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 < 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.

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WHAT'S KNOWN ON THIS SUBJECT: Rates of performing skeletal survey (SS) for young children presenting with fractures and at risk for abuse vary substantially across providers, with disparities associated with patients' characteristics. Lack of consensus regarding indications for SS also contributes to this variation. WHAT THIS STUDY ADDS:The results of this study provide a set of explicit consensus guidelines, based on the literature and on the knowledge of experts from several medical specialties, for identifying children with fractures who should undergo an initial SS.abstract OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in children ,24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. METHODS: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 ,24 months old. After discussion on the initial ratings, panelists rerated 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. RESULTS: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 ,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. CONCLUSIONS: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. Pediatrics 2014;134:45-53

BackgroundClinical 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.MethodsWe 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.ResultsAcross 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.ConclusionsStudies 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.

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