications concern the need to help clients understand what to expect from the therapy process, and to educate therapists about engagement strategies.

Evaluation of an innovative tool for child sexual abuse education.

Child sexual abuse poses a serious threat to public health and is often unreported, unrecognized, and untreated. Prevention, early recognition, and treatment are critically important to reduce long-term effects. Little data are available on effective methods of preventing child sexual abuse. The current research demonstrates a unique approach to promoting awareness and stimulating discussion about child sexual abuse. Qualitative methods have rarely been used to study child sexual abuse prevention. Qualitative inductive analyses of interviews from 20 key informants identified both positive and negative assessments with six emergent themes. The themes revealed inherent tensions in using narrative accounts to represent the complex cultural context within which child sexual abuse occurs. More research is needed, but the program shows potential as a methodology to raise awareness of child sexual abuse.

Features and impacts of five multidisciplinary community-university research partnerships.

Despite the increasing number of multidisciplinary community-university research partnerships designed to address real-world issues, little is known about their nature. This article describes the features and impacts of five research partnerships addressing health or social service issues, which constituted a convenience sample from the province of Ontario, Canada. The article describes their characteristics, ways of operating, outputs, types of requests received from community members and mid-term impacts. Requests directed to partnerships were tracked over a 10-month period in 2003 to 2004, using a research contact checklist, and 174 community members later completed an impact questionnaire capturing perceptions of the impacts of the partnerships on personal knowledge and research skill development, organisational/group access to and use of information, and community and organisational development. The data indicated that partnerships had similar priorities and magnitudes of mid-term impacts, yet differed in the scope of their partnering, realm of intended influence and the number of mechanisms used to engage and communicate with target audiences. The partnerships produced different types of outputs and received different types of requests from community members. The findings inform researchers about partnership diversity and help to establish more realistic expectations about the magnitude of partnerships' impacts.

A measure of community members' perceptions of the impacts of research partnerships in health and social services.

Currently, there are no psychometrically sound outcome measures by which to assess the impacts of research partnerships. This article describes the development of a 33-item, survey questionnaire measuring community members' perceptions of the impact of research partnerships addressing health or social issues. The Community Impacts of Research Oriented Partnerships (CIROP) was developed using information from the literatures on health promotion, community development, research utilization, and community-based participatory research, and from focus groups involving 29 key informants. Data from 174 community members were used to determine the factor structure, internal consistency, and test-retest reliability of the four CIROP scales, and to provide evidence of construct validity. The CIROP informs research partnerships about the extent of their impact in the areas of Personal Knowledge Development, Personal Research Skill Development, Organizational/Group Access To and Use of Information, and Community and Organizational Development, allowing them to demonstrate accountability to funding bodies. As well, the CIROP can be used as a research tool to assess the effectiveness of knowledge sharing approaches, determine the most influential activities of research partnerships, and determine structural characteristics of partnerships associated with various types of impact. The CIROP provides a better understanding of community members' perspectives and expectations of research partnerships, with important implications for knowledge transfer and uptake.

Retinal hemorrhages in children following fatal motor vehicle crashes: a case series.

OBJECTIVE: To demonstrate the severity of ocular findings in young children who died of injuries due to motor vehicle crashes. METHODS: Case series of 10 children younger than 3 years who were fatally injured in motor vehicle crashes between January 1, 1994, and December 31, 2002. All children underwent autopsy that included eye examination. All available medical and autopsy records, pathology slides and photographs, and police and traffic department reports were reviewed for each case. RESULTS: Eight patients had retinal hemorrhages, which extended into the periphery in 13 eyes and were bilateral in 7 patients. Three patients had elevated circular retinal folds. Six patients had hemorrhages below the internal limiting membrane, but no patients had deeper splitting of the retina. Nine patients had optic nerve sheath hemorrhages. CONCLUSION: The association of extensive, sometimes severe, ocular hemorrhages with fatal accidental trauma, compared with previous reports of accidental trauma with no or few hemorrhages, indicates the severity of injury required to cause hemorrhages of this magnitude.

A framework of operating models for interdisciplinary research programs in clinical service organizations.

A framework of operating models for interdisciplinary research programs in clinical service organizations is presented, consisting of a "clinician-researcher" skill development model, a program evaluation model, a researcher-led knowledge generation model, and a knowledge conduit model. Together, these models comprise a tailored, collaborative approach to enhancing research-informed practice in community-based clinical service organizations. The models place different degrees of emphasis on the development of research-related skills in practitioners, the generation of knowledge tailored to clinical practice, and knowledge sharing. The nature, philosophical basis, roles of research staff members, outputs and impacts, and strengths and limitations of each model are described, in the context of a long-standing, interdisciplinary research program in a children's rehabilitation service organization. The use of the model framework as a tool for the design of interdisciplinary, community-based research programs is discussed.

The development of expertise in paediatric rehabilitation therapists: the roles of motivation, openness to experience, and types of caseload experience.

BACKGROUND/AIM: A transdisciplinary approach was taken to study the nature of variables associated with the development of expertise in 71 paediatric rehabilitation therapists (i.e. physical, occupational, speech, behavioural, and recreational therapists). METHODS: Six groups of practising therapists were identified based on expertise status (novice, intermediate, and expert, as determined by a multifaceted assessment battery), and their level of clinical experience (10 years or less, more than 10 years). Scores for these six therapist groups were examined on three variables generally considered to be associated with the development of expertise--motivation, openness to experience (as defined by the critical-thinking dispositions of truth-seeking, open-mindedness, and cognitive maturity), and features of their clinical caseload experience (i.e. breadth of experience as measured by number of different client age groups worked with, the complexity of clients' needs, and experience in delivering services to adolescents, school-age children, preschoolers, and infants). RESULTS: Low-experience experts ('young stars') had the highest motivation, truth-seeking, and open-mindedness scores of all groups, the highest percentage of clients with complex service needs, and were more likely to work with adolescents. CONCLUSIONS: The major differences between therapists who attain expertise quickly versus those who remain novices after many years of experience appear to be motivation and complexity of work experiences. Implications for supporting the development of expertise in practising therapists are discussed.

The development of expertise in pediatric rehabilitation therapists: changes in approach, self-knowledge, and use of enabling and customizing strategies.

PURPOSE: To examine the clinical decision making of novice, intermediate, and expert pediatric rehabilitation therapists from various disciplines. METHODS: Two qualitative studies were conducted. Thirteen therapists took part in a study using the critical incident interview technique and 11 therapists took part in a study using the 'think aloud' technique. Therapists were classified as novice, intermediate, or expert in developmental level based on a cluster analysis of data collected using a multifaceted battery of assessment tools. Data were analyzed using a grounded theory approach. RESULTS: Expert and intermediate therapists differed from novices with respect to content, self-, and procedural knowledge. CONCLUSION: With increasing expertise, therapists use a supportive, educational, holistic, functional, and strengths-based approach; have heightened humility yet increased self-confidence; and understand how to facilitate and support client change and adaptation by using principles of engagement, coherence, and manageability. Expert therapists use enabling and customizing strategies to ensure a successful therapeutic session, optimize the child's functioning in the mid-term, and ensure child and family adaptation and accommodation over the longer-term.

Antibiotic resistance patterns in children hospitalized for urinary tract infections.

BACKGROUND: Children admitted to the hospital with urinary tract infections (UTIs) receive empirical antibiotic therapy. There is limited information on bacterial resistance to commonly prescribed intravenous antibiotics or on the risk factors for increased resistance in these patients. OBJECTIVES: To determine the antibiotic resistance pattern in children admitted to the hospital with UTIs, and to determine if history of UTI, antibiotic prophylaxis, or vesicoureteral reflux increases the risk of resistant organisms. DESIGN/METHODS: We reviewed all of the cases of UTI in children up to 18 years of age who were admitted during a 5-year period to Children's Hospital of Wisconsin, Milwaukee. We recorded age, sex, culture and sensitivity results, imaging that was performed, and past medical history. RESULTS: We identified 361 patients with UTIs. Escherichia coli caused 87% of the infections, although E coli was significantly less common in children receiving prophylactic antibiotics (58%; P<.001) or in children with a history of UTI (74%; P<.001). Resistance to cefotaxime sodium was 3% in the patients not receiving antibiotic prophylaxis, but was 27% in the children receiving prophylactic antibiotics (relative risk, 9.9; 95% confidence interval, 4.0-24.5; P<.001). Resistance to aminoglycoside antibiotics was 1% in the children not receiving prophylaxis and 5% in the children receiving prophylactic antibiotics. CONCLUSIONS: Children who are receiving prophylactic antibiotics and are admitted to the hospital for a UTI are often infected with an organism that is resistant to third-generation cephalosporins. These children are more appropriately treated with an aminoglycoside antibiotic.

The pediatrician's role in recognizing and intervening in postpartum depression.

Increasing evidence of postpartum depression is encouraging pediatricians to include screening and intervention for postpartum depression in standard newborn and infant care. Pediatricians have the most frequent exposure to mothers and infants in the most high-risk time period and they have a vested interest in the well-being of the child and mother. Because the time required to achieve basic screening and referral services is minimal, there is enough evidence that postpartum screening and intervention are crucial components of comprehensive newborn and infant care. It is incumbent upon pediatricians to screen for and intervene in cases of postpartum depression to provide thorough care for infants and their families.

Follow-up urine cultures and fever in children with urinary tract infection.

BACKGROUND: The American Academy of Pediatrics practice parameter for urinary tract infection suggests a repeat urine culture if the expected clinical response is not achieved within the first 48 hours of therapy. The utility of repeat urine cultures and clinical significance of fever at 48 hours is unclear. OBJECTIVES: To determine the frequency of positive repeat urine cultures in children admitted to the hospital with urinary tract infection, and to describe the fever curves of children admitted to the hospital with urinary tract infection. DESIGN AND METHODS: We reviewed all cases of urinary tract infection in children 18 years and younger who were admitted during a 5-year period to Children's Hospital of Wisconsin (Milwaukee). We recorded temperatures from hospital admission to discharge, age, sex, initial and follow-up culture results, antibiotics received, imaging performed, and medical history. RESULTS: Urinary tract infection was identified in 364 patients, and 291 (79.9%) had follow-up urine cultures. None were positive. Follow-up cultures produced 21,388.50 US dollars in patient charges. Fever lasted beyond 48 hours in 32% of patients. Older children were more likely to have fever beyond 48 hours. CONCLUSIONS: Follow-up urine cultures were of no utility in children hospitalized for urinary tract infection, including those with fever lasting beyond 48 hours or those with an underlying urologic disease. Fever beyond 48 hours is common and should not be used as a criterion for obtaining a repeat urine culture. These conclusions are valid for children with vesicoureteral reflux. Such an approach would result in significant cost savings.