Monday, October 12, 2015

An Ugly Reality: A Study of Developmental Behavior Of Children Born From Sexual Violence

By: Lydia Furman, MD,  Assistant Editor

      In a recently released study in Pediatrics, Dr. Rouhani et al. (doi: 10.1542/peds.2014-3373) presented us with a must read article about the burdens and experiences of women who are raising children conceived through sexual violence in the Democratic Republic of Congo (DRC) (ref here).  My first thought on reading this incredible article was that one does not need to go to the Democratic Republic of Congo (DRC) to meet women who are raising children conceived through sexual violence. Their conclusions are logical and intuitive, yet ground breaking, and I believe I can apply their “lessons” in my own practice. These authors interviewed over 700 women who are raising a child conceived through sexual assault. They used a specific method of locating hard-to-reach populations, called respondent driven sampling, in which ten initial identified women each recruited three other women, who then recruited three other women, and so on until the full population was identified.
      Please read the article to immerse yourself in the study, because likely you will find other parts of the work more meaningful than what captured me. What impressed me most was the extraordinary resilience of the women and of the maternal-child relationship.  Over one third of women reported that their community stigmatized their child, and over one third reported that their community stigmatized them personally. “Perceived acceptance of the child” by spouse, community and family seemed surprisingly low to me, given that the entire community was exposed to known, ongoing and multiple sexual assaults. Yet, despite all of this, 80.5% of women had “positive regard” (questions drawn from the Parental Stress Scale) for their child and 73.0% had “high attunement” (defined as “…awareness of, sensitivity to, and responsiveness to the child’s needs…”). So in the face of incomprehensible stress and challenge, including seeing their assailant and recalling the assault when looking at their child, the great majority of women are raising their children with engagement and kindness, as best one can understand. The authors’ multivariate analysis examines this question quantitatively and expands understanding further.
      While the upheaval in The DRC is notorious for the horror of widespread sexual violence, utilized as a weapon of war, the problems that women must face in raising a child who is the product of a rape respect no geographic boundaries. An issue that clinicians practicing in the US may have to recognize among women raising a child conceived through sexual violence is the complex racism of skin tone, which rears its ugly head when mother and child have obviously different skin colors or eye colors, prompting family or non-family members to ask about paternity. In the United States (US) it may be more possible for women to avoid stigma by non-acknowledgement of the sexual violence (e.g. by asking for non-inclusion of the information in the child’s medical record), but this does not permit future providers to treat the mother optimally (since she may have depression, anxiety, or other sequelae that are then not recognized), and this also makes support of any discussion she may want or need to have about conceiving in the setting of sexual violence   almost impossible.
       While Dr. Rouhani and colleagues studied a population in whom approximately 40% of women experienced sexual violence, it is sobering to realize that the Centers for Disease Control and Prevention (CDC) reports that “nearly one in five (18.3%) of women (in the US) … reported experiencing rape at some time in their lives” ( ). While a continent and world away for some, this is a reality we cannot ignore. Ultimately prevention is the best cure, but in the meantime, removing stigma is critical.  Work is underway to support de-stigmatization of sexual violence in the DRC, for example through the Harvard Humanitarian Initiative (, and a brief search reveals relatively limited initiatives in the US, most primarily focused on domestic violence (for example, Triumph, a network for survivors of domestic violence, We have work to do, and the superb research of Dr. Rouhani and colleagues in the DRC is a wakeup call to all of us.

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Friday, October 9, 2015

Hospital Variation on Care Utilization by Children with Medical Complexity: Does It Happen and What Do We Do about It?

By: Lewis First, MD, MS; Editor-in-Chief      

          Thanks to the information we can get from payer claim databases, we can learn a lot about variations in care delivery regarding different patient populations. One of those populations is the group of children with medical complexity who receive care daily at our children’s hospitals.  So how consistent is the care delivery across hospitals? Ralston et al. (doi: 10.1542/peds.2014-3920), in an article being released this month in our journal, performed a retrospective population-based observational cohort study that examined payer claims of all children from 1 month to 18 years with medical complexity in Maine, New Hampshire and Vermont.  Sadly there is more variation in care across the 6 hospitals studied in these states than one might suspect.  Where are these variations occurring?  Virtually everywhere--inpatient, outpatient, in intensive care units, and in the emergency department.  Even use of ancillary tests like radiology showed substantive variation.
So what does a study like this suggest?  Drs. Thomson and Shah offer a commentary on variability in health care utilization that accompanies this study and suggest how we can learn from the results being shared in this and other care variation studies that our journal and many others seem to publishing on a frequent basis.  We encourage you to read both the study and commentary and gain a better understanding of how this data might identify best practices for these patients that can then be shared and standardized across hospitals and across states. \
 If your state has an all-payer claims database, you might want to explore what that database is saying about your utilization rates and compare them to the data in this study. If the focus of care nowadays is on managing populations with high quality and lower cost, it is studies like this one that can set the stage to make that happen. 

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Wednesday, October 7, 2015

Text Message Reminders for Adolescent Vaccination: Is It Worth A Click?

By: Terrill Bravender, MD, MPH,  

      Does your office have a reminder system for patients? Most offices have some sort of automated
reminder system for upcoming appointments, usually a letter sent home or a reminder phone call. What about calls for delayed health maintenance visits or vaccines? If so, are these also mailed letters or phone calls? Or perhaps your office is more cutting edge and uses email reminders via a patient portal. Is this helpful for reaching your adolescent patients? After all, my 15 year old son has told me multiple times: “email is for old people, you should just text me instead.” As far back as 2010, adolescents averaged sending and receiving about 4,000 texts per month. More recent data are a bit more difficult to quantify, since SMS (short message service) texts via your cell phone provider are only one way to send electronic messages.
      Facebook messenger and iMessage are not quantified by cell phone providers, and temporary messaging services such as Snapchat, Wickr, and Slingshot, and even anonymous services such as YickYak have become more and more popular. Regardless of the service used, the “phone” part of an adolescent’s cell phone seems to have become the least important component, and I’m not even sure where email falls on the list. Many physicians are cognizant of this, and have used text messaging and other similar technologies to improve asthma care, diabetes care, and even sunscreen use.
       Electronically connecting with teenagers may be helpful for those health-related behaviors over which teens have control, but what about trying to get teens into the clinic? Teens have low rates of adherence with annual exam recommendations, and their immunization rates remain unacceptably low. Most adolescents depend on their parents to make appointments and provide transportation, so texting teens about the need for annual health exams or immunizations seems unlikely to have much of an effect.
      In this issue of Pediatrics, Dr. O'Leary et al. (doi: 10.1542/peds.2015-1089) report their experience using a text messaging reminder system for parents. Teens followed by various private practices and safety-net clinics who were due to vaccines or well visits were randomized to either usual care (no messages), or to have their parents receive a text message asking for a response. Parents could respond via text asking for the clinic to call to make an appointment, indicate that they would call the clinic themselves, or text STOP to get the messages to stop.
      Although only 30% of parents responded to the texts, most of those who responded asked for the clinic to call them to make an appointment. Members of the group who were sent text messages (regardless of response) were more likely to receive needed immunizations. The authors also analyzed the costs associated with this intervention, which were moderate but not negligible. However, with increasingly prevalent use of electronic medical records, the intervention seems to have great potential for automation. So when setting up such a system, it looks like we shouldn’t forget to text the parents, too.

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Tuesday, October 6, 2015

Are You on Guard for Sentinel Injuries that Could Require Testing for Child Physical Abuse?

By: Lewis First, MD, MS; Editor-in-Chief      

         We are certainly aware of our need to be vigilant for child abuse and neglect—and yet despite our best efforts, abuse can still go unsuspected and undetected.  Recently the identification of “sentinel” injuries have been noted as perhaps being a harbinger to look harder for signs of physical abuse—but just how often does such an injury indicate abuse—and just what are these “sentinel injuries”?  Lindberg et al. (doi: 10.1542/peds.2015-1487) share with us the rates of abuse found in the setting of sentinel injuries across major children’s hospitals using a retrospective analysis of data obtained on 30,355 children with sentinel injuries.   
       The key take-away from this study is that some sentinel injuries such as rib fractures, abdominal trauma, or intracranial hemorrhage indicate a high risk of abuse and yet the diagnostic workup for abuse varies greatly across children’s hospitals when these injuries present.  To gain a better understand of just what counts as a sentinel injury and what diagnostic studies might be considered if you need to look harder for signs of nonaccidental physical abuse in the setting of these injuries, read this study and you’ll learn a lot more.   
        As a result, perhaps you’ll do more to evaluate when these injuries present to you or ask that more be done when you are called about these children being evaluated in your local emergency department.

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