Does Postmortem Imaging Provide Additional Findings After Unexpected Deaths in Infants and Children?

METHODS: We performed a retrospective study of unexpected deaths in children 2 years or younger between 2008 and 2018. Children with known traumatic deaths and those transferred after a cardiopulmonary arrest at an outside institution were excluded. We collected patient demographics, physical examination findings, and type of PMI performed along with their results. RESULTS: We analyzed 150 deaths with majority (128; 85.3%) being infants. No PMI was performed in 20 children (13.3%). An autopsy was not performed in 22 children (14.6%). A skeletal survey and an autopsy were performed only in 72.6% (93/128) infants. PMI provided additional findings in 51 infants (34%) and 13 children (59.1%) aged 13 to 24 months. PMI identified abuse in 11 children with a negative physical examination result, 3 of whom had a negative autopsy. CONCLUSIONS: The American Academy of Pediatrics recommendations of performance of a skeletal survey and an autopsy were not adhered to after all infant deaths. PMI is useful in identification of additional findings in children 2 years or younger, especially those concerning for physical abuse in infants with a negative physical examination.

Commotio cordis: A case report of a fatal blow.

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.

Human Trafficking of Children.

Human trafficking has been increasingly recognized worldwide as a major public health problem. It is a crime based on exploitation of the most vulnerable and marginalized people of any community and is a violation of human rights. Children, especially immigrant and refugee children, are at risk of victimization and may experience considerable physical and mental health consequences. Adding these problems to pre-existing vulnerabilities and adversities makes human trafficking a complex health issue that needs to be addressed by a multidisciplinary team that includes health care providers. This article aims to provide an overview of human trafficking and the red flags that may alert the pediatrician to the possibility of exploitation, with a special focus on immigrant and refugee children. It describes a trauma-informed, rights-based approach and discusses ways in which pediatricians can contribute to a multidisciplinary response to human trafficking. [Pediatr Ann. 2020;49(5):e209-e214.].

Child sexual abuse: can anatomy explain the presentation?

This article discusses a 4-year-old girl who displayed behavioral symptoms consistent with posttraumatic stress disorder. She was recently placed in foster care due to emotional and physical neglect. During her clinic visit, she disclosed being sexually abused by her father with a knife. Results of her general and anogenital physical examinations were normal. The case discussion proposes an explanation for how a maltreated child (1) develops behavioral problems, (2) has a normal genital examination despite the history of sexual abuse, and (3) has an implausible disclosure of her father hurting her with a knife. As part of the Integrating Basic Science into Clinical Teaching Initiative series, basic science principles are the method of explanation. The case discussion is an attempt to understand the science responsible for the disease that is present and make that understanding useful for future clinical problem solving.

Home versus hospital intravenous antibiotic therapy for acute pulmonary exacerbations in children with cystic fibrosis.

To compare the effectiveness of home versus hospital intravenous (IV) antibiotic therapy for acute pulmonary exacerbations in children with cystic fibrosis (CF). A retrospective chart review was performed of 143 encounters for pulmonary exacerbations in 50 patients with CF. All encounters were categorized into two groups based on location of completion of antibiotic therapy: hospital group completed treatment in hospital (n = 64), home group completed treatment at home (n = 79). Percent change was calculated for forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1), forced expiratory flow rate between 25 percent and 75 percent of vital capacity (FEF(25-75%)), maximum forced expiratory flow (FEF(max)), oxygen saturation (O2 SAT), and weight. Means of percent change (PC) from the beginning to the end of IV antibiotic treatment in outcome variables were compared. Total duration of treatment was compared between the two groups. The two groups had no significant differences at baseline in all outcome variables. Treatment of exacerbations in both groups resulted in significant improvement of lung function, O2 SATS, and weight (P

Ethnicity and gender related differences in extended intraesophageal pH monitoring parameters in infants: a retrospective study.

BACKGROUND: Gastroesophageal reflux disease (GERD) is believed to be more common in adult males as compared to females. It also has been shown in adults to be more common in Caucasians. We wanted to determine ethnicity and gender related differences for extended pH monitoring parameters in infancy. METHODS: Extended pH monitoring data (EPM) from infants < 1 year of age were reviewed. Results were classified in two groups, as control and Gastroesophageal reflux disease (GERD) group based on the reflux index (RI). The GERD group had RI of equal to or more than 5% of total monitoring period. The parameters of RI, total number of episodes of pH < 4, and the number of episodes with pH < 4 lasting more than 5 minutes were compared by genders and by ethnic groups, Caucasians and African American (AA). RESULTS: There were 569 infants, 388 controls, 181 with GERD (320 males, 249 females; 165 Caucasians, 375 AA). No statistical difference in EPM parameters was detected between genders in both groups. However, Caucasian infants had a significantly higher incidence of GERD than AA infants (p = 0.036). On stratifying by gender, Caucasian females had a significantly higher number of reflux episodes > 5 minutes as compared to AA females in the control group (p = 0.05). Furthermore, Caucasian females with GERD showed an overall higher trend for all parameters. Caucasian males had a trend for higher mean number of reflux episodes as compared to AA males in the control group (p = 0.09). CONCLUSION: Although gender specific control data do not appear warranted in infants undergoing EPM, ethnic differences related to an overall increased incidence of pathologic GERD in Caucasian infants should be noted.