Pediatric literature gives insight on new therapies for children

Key Points

Seattle - Recent publications in pediatric literature are driving practice changes relative to conditions ranging from Kawasaki disease to child abuse to hemangiomas.

Perhaps the most important recent pediatric publication many dermatologists may have missed addresses evaluating abuse versus accidental trauma in infants and young children, says Robert Sidbury, M.D., M.P.H., chief of pediatric dermatology and associate professor of pediatrics, Seattle Children's Hospital.

"This is an extraordinarily difficult scenario, so having any sort of objective evidence upon which to base your recommendation" to call in a child-services agency is extremely helpful, he says.

"It's not going to make it an easy evaluation, but it will make it less prosecutorial," Dr. Sidbury says.

Predicting abuse

To that end, investigators analyzed the bruises of 95 children up to 48 months old in light of demographic and other factors, attempting to develop a predictive model. These researchers identified location (torso, ear and neck in children less than 4 years old) as one predictive factor for nonaccidental trauma (Pierce MC, Kaczor K, Aldridge S, et al. Pediatrics. 2010;125(1):67-74. Epub 2009 Dec 7. Erratum in: Pediatrics. 2010;125(4):861). "That doesn't mean every ear bruise is nonaccidental, but it's one more thing to factor in when trying to make this difficult decision," Dr. Sidbury says.

Similarly, the presence of multiple bruises may suggest nonaccidental trauma, while the presence of any bruises on infants less than 4 months old prove predictive in the study. "If they don't cruise, they don't bruise," he says, meaning that infants too young to crawl generally don't bruise themselves.

Additionally, Dr. Sidbury says he looks for the "hair on the back of my neck sign: Is there anything about the interaction between parent and child that makes me uncomfortable?" Children who act overly passive or frightful with him also raise his suspicion, he says.

"Don't use any of these factors in isolation," he cautions, "but together they paint a picture and allow you to make a more educated evaluation." Whenever he finds himself considering such factors, Dr. Sidbury says, he seeks input from the child's pediatrician.

"As awful as missing child abuse is, falsely raising this specter can be very damaging to a family," he says.