<p><strong>OBJECTIVES: </strong>We aimed to estimate the prevalence of abuse in young children presenting with rib fractures and to identify demographic, injury, and presentation-related characteristics that affect the probability that rib fractures are secondary to abuse.</p>

<p><strong>METHODS: </strong>We searched PubMed/MEDLINE and CINAHL databases for articles published in English between January 1, 1990, and June 30, 2014 on rib fracture etiology in children 5 years or younger. Two reviewers independently extracted predefined data elements and assigned quality ratings to included studies. Study-specific abuse prevalences and the sensitivities, specificities, and positive and negative likelihood ratios of patients' demographic and clinical characteristics for abuse were calculated with 95% confidence intervals.</p>

<p><strong>RESULTS: </strong>Data for 1396 children 48 months or younger with rib fractures were abstracted from 10 articles. Among infants younger than 12 months, abuse prevalence ranged from 67% to 82%, whereas children 12 to 23 and 24 to 35 months old had study-specific abuse prevalences of 29% and 28%, respectively. Age younger than 12 months was the only characteristic significantly associated with increased likelihood of abuse across multiple studies. Rib fracture location was not associated with likelihood of abuse. The retrospective design of the included studies and variations in ascertainment of cases, inclusion/exclusion criteria, and child abuse assessments prevented further meta-analysis.</p>

<p><strong>CONCLUSIONS: </strong>Abuse is the most common cause of rib fractures in infants younger than 12 months. Prospective studies with standardized methods are needed to improve accuracy in determining abuse prevalence among children with rib fractures and characteristics associated with abusive rib fractures.</p>

<p><strong>OBJECTIVE: </strong>We aimed to examine abusive head trauma (AHT) incidence before, during and after the recession of 2007-2009 in 3 US regions and assess the association of economic measures with AHT incidence.</p>

<p><strong>METHODS: </strong>Data for children &lt;5 years old diagnosed with AHT between January 1, 2004, and December 31, 2012, in 3 regions&nbsp;were linked to county-level economic data using an ecologic time series analysis. Associations between county-level AHT rates and recession period as well as employment growth, mortgage delinquency, and foreclosure rates were examined using zero-inflated Poisson regression models.</p>

<p><strong>RESULTS: </strong>During the 9-year period, 712 children were diagnosed with AHT. The mean rate of AHT per 100,000 child-years increased from 9.8 before the recession to 15.6 during the recession before decreasing to 12.8 after the recession. The AHT rates after the recession were higher than the rates before the recession (incidence rate ratio 1.31, P&nbsp;=&nbsp;.004) but lower than rates during the recession (incidence rate ratio 0.78, P = .005). There was no association between the AHT rate and employment growth, mortgage delinquency rates, or foreclosure rates.</p>

<p><strong>CONCLUSIONS: </strong>In the period after the recession, AHT rate was lower than during the recession period yet higher than the level before the recession, suggesting a lingering effect of the economic stress of the recession on maltreatment risk.</p>

<p><strong>BACKGROUND AND OBJECTIVE: </strong>Education of residents in academic medical centers occurs as part of clinical care, but little is known about the relationship between clinical workload and educational experiences among pediatric residents. The goal of this study was to assess residents' perceptions of learning on inpatient services at a children's hospital in relation to perceived workload and actual patient census.</p>

<p><strong>METHODS: </strong>This was a prospective cohort study of pediatric residents at 1 urban academic children's hospital. Surveys on educational experience were administered weekly to residents on 12 inpatient units from October 2010 to June 2011. Daily peak medical inpatient census data were collected, and Pearson correlations were performed.</p>

<p><strong>RESULTS: </strong>Mean weekly response rate was 25%. Perceived workload was correlated with weekly peak of patient census for interns (r = 0.66; P= .00) and senior residents (r = 0.73; P = .00). Many aspects of perceived learning were negatively correlated with perceived workload among interns and residents in "acute care" units. Activities beyond direct patient care (eg, attending conferences, independent reading) revealed more negative correlation than educational experience during rounds. Among seniors, scores of aspects of perceived learning did not correlate with workload.</p>

<p><strong>CONCLUSIONS: </strong>The study found mostly negative associations between high perceived workload and perceived learning, especially for interns. Results suggest varied impact of workload on perceived learning by training year. Although patient care is essential for resident education, higher workload may adversely affect learning opportunities for pediatric trainees. More research is needed to identify if generalizable thresholds of patient census and/or clinical workload cause declines in perceived or real education.</p>

<p>To evaluate the association between economic indicators (unemployment and mortgage foreclosure rates) and volume of investigated and substantiated cases of child maltreatment at the county level from 1990 to 2010 in the Commonwealth of Pennsylvania. County-level investigated reports of child maltreatment and proportion of investigated cases substantiated by child protective services in the Commonwealth of Pennsylvania were compared with county-level unemployment rates from 1990 to 2010, and with county-level mortgage foreclosure rates from 2000 to 2010. We employed fixed-effects Poisson regression modeling to estimate the association between volume of investigated and substantiated cases of maltreatment, and current and prior levels of local economic indicators adjusting for temporal trend. Across Pennsylvania, annual rate of investigated maltreatment reports decreased through the 1990s and rose in the early 2000s before reaching a peak of 9.21 investigated reports per 1,000 children in 2008, during the recent economic recessionary period. The proportion of investigated cases substantiated, however, decreased statewide from 33 % in 1991 to 15 % in 2010. Within counties, current unemployment rate, and current and prior-year foreclosure rates were positively associated with volume of both investigated and substantiated child maltreatment incidents (p &lt; 0.05). Despite recent increases in investigations, the proportion of investigated cases substantiated decreased by more than half from 1990 to 2010 in Pennsylvania. This trend suggests significant changes in substantiation standards and practices during the period of study. Economic indicators demonstrated strong association with investigated and substantiated maltreatment, underscoring the urgent need for directing important prophylactic efforts and resources to communities experiencing economic hardship.</p>

<p><strong>OBJECTIVE: </strong>To develop guidelines for performing initial skeletal survey (SS) in children &lt;24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties.</p>

<p><strong>METHODS: </strong>Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children &lt;24 months old. After discussion on the initial ratings, panelists re-rated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary.</p>

<p><strong>RESULTS: </strong>Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children &lt;12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type.</p>

<p><strong>CONCLUSIONS: </strong>A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse.</p>

<p><strong>BACKGROUND: </strong>Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is difficult. Therefore the purpose of this study is to estimate the proportion of femur fractures in young children attributable to abuse and to identify demographic, injury and presentation characteristics that affect the probability that femur fractures are secondary to abuse.</p>

<p><strong>METHODS: </strong>We conducted a systematic review of published articles written in English between January 1990 and July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in PubMed/MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included study quality indicators. A meta-analysis was not performed due to study population heterogeneity.</p>

<p><strong>RESULTS: </strong>Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old with femur fractures. Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal fractures were associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type, however, were not associated with abuse.</p>

<p><strong>CONCLUSIONS: </strong>Studies commonly find a high proportion of abuse among children less than 12 months old with femur fractures. The reported trauma history, physical examination findings and radiologic results must be examined for characteristics that increase or decrease the likelihood of abuse determination.</p>

<p><strong>OBJECTIVE: </strong>To develop guidelines for performing an initial skeletal survey (SS) for children &lt;24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion.</p>

<p><strong>METHODS: </strong>Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children &lt;24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS.</p>

<p><strong>RESULTS: </strong>Panelists agreed that SS is "appropriate" for 62% (136/219) of scenarios, and "inappropriate" for children ≥ 12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is "necessary" for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants &lt;6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children &lt;12 months.</p>

<p><strong>CONCLUSIONS: </strong>The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising.</p>