Development of a risk-stratification tool for medical child abuse in failure to thrive.

OBJECTIVE: To develop a risk-stratification tool to help identify medical child abuse (MCA) in children evaluated for failure to thrive (FTT). PATIENTS AND METHODS: In this case-control study, the control group consisted of children who were seen in the pediatric gastroenterology department and diagnosed with FTT before the age of 5 years between 2000 and 2010. Cases were distinguished by having also been referred to the Child Advocacy Committee at the Cleveland Clinic Foundation (CCF) and/or reported to the Department of Child and Family Services by the CCF as a possible case of MCA. We used retrospective chart review to compare 17 cases of MCA with 68 controls. Classification-tree analysis was used to generate the risk-stratification tool. RESULTS: A risk-stratification tool, in the form of a classification tree, was developed and incorporated the following individual risk indicators: (1) ≥ 5 organ systems involved; (2) absence of serious congenital anomaly or confirmed genetic disorder; (3) ≥ 5 reported allergies; and (4) refusal of services from a multidisciplinary feeding team. Overall, the classification tree had a sensitivity of 100% and a specificity of 96%. CONCLUSIONS: The results of this study suggest that a diagnosis of MCA may be suspected in children with FTT on the basis of features in the initial presentation and clinical course. Using the proposed risk-stratification tool that incorporates these features might assist in earlier identification of medically abused children and reduce morbidity and mortality.

Vision First, a program to detect and treat eye diseases in young children: the first four years.

PURPOSE: The Vision First program began in the fall of 2002 as a community outreach initiative by the Cleveland Clinic Cole Eye Institute in partnership with the Cleveland Metropolitan School District. It was designed to provide free eye examinations to all prekindergarten, kindergarten, and first grade students enrolled in Cleveland City public schools in order to diagnose refractive errors, amblyopia, and strabismus, so that treatment is instituted and the best possible visual outcome attained. METHODS: Examinations are performed in 2 lanes of a specially outfitted recreational vehicle. All children undergo monocular visual acuity testing at distance and near, stereopsis testing, cover testing at distance and near, testing of versions, and external ocular inspection. If a child fails any part of this examination according to the guidelines set by the American Academy of Pediatrics, cycloplegic drops are instilled and an optometrist refracts the child on location and performs indirect ophthalmoscopy. Glasses are prescribed and follow-up with a pediatric ophthamologist is arranged. RESULTS: During the first 4 years of the program, 22,988 examinations were performed. Seven percent of children had errors of refraction that necessitated optical correction, about 2.1% had strabismus, and 1.7% had amblyopia. The cost per student per year was around $23 excluding glasses. CONCLUSIONS: About 10% of 5- and 6-year-old schoolchildren have eye problems that require either glasses or treatment for strabismus or amblyopia. The Vision First model brings eye care professionals to the schools and provides effective comprehensive screening of all children, as well as detailed examination and referral of those with significant eye problems.