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Importance Child maltreatment is a risk factor for poor health throughout the life course. Existing estimates of the proportion of the U.S. population maltreated during childhood are based on retrospective self-reports. Records of officially confirmed maltreatment have been used to produce annual rather than cumulative counts of maltreated individuals. Objective To estimate the proportion of U.S. children who are substantiated or indicated for maltreatment by Child Protective Services (referred to as confirmed maltreatment) by age 18. Design, Setting, and Participants The National Child Abuse and Neglect Data System (NCANDS) Child File includes information on all U.S. children with a confirmed report of maltreatment, totaling 5,689,900 children (2004-2011). We developed synthetic cohort life tables to estimate the cumulative prevalence of confirmed childhood maltreatment by age 18. Main Outcome Measure The cumulative prevalence of confirmed child maltreatment between birth and age 18 by race/ethnicity, sex, and year. Results At 2011 rates, 12.5% [95% CI: 12.5%, 12.6%] of U.S. children will experience a confirmed case of maltreatment by age 18. Girls have a higher cumulative prevalence than boys (13.0% [95% CI: 12.9%, 13.0%] vs. 12.0% [95% CI: 12.0%, 12.1%]). Black (20.9% [95% CI: 20.8%, 21.1%]), Native American (14.5% [95% CI: 14.2%, 14.9%]), and Hispanic (13.0% [95% CI: 12.9%, 13.1%]) children have higher prevalences than White (10.7% [95% CI: 10.6%, 10.8%]) or Asian/Pacific Islander (3.8% [95% CI: 3.7%, 3.8%]) children. The risk of maltreatment is highest in the first few years of life; 2.1% [95% CI: 2,1%, 2.1%] of children have confirmed maltreatment by age 1, and 5.8% [95% CI: 5.8%, 5.9%] have confirmed maltreatment by age 5. Estimates from 2011 were consistent with those from 2004-2010. Conclusions and Relevance Annual rates of confirmed child maltreatment dramatically understate the cumulative number of children confirmed as maltreated during childhood. Our findings indicate that 1 in 8 U.S. children will be confirmed as victims of maltreatment by age 18, far greater than the 1 in 100 children whose maltreatment is confirmed annually. For Black children, the cumulative prevalence is 1 in 5; for Native American children, it is 1 in 7.

Key Points Question How have US mortality rates for pediatric opioid poisonings changed over the past 2 decades? Findings In this cross-sectional study, 8986 children and adolescents died between 1999 and 2016 from prescription and illicit opioid poisonings. During this time, the mortality rate increased 268.2%. Meaning Pediatric-specific and family-centered interventions are needed to address pediatric opioid poisonings, a growing public health problem in the United States.

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Developed and validated an instrument for identifying children perceived as vulnerable. Mothers of 1,095 children, aged 4-8 years, completed interviews that included the original 12-item Child Vulnerability Scale. Eight items that correlated best with each of two major variables that contribute to vulnerability were retained in the revised scale and a cutoff score was identified for children perceived as vulnerable. The internal consistency of the revised scale was good. Using the revised scale, 10.1% of children were identified as perceived vulnerable. Children categorized as perceived vulnerable had a significant increase in behavior problems and acute medical visits. The revised Child Vulnerability Scale should be useful in providing a better understanding of the causes and effects of an important factor in child development.

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IMPORTANCE National data show a parallel relationship between recent trends in opioid prescribing practices and hospitalizations for opioid poisonings in adults. No similar estimates exist describing hospitalizations for opioid poisonings in children and adolescents. OBJECTIVE To describe the incidence and characteristics of hospitalizations attributed to opioid poisonings in children and adolescents. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of serial cross-sectional data from a nationally representative sample of US pediatric hospital discharge records collected every 3 years from January 1, 1997, through December 31, 2012. The Kids' Inpatient Database was used to identify 13 052 discharge records for patients aged 1 to 19 years who were hospitalized for opioid poisonings. Data were analyzed within the collection time frame. MAIN OUTCOMES AND MEASURES Poisonings attributed to prescription opioids were identified by codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. In adolescents aged 15 to 19 years, poisonings attributed to heroin were also identified. Census estimates were used to calculate incidence per 100 000 population. The Cochran-Armitage test for trend was used to assess for changes in incidence over time. RESULTS From 1997 to 2012, a total of 13 052 (95% CI, 12 500-13 604) hospitalizations for prescription opioid poisonings were identified. The annual incidence of hospitalizations for opioid poisonings per 100 000 children aged 1 to 19 years rose from 1.40 (95% CI, 1.24-1.56) to 3.71 (95% CI, 3.44-3.98), an increase of 165% (P for trend, <.001). Among children 1 to 4 years of age, the incidence increased from 0.86 (95% CI, 0.60-1.12) to 2.62 (95% CI, 2.17-3.08), an increase of 205% (P for trend, <.001). For adolescents aged 15 to 19 years, the incidence increased from 3.69 (95% CI, 3.20-4.17) to 10.17 (95% CI, 9.48-10.85), an increase of 176% (P for trend, <.001). In this age group, poisonings from heroin increased from 0.96 (95% CI, 0.75-1.18) to 2.51 (95% CI, 2.21-2.80), an increase of 161% (P for trend, <.001); poisonings involving methadone increased from 0.10 (95% CI, 0.03-0.16) to 1.05 (95% CI, 0.87-1.23), an increase of 950% (P for trend, <.001). CONCLUSIONS AND RELEVANCE During the course of 16 years, hospitalizations attributed to opioid poisonings rose nearly 2-fold in the pediatric population. Hospitalizations increased across all age groups, yet young children and older adolescents were most vulnerable to the risks of opioid exposure. Mitigating these risks will require comprehensive strategies that target opioid storage, packaging, and misuse.

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Pediatrics 2014;133:e477-e489 INTRODUCTIONFractures are the second most common injury caused by child physical abuse; bruises are the most common injury. 1 Failure to identify an injury caused by child abuse and to intervene appropriately may place a child at risk for further abuse, with potentially permanent consequences for the child. 2-4 Physical abuse may not be considered in the physician' s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse. 5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed. 3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes. 3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted. 2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and family. To identify child abuse as the cause of fractures, the physician must take into consideration the history, the age of the child, the location and type of fracture, the mechanism that causes the particular type of fracture, and the presence of other injuries while also considering other possible causes. DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted InjuriesFractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries. [6][7][8] In infants and toddlers, physical FROM THE AMERICAN ACADEMY OF PEDIATRICSGuidance for the Clinician in Rendering Pediatric Care by guest on May 11, 2018 http://pediatrics.aappublications.org/ Downloaded from abuse is the cause of 12% to 20% of fractures. 9 Although unintentional fractures are much more common than fractures caused by child abuse, the physician needs to remain aware of the possibility of inflicted injury. Although some fracture types are highly suggestive of physical abuse, no pattern can exclude child abuse. 10,11 Specifically, it is important to recognize that any fracture, even fractures that are commonly noninflicted injuries, can be caused by child abuse. Certain details that can help the physician determine whether a fracture was caused by abuse rather than unintentional injury include the hist...