10 years later: revisiting the patchwork quilt of child protection in Canada.

BACKGROUND: In 2007, a Paediatrics & Child Health article characterized the Canadian academic Child and Youth Protection Programs (CYPPs) depicting the wide variation in clinical services and resources across the country as 'a threadbare patchwork quilt'. This study aimed to expand and update the knowledge gained from that original project a decade later. The aim of this research was to understand the current structure, functioning, and experiences of the existing Canadian CYPPs. METHODS: A mixed-methods design was utilized and all program directors of Canadian CYPPs were invited to participate. An online survey was distributed using REDCap to collect quantitative data on program characteristics. Program directors participated in one-on-one semi-structured telephone interviews to gather qualitative information regarding their program's strengths and needs, resources, as wellas reflections on their experiences working within this evolving field. RESULTS: In total, 15 of 16 CYPP directors participated in the online survey. CYPPs remained relatively consistent in the variety of allied health care professionals on their team, and have ongoing work in research, education, and advocacy. Recurrent themes that emerged from the qualitative interview data included the strength of the team, comments on stress and wellness, expertise in the field, and desire for additional advocacy. CONCLUSION: Current information was gathered on the structure, function, and experiences of Canadian CYPPs. Areas of growth include collaborative practice at the Child and Youth Advocacy Centres and deliberate attention to wellness. Child maltreatment continues to be an important health and social issue and review of the present-day landscape is critical to better inform research, education, and resource planning.

Suspected Radial Head Subluxation in Infants: The Need for Radiologic Evaluation.

ABSTRACT: Radial head subluxation ("pulled elbow" or "nursemaid's elbow") is a common pediatric condition in children aged 1 to 4 years, although it is an uncommon finding in nonambulatory infants. It is a clinical diagnosis, and further investigations such as x-ray are not routinely done. We present a case series of 2 nonambulatory infants with forearm fractures that were initially diagnosed as radial head subluxation. Current literature supports the use of x-ray in children with atypical or unclear history prior to an attempted pulled elbow reduction. We suggest that this recommendation should be extended to all nonambulatory infants, given the unlikely diagnosis of radial head subluxation, and the necessity for early recognition of injuries that may be indicators of abuse.

Experience of Caring for a Child With Type 1 Diabetes Mellitus in a Food-Insecure Household: A Qualitative Evaluation.

OBJECTIVES: An earlier study from Nova Scotia showed that food insecurity (FI) is more prevalent (21.9%) in families of children with diabetes, yet little is known about its impact on these families. We aimed to describe the day-to-day experiences of families living with FI while caring for a child with type 1 diabetes (T1D). METHODS: This investigation was a qualitative study with thematic analyses using semistructured interviews to explore perceptions of caregivers living with pediatric T1D and FI (N=13 households). RESULTS: Three major themes emerged: 1) FI had a disproportionate impact on families after T1D diagnosis compared with before diagnosis. The cost of healthy food threatened food security before T1D; however, there is increased hardship once high-quality food and hypoglycemia supplies are required. 2) Sacrifices to combat FI have disproportionate impacts among family members. At times, caregivers sacrificed the needs (food, medicine) of other family members (including children) to prioritize the needs of the child with T1D. 3) Caregivers perceived T1D needs as posing unique barriers to traditional FI supports, such as school breakfast programs. CONCLUSIONS: This study provides insight into the realities of life with pediatric T1D and FI. Living with T1D and FI poses challenges, and caregivers often cope by making difficult choices when providing for their family. Caregivers struggled to meet dietary recommendations while finding that T1D needs are often not met by traditional FI supports. This suggests that T1D clinicians should assess FI and help families in problem solving to mitigate its impact.

The medical evaluation of prepubertal children with suspected sexual abuse.

Child sexual abuse is an important and not uncommon problem. Children who have been sexually abused may present to a physician's office, urgent care centre, or emergency department for medical evaluation. A medical evaluation can provide reassurance to both child and caregiver, identify care needs, and offer an accurate interpretation of findings to the justice and child welfare systems involved. Given the potential medico-legal implications of these assessments, the performance of a comprehensive evaluation requires both current knowledge and clinical proficiency. This position statement presents an evidence-based, trauma-informed approach to the medical evaluation of prepubertal children with suspected or confirmed sexual abuse.

Child and youth advocacy centres: A change in practice that can change a lifetime.

While often a silent and invisible issue, childhood trauma is pervasive, and has profound individual, societal and economic impacts. Many forms of childhood trauma exist, including child physical and sexual abuse. Given the prevalence, impact and availability of prevention and intervention approaches, child abuse deserves the same level of awareness, policy priority and investment as is directed to other issues of significant public health importance. The complex issue of child abuse requires a coordinated multifaceted response, which minimizes system trauma and revictimization for the child and family. The Child and Youth Advocacy Centre (CYAC) model brings together various sectors to create an integrated, multidisciplinary response that is client-centred and trauma-informed. To ensure that all children, youth and their families who have experienced maltreatment have access to the CYAC model of care when needed, sustainable funding investment in CYACs should be a priority for government at all levels.

The impact of an educational intervention on knowledge about infant crying and abusive head trauma.

BACKGROUND: Infants follow a predictable trajectory of increased early crying. Frustration with crying is reported to be a trigger for abusive head trauma (AHT). OBJECTIVE: To evaluate the impact of postpartum delivery of the educational program, the Period of PURPLE Crying (PURPLE), in a group of first-time mothers. The primary objective was to determine whether there was a change in knowledge about infant crying and shaking after exposure to PURPLE. Factors associated with change in knowledge were also examined. METHOD: A total of 93 participants were recruited over a four-month period at a tertiary care hospital in Nova Scotia. Pre- and postintervention data were collected. RESULTS: Knowledge about infant crying increased significantly after program delivery (P=0.001). Low baseline crying knowledge was a significant predictor of increased knowledge about infant crying (P≤0.01). There was an insignificant decrease in shaking knowledge (P=0.5), which may have been the consequence of high baseline knowledge. CONCLUSION: An educational program for new parents appears to be warranted, especially with respect to improving knowledge about infant crying. This may have a positive benefit in AHT prevention. Additional studies are required to evaluate the impact of the program on other caregivers and on rates of AHT.

HISTORIQUE: Les nourrissons suivent une trajectoire prévisible d'augmentation des pleurs peu après la naissance. La frustration à l'égard de ces pleurs est considérée comme un déclencheur des traumatismes crâniens non accidentels (TCNA). OBJECTIF: Évaluer l'effet de la transmission d'un programme d'éducation postnatale, la Period of PURPLE Crying (PURPLE), à un groupe de mères d'un premier enfant. L'objectif primaire consistait à déterminer si les connaissances relatives aux pleurs et aux secousses des nourrissons changeaient après l'exposition à PURPLE. Les facteurs liés aux changements de connaissances ont également été examinés. MÉTHODOLOGIE: Les chercheurs ont recruté 93 participantes sur une période de quatre mois dans un hôpital de soins tertiaires de la Nouvelle-Écosse. Ils ont colligé les données avant et après l'intervention. RÉSULTATS: Les connaissances sur les pleurs des nourrissons augmentaient de manière significative après la prestation du programme (P=0,001). Le peu de connaissances sur les pleurs en début d'étude était un prédicteur important d'augmentation des connaissances sur les pleurs des nourrissons (P≤0,01). Il y avait une diminution non significative des connaissances sur les secousses (P=0,5), qui peut découler des connaissances importantes avant l'intervention. CONCLUSION: Un programme d'éducation pour les nouveaux parents semble justifié, particulièrement pour accroître les connaissances sur les pleurs des nourrissons. Il pourrait contribuer à prévenir les TCNA. Il faudra réaliser d'autres études pour évaluer l'effet du programme auprès d'autres personnes qui s'occupent de nourrissons et sur le taux de TCNA.

Validation of a clinical prediction rule for pediatric abusive head trauma.

BACKGROUND AND OBJECTIVE: To reduce missed cases of pediatric abusive head trauma (AHT), Pediatric Brain Injury Research Network investigators derived a 4-variable AHT clinical prediction rule (CPR) with sensitivity of .96. Our objective was to validate the screening performance of this AHT CPR in a new, equivalent patient population. METHODS: We conducted a prospective, multicenter, observational, cross-sectional study. Applying the same inclusion criteria, definitional criteria for AHT, and methods used in the completed derivation study, Pediatric Brain Injury Research Network investigators captured complete clinical, historical, and radiologic data on 291 acutely head-injured children <3 years of age admitted to PICUs at 14 participating sites, sorted them into comparison groups of abusive and nonabusive head trauma, and measured the screening performance of the AHT CPR. RESULTS: In this new patient population, the 4-variable AHT CPR demonstrated sensitivity of .96, specificity of .46, positive predictive value of .55, negative predictive value of .93, positive likelihood ratio of 1.67, and negative likelihood ratio of 0.09. Secondary analysis revealed that the AHT CPR identified 98% of study patients who were ultimately diagnosed with AHT. CONCLUSIONS: Four readily available variables (acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture) identify AHT with high sensitivity in young, acutely head-injured children admitted to the PICU.

The experience of paediatric residents participating in a child protection rotation: A qualitative study.

BACKGROUND: Practitioners working in the field of child maltreatment are at risk for vicarious traumatization. For Canadian paediatric residents, exposure to child abuse during training is limited. OBJECTIVE: To explore how paediatric residents experience a mandatory rotation within a hospital-based child protection team (CPT) from an emotional and professional development standpoint. METHOD: Eight paediatric residents were interviewed following their CPT rotation and transcripts were analyzed using a phenomenological approach. Exemplar quotes were then highlighted. RESULTS: FOUR MAJOR THEMES WERE IDENTIFIED: baseline experiences; individual resident factors; intrinsic CPT rotation factors; and overall rotation assessment. The themes and their subthemes were used to inform a conceptual model of residents' experiences. CONCLUSIONS: The knowledge provided through residents' accounts can be applied to strengthen future educational opportunities in the field of child maltreatment and offer insight to help guide the development of support systems and debriefing processes that are important in this challenging field.

HISTORIQUE: Les praticiens qui exercent dans le domaine de la maltraitance des enfants sont vulnérables aux traumatismes transmis par personne interposée. Les résidents en pédiatrie canadiens sont peu exposés à la maltraitance d'enfants pendant leur formation. OBJECTIF: Explorer comment des résidents en pédiatrie ont vécu leur rotation obligatoire au sein d'une équipe de protection de l'enfance en milieu hospitalier (PEH) sur le plan affectif et professionnel. MÉTHODOLOGIE: Huit résidents en pédiatrie ont subi une entrevue après leur rotation en PEH. Les chercheurs en ont analysé la transcription au moyen d'une démarche phénoménologique. Ils ont ensuite fait ressortir des citations exemplaires. RÉSULTATS: Quatre grands thèmes ont été dégagés : expériences de base, facteurs propres à chaque résident, facteurs intrinsèques à la rotation en PEH et évaluation globale de la rotation. Les chercheurs ont utilisé les thèmes et les sous-thèmes pour étayer un modèle conceptuel des expériences des résidents. CONCLUSIONS: Les connaissances acquises grâce aux comptes rendus des résidents peuvent servir à renforcer les futures possibilités de formation dans le domaine de la maltraitance d'enfants et offrent un aperçu pour orienter l'élaboration de systèmes de soutien et les processus de retour sur les événements importants dans ce milieu difficile.

The importance of child and youth death review.

The mandate of a formal child death review (CDR) system is to advance understanding of how and why children die, to improve child health and safety, and to prevent deaths and injuries in the future. Areas in which CDR has provided valuable information and/or intervention include sudden death in infancy, unintentional injuries (the leading cause of death in Canadian children and youth one to 19 years of age), suicide in youth, and deaths due to homicide or child maltreatment. When collected systematically using common definitions, information regarding deaths in children and youth can help with understanding the scope of problems. Information about the context of a death can inform potential prevention or intervention activities. CDR can improve medical and mental health best practices, child welfare policies and procedures, and legislation and education relevant to public health and safety. In the United States, the United Kingdom, Australia and New Zealand, CDR processes are mandated by legislation. In Canada, death review teams have diverse structures and functions, and the CDR system is less well developed. The present statement addresses the need for formal, organized child and youth death review in Canada to help strengthen and systemize injury and death prevention efforts.

Le mandat du système officiel d'examen des décès d'enfants (EDE) vise à faire progresser les connaissances sur les causes et le contexte des décès d'enfants, à améliorer la santé et la sécurité des enfants et à prévenir de futurs décès et blessures. L'EDE a fourni de l'information ou des interventions précieuses dans plusieurs secteurs, dont la mort subite pendant la première enfance, les blessures non intentionnelles (la principale cause de décès chez les enfants et les adolescents canadiens de un à 19 ans), le suicide à l'adolescence et les décès par homicide ou maltraitance d'enfant. Lorsqu'elle est recueillie de manière systématique au moyen de définitions communes, l'information relative aux décès d'enfants et d'adolescents peut contribuer à comprendre la portée des problèmes. L'information sur le contexte du décès peut étayer des activités potentielles de prévention ou d'intervention. L'EDE peut améliorer les pratiques exemplaires en matière de santé physique et mentale, les politiques et démarches relatives à la protection de la jeunesse, de même que les lois et l'éducation en matière de santé et sécurité publiques. Aux États-Unis, au Royaume-Uni, en Australie et en Nouvelle-Zélande, les processus d'EDE sont mandatés par la loi. Au Canada, la structure et les fonctions des équipes d'examen des décès sont variées, et le système d'EDE est moins développé. Le présent document de principes traite de la nécessité d'adopter un examen des décès d'enfants et d'adolescents plus officialisé et organisé au Canada, afin de renforcer et de systématiser les efforts en matière de prévention des blessures et des décès.

The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective.

Bruises commonly occur in children and are most often the result of a minor accidental injury. However, bruises can also signal an underlying medical illness or an inflicted injury (maltreatment). Although bruising is the most common manifestation of child physical maltreatment, knowing when to be concerned about maltreatment and how to assess bruises in this context can be challenging for clinicians. Based on current literature and published recommendations, this practice point will help clinicians to distinguish between accidental and inflicted bruises, to evaluate and manage bruising in the context of suspected child maltreatment, and to evaluate for an underlying medical predisposition to bruising.

Les ecchymoses sont courantes chez les enfants et découlent souvent d'une blessure accidentelle mineure. Cependant, elles peuvent également signaler une maladie sous-jacente ou une blessure infligée (maltraitance). Même si les ecchymoses sont les manifestations les plus courantes de la maltraitance physique des enfants, il peut être difficile pour les cliniciens de savoir quand s'inquiéter d'un risque de maltraitance et comment évaluer les ecchymoses dans un tel contexte. D'après les publications et les recommandations publiées récentes, le présent point de pratique aide les cliniciens à distinguer les ecchymoses accidentelles et infligées, à évaluer et à prendre en charge les ecchymoses en présence d'une maltraitance présumée d'enfant et à évaluer la prédisposition médicale sous-jacente aux ecchymoses.

An approach to child maltreatment documentation and participation in the court system.

When asked to provide an assessment of a patient for whom there are concerns of suspected maltreatment, the clinician may have uncertainty about how to best proceed for a number of reasons including the actual or potential involvement of a child welfare authority. Existing literature helps to define the role of the medical expert in child abuse assessments, but there is little published guidance targeted to the general practitioner. The present article offers practical advice about the approach to: documentation of a child abuse assessment; providing testimony and behaviour in the court system for the nonexpert; and, finally, guidance for individuals giving expert or opinion evidence for medicolegal purposes. In all cases, if the clinician has specific concerns or unanswered questions about their role and responsibilities, they can contact their professional medicolegal association for support.

Lorsqu'on lui demande d'évaluer un patient chez qui on craint une maltraitance, le clinicien peut s'interroger sur la meilleure façon de procéder, et ce, pour plusieurs raisons, y compris la participation réelle ou potentielle d'une agence de protection de l'enfance. Les publications contribuent à définir le rôle de l'expert médical dans l'évaluation de la maltraitance des enfants, mais peu de directives publiées sont destinées au généraliste. Le présent article contient des conseils pratiques sur l'approche envers les traces écrites de l'évaluation de la maltraitance des enfants, la présentation du témoignage et le comportement du non-expert au sein du système judiciaire et des directives aux personnes qui présentent des preuves d'expert ou d'opinion pour des besoins médicolégaux. Dans tous les cas, si le clinicien a des inquiétudes particulières ou désire obtenir des réponses sur son rôle et ses responsabilités, il peut obtenir du soutien auprès de son association médicolégale professionnelle.

Temporary tattoos to simulate skin disease: report and validation of a novel teaching tool.

PURPOSE: Dermatology is a visual specialty requiring examination and description of skin lesions and the development of analytic skills to establish a diagnosis. Student education in dermatology is challenged by several factors. Although 10% to 15% of a general practitioner's consultations are related to the skin, dermatology is often underrepresented in undergraduate medical curriculums. In addition, more serious lesions, such as malignant melanoma (MM), are promptly biopsied and may not be available for students' examination. The authors carried out this study to learn whether a novel educational tool, a temporary tattoo, could successfully simulate an MM. METHOD: Eighty-one dermatologists and 14 dermatology residents participated in this validity study of a tattoo applied to the arm of a standardized patient (SP) to simulate an MM. The study was conducted at the 82nd Annual Canadian Dermatology Association Conference held in June 2007 in Toronto, Canada. RESULTS: A correct diagnosis was made by 93.8% (76/81) of the dermatologists and 90.5% of the participants (86/95) overall. The tattoo was also evaluated as being very realistic on a five-point Likert scale. CONCLUSIONS: The validation of the tattoo shows potential for use in medical education, such as SP visits and examinations. This teaching tool can be used to simulate a variety of skin lesions, providing a way to visually examine a lesion on the skin of an SP, which would enhance the medical student's learning experience.

A commentary on mandatory reporting legislation in the United States, Canada, and australia: a cross-jurisdictional review of key features, differences, and issues.

Mathews and Kenny recently reviewed the current state of mandatory reporting laws in Australia, Canada, and the United States. The purpose of this article is to draw attention to existing differences between these countries regarding exposure to domestic violence (EDV) and to discuss EDV as a specific and detrimental form of child abuse.

Into hot water head first: distribution of intentional and unintentional immersion burns.

INTRODUCTION: Experience with several, previously unreported, intentional face-first immersion burns led us to evaluate the distribution of inflicted and unintentional immersion scald burns in a hospital series. SETTING: (1) Authors' clinical and legal practices; (2) Burn center at regional Level 1 trauma hospital. SUBJECTS: : (1) Case series of face-first, inflicted immersion burn victims; (2) Consecutive hospitalized scald burn victims younger than 5 years old, 1/3/1996 to 3/25/2000. METHODS: (1) Individual case reports; (2) Retrospective records review. Simple descriptive statistics, Fisher Exact test and t test. RESULTS: (1) Six cases of inflicted head and neck immersion injury are described. Four were tap water and 2 food/drink scalds. (2) 22/195 hospitalized victims had sustained immersion burns, 13 from tap water and 9 from other fluids. Six (46%) tap water immersions and no (0%) other immersions had inflicted injuries (P = 0.05). Two of the tap water immersions and one other source immersion included burning of the head and neck. Of these, one tap water immersion, but no other immersion, was inflicted. In no patients were head and neck injuries the sole or predominant site of scalding. In all, 9 children sustained inflicted scalds. Bilateral lower extremity tap water immersion scalds occurred in 100% (6/6) of abusive and 29% (2/7) of unintentional injuries (P = 0.02). Buttock and perineal injuries occurred in 67% (4/6) inflicted versus 29% (2/7) unintentional tap water immersion scalds (P = 0.28). Other fluids caused bilateral lower extremity immersion burns in 3/9 (33 %) unintentionally injured patients, but no abused children (NS). CONCLUSIONS: Craniofacial immersion injury, although seen by the authors in legal cases, is infrequent. It was present incidentally in one inflicted tap water burn in the consecutive hospital series. This series affirms the predominance of bilateral lower extremity burns in inflicted tap water immersions. Buttock/perineal immersions were more common with abuse than with unintentional injury.