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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, Mary Clyde Pierce, Nancy S Harper, 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 
The Rational Clinical Examination Trauma and Injury child abuse Psychiatry and Behavioral Health Child and Adolescent Psychiatry

Screening for Intimate Partner Violence and Caregiver Abuse of Older or Vulnerable Adults

Author/s: 
US Preventive Services Task Force Recommendation Statement, Michael Silverstein, John B Wong, Esa M Davis, David Chelmow, Tumaini Rucker Coker, Alicia Fernandez, Ericka Gibson, Carlos Roberto Jaén, Marie Krousel-Wood, Sei Lee, Wanda K Nicholson, Goutham Rao, John M Ruiz, James Stevermer, Joel Tsevat, Sandra Millon Underwood, Sarah Wiehe

IMPORTANCE: Intimate partner violence (IPV) affects millions of US residents across the lifespan and is often unrecognized. Abuse of older or vulnerable adults by a caregiver or someone else they may trust is common and can result in significant injury, death, and long-term adverse health consequences.
OBJECTIVE: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for IPV, abuse of older adults, and abuse of vulnerable adults.
POPULATION: The recommendation on screening for IPV applies to adolescents and adults who are pregnant or postpartum, and women of reproductive age. The recommendation on screening in older and vulnerable adults applies to persons without recognized signs and symptoms of abuse or neglect.
EVIDENCE ASSESSMENT: The USPSTF concludes that screening for IPV in women of reproductive age, including those who are pregnant and postpartum, and providing or referring those who screen positive to multicomponent interventions has a moderate net benefit. The USPSTF concludes that the benefits and harms of screening for caregiver abuse and neglect in older or vulnerable adults are uncertain and that the balance of benefits and harms cannot be determined.
RECOMMENDATION: The USPSTF recommends that clinicians screen for IPV in women of reproductive age, including those who are pregnant and postpartum. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for caregiver abuse and neglect in older or vulnerable adults.

Keywords 
intimate partner violence abuse caregiver abuse Adults

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

Adolescent-Centered Sexual and Reproductive Health Communication

Author/s: 
Bianca A Allison, Tracey A Wilkinson, Julie Maslowsky

This JAMA Insights explores how clinicians can effectively communicate person-centered health care information to adolescents regarding sexual and reproductive health, contraception, and sexually transmitted infection testing and treatment.

Keywords 
contraception adolescent sexual behavior

Stimulant Management of Attention-Deficit/Hyperactivity Disorder for the Pediatric Prescriber: A Review of Stimulant-Dosing Strategies and An Overview of New Stimulants

Author/s: 
Courtney Romba, Jasleen Singh

Pediatricians are often the first providers to assess and treat attention-deficit/hyper-activity disorder (ADHD) in youth. While a variety of pharmacological and psychosocial interventions exist for ADHD, stimulants remain the first-line medication treatment. Many stimulant formulations now exist, providing the pediatric prescriber with a diverse repertoire of treatment options. This article is tailored to the pediatric prescriber in the primary care setting and discusses stimulant management, with emphasis on dosing equivalencies, common stimulant-dosing strategies, and newer stimulants.

Keywords 
Pediatricians adolescent ADHD

Adolescent-Centered Sexual and Reproductive Health Communication

Author/s: 
Bianca A Allison, Tracey A Wilkinson, Julie Maslowsky

This JAMA Insights explores how clinicians can effectively communicate person-centered health care information to adolescents regarding sexual and reproductive health, contraception, and sexually transmitted infection testing and treatment.

Keywords 
adolescent sexuality sexually transmitted diseases

Obesity in Adolescents: A Review

Author/s: 
Aaron S Kelly, Sarah C Armstrong, Marc P Michalsky, Claudia K Fox

Importance: Obesity affects approximately 21% of US adolescents and is associated with insulin resistance, hypertension, dyslipidemia, sleep disorders, depression, and musculoskeletal problems. Obesity during adolescence has also been associated with an increased risk of mortality from cardiovascular disease and type 2 diabetes in adulthood.

Observations: Obesity in adolescents aged 12 to younger than 18 years is commonly defined as a body mass index (BMI) at the 95th or greater age- and sex-adjusted percentile. Comprehensive treatment in adolescents includes lifestyle modification therapy, pharmacotherapy, and metabolic and bariatric surgery. Lifestyle modification therapy, which includes dietary, physical activity, and behavioral counseling, is first-line treatment; as monotherapy, lifestyle modification requires more than 26 contact hours over 1 year to elicit approximately 3% mean BMI reduction. Newer antiobesity medications, such as liraglutide, semaglutide, and phentermine/topiramate, in combination with lifestyle modification therapy, can reduce mean BMI by approximately 5% to 17% at 1 year of treatment. Adverse effects vary, but severe adverse events from these newer antiobesity medications are rare. Surgery (Roux-en-Y gastric bypass and vertical sleeve gastrectomy) for severe adolescent obesity (BMI ≥120% of the 95th percentile) reduces mean BMI by approximately 30% at 1 year. Minor and major perioperative complications, such as reoperation and hospital readmission for dehydration, are experienced by approximately 15% and 8% of patients, respectively. Determining the long-term durability of all obesity treatments warrants future research.

Conclusions and relevance: The prevalence of adolescent obesity is approximately 21% in the US. Treatment options for adolescents with obesity include lifestyle modification therapy, pharmacotherapy, and metabolic and bariatric surgery. Intensive lifestyle modification therapy reduces BMI by approximately 3% while pharmacotherapy added to lifestyle modification therapy can attain BMI reductions ranging from 5% to 17%. Surgery is the most effective intervention for adolescents with severe obesity and has been shown to achieve BMI reduction of approximately 30%.

Keywords 
obesity adolescents overweight children
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