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Has This Child Experienced Physical Abuse?: The Rational Clinical Examination Systematic Review

Author/s: 
Sonal N Shah, Hiu-Fai Fong, Suzanne B Haney, Nancy S Harper, Mary Clyde Pierce, Mark I Neuman

Importance: Nearly 100 000 children experience physical abuse each year in the US. Among approximately 2000 annual deaths related to child maltreatment, more than 40% resulted from physical abuse, and half of those children were younger than 1 year. Many of these young children had unidentified abusive injuries before the fatal event.

Objective: To determine the accuracy of clinical and radiologic findings for identifying physical abuse among children who have sustained an injury.

Data sources and study selection: MEDLINE, PubMed Central, and Embase were searched for articles published from 1970 to September 2024. Three authors identified studies describing clinical and radiologic characteristics in children and adolescents undergoing assessment for physical abuse.

Data extraction and synthesis: The number of children with and without each clinical or radiologic finding, and the presence or absence of physical abuse, which had been determined by expert panels, predefined criteria, or standardized scales that quantify the level of concern for abuse, were recorded.

Main outcomes and measures: The sensitivity, specificity, and likelihood ratios (LRs) of each finding for the presence of physical abuse were calculated and the range or calculated summary measures were reported when the finding was evaluated in more than 1 study.

Results: Of 7378 unique articles, 18 studies met inclusion criteria. The prevalence of physical abuse in these 18 studies ranged from 5% to 79%. Studies that were focused on skin findings in children evaluated for trauma showed that the presence of oral injury such as a torn frenulum (positive LR, 6.6 [95% CI, 3.2-14.0]), bruising on the buttocks (positive LR range, 15-83) or neck (positive LR range, 2.2-84), patterned bruises (positive LR range, 2.0-66), and subconjunctival hemorrhage (positive LR range, 5.4-130) were associated with increased likelihood of physical abuse. In studies of hospitalized children with head injury, the presence of retinal hemorrhages (positive LR, 11.0 [95% CI, 4.0-32.0]), seizures (positive LR, 3.9 [95% CI, 2.4-6.5]), hypoxic ischemic injury (positive LR, 3.4 [95% CI, 1.8-6.4]), or a subdural hematoma (positive LR, 3.2 [95% CI, 2.6-3.8]) increased the likelihood of physical abuse. In studies examining children who underwent skeletal surveys, a single fracture (positive LR, 5.9 [95% CI, 2.9-12.0]) or multiple fractures (positive LR, 3.8 [95% CI, 2.4-6.0]) increased the likelihood of physical abuse.

Conclusions and relevance: A detailed physical examination that reveals oral injury, bruises on the buttocks or neck, patterned bruises, and subconjunctival hemorrhage in young children should alert clinicians to the possibility of physical abuse. Findings on neuroimaging and ophthalmologic evaluation in infants and young children with head trauma can help clinicians determine the likelihood of physical abuse.

Keywords 
physical abuse child abuse

Efficacy of interventions for the treatment of irritable bowel syndrome, functional abdominal pain-not otherwise specified, and abdominal migraine in children: a systematic review and network meta-analysis

Author/s: 
Vasiliki Sinopoulou, Jip Groen, Morris Gordon, Ed Mougey, James P Franciosi, Tim G J de Meij, Merit M Tabbers, Marc A Benninga

Background: Many treatments for abdominal pain-related disorders of gut-brain interaction (AP-DGBI) in children have been studied. We aimed to assess the efficacy and safety of all known treatment options for paediatric AP-DGBI.

Methods: For this systematic review and network meta-analysis, we searched Embase, MEDLINE, and CENTRAL databases from inception to Jan 16, 2025, for published randomised controlled trials. We included trials of any treatment for AP-DGBIs (irritable bowel syndrome, functional abdominal pain-not otherwise specified, and abdominal migraine, excluding functional dyspepsia) in children aged 4-18 years. We excluded randomised controlled trials that solely included children with functional dyspepsia, but we included studies in which children with functional dyspepsia were included alongside children with the other AP-DGBI diagnoses and outcome data could not be separated. Data extraction and quality appraisal were performed in duplicate. The primary outcome for this network meta-analysis was author-defined treatment success. Network meta-analysis methodology was used within a frequentist framework using multivariate meta-analysis and outcomes were assessed using the Grading of Recommendations, Assessment, Development and Evaluation methodology. Clinical relevance of effect sizes was interpreted according to consensus definitions.

Findings: Of 19 337 records identified through the database search, 155 records representing 91 original randomised controlled trials were included in the network meta-analysis: these 91 trials comprised 7226 participants (4119 females and 2673 males). 12 studies assessed dietary treatments (n=730), 25 assessed pharmacological treatments (n=2140), 23 assessed probiotic treatments (n=1762), and 35 assessed psychosocial treatments (n=2952). Two treatments were probably more effective for treatment success than control treatments (moderate certainty): hypnotherapy (risk ratio [RR] 4·99 [95% CI 2·15 to 11·57]; large effect size) and cognitive behavioural therapy (CBT; RR 1·99 [95% CI 1·33 to 2·98]; moderate effect size). All other treatments evaluated for treatment success were either not effective or the data were of very low certainty and thus no conclusions could be made.

Interpretation: Hypnotherapy and CBT show moderate certainty for treatment efficacy with clinically relevant effect sizes. No conclusions can be made about the other therapies and treatment success due to very low evidence certainty. Future randomised controlled trials should focus on improving the evidence certainty for those other therapies with regard to core AP-DGBI outcomes.

Funding: None.

Keywords 
abdominal pain Irritable Bowel Syndrome Migraine Disorders gut-brain interaction

Managing obesity in children: a clinical practice guideline

Author/s: 
Geoff D C Ball, Roah Merdad, Catherine S Birken, Tamara R Cohen, Brenndon Goodman, Stasia Hadjiyannakis

Background: Obesity is a complex, chronic, stigmatized disease whereby abnormal or excess body fat may impair health or increase the risk of medical complications, and can reduce quality of life and shorten lifespan in children and families. We developed this guideline to provide evidence-based recommendations on options for managing pediatric obesity that support shared decision-making among children living with obesity, their families, and their health care providers.

Methods: We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We used the Guidelines International Network principles to manage competing interests. Caregivers, health care providers, and people living with obesity participated throughout the guideline development process, which optimized relevance. We surveyed end users (caregivers, health care providers) to prioritize health outcomes, completed 3 scoping reviews (2 on minimal important difference estimates; 1 on clinical assessment), performed 1 systematic review to characterize families' values and preferences, and conducted 3 systematic reviews and meta-analyses to examine the benefits and harms of behavioural and psychological, pharmacologic, and surgical interventions for managing obesity in children. Guideline panelists developed recommendations focused on an individualized approach to care by using the GRADE evidence-to-decision framework, incorporating values and preferences of children living with obesity and their caregivers.

Recommendations: Our guideline includes 10 recommendations and 9 good practice statements for managing obesity in children. Managing pediatric obesity should be guided by a comprehensive child and family assessment based on our good practice statements. Behavioural and psychological interventions, particularly multicomponent interventions (strong recommendation, very low to moderate certainty), should form the foundation of care, with tailored therapy and support using shared decision-making based on the potential benefits, harms, certainty of evidence, and values and preferences of children and families. Pharmacologic and surgical interventions should be considered (conditional recommendation, low to moderate certainty) as therapeutic options based on availability, feasibility, and acceptability, and guided by shared decision-making between health care providers and families.

Interpretation: This guideline will support children, families, and health care providers to have informed discussions about the balance of benefits and harms for available obesity management interventions to support value- and preference-sensitive decision-making

Keywords 
obesity children pediatric obesity

Diagnosis and management of depression in adolescents

Author/s: 
Daphne J Korczak, Clara Westwell-Roper, Roberto Sassi

KEY POINTS
Depression is common among adolescents in Canada and has the potential to negatively affect long-term function and quality of life; despite this, in most affected adolescents depression remains undetected and untreated.

Management requires a multimodal approach, including risk assessment, psychoeducation, psychotherapeutic and pharmacologic treatment, and interventions to address contributing factors.

Support from child and adolescent psychiatrists may be required in the case of diagnostic uncertainty and complex presentations, as well as for patients who do not respond to first-line treatments.

Keywords 
depression depression screening childhood adolescents

What Parents Need to Know About Peanut Allergy

Author/s: 
Alexander W Fender, Jennifer L Thompson, Lindsay A Thompson

Peanut allergy can range from mild to severe, even causing life-threatening reactions.

Peanut allergy affects 1% to 3% of people in the US. It typically develops in young children and usually lasts their whole life. While there is no definitive cure once someone has a peanut allergy at this time, we now know that giving peanut protein to infants starting at an early age can help to prevent development of peanut allergy. The Learning Early About Peanut Allergy (LEAP) trial demonstrated how early introduction of peanut can help prevent children from becoming allergic to peanut.

Keywords 
peanut allergy Food Allergies Skin Tests children

Pediatric sialorrhea (drooling)

Author/s: 
Karan Gandhi, Julie E Strychowsky, Breanna A Chen

Sialorrhea is common in children with neurologic impairment

Sialorrhea can be normal in children with typical development until age 4 years. It occurs in as many as 44% of children with cerebral palsy.1 It typically results from poor oral motor control and fluctuates alongside the child’s developmental trajectory. Reversible contributors such as nasal obstruction, dental issues, and medication effects (e.g., benzodiazepines and clozapine) should be considered.

Keywords 
drooling children Otolaryngology oral health pediatrics

Recommended Immunizations for Children 7–18 Years Old, United States, 2024

This parent-friendly schedule is recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), and American Academy of Family Physicians (AAFP).

Keywords 
Immunization Immunization Schedule vaccination vaccination recommendations
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