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Biomedical subjects

J M Leventhal

Publications and source records attributed to J M Leventhal.

At least 55 records · Page 3Linked to original sources
PubMed1991

Long-bone fractures in young children: distinguishing accidental injuries from child abuse.

While testifying in child abuse cases, physicians have been frustrated by the lawyer who asks, "Doctor, how did this injury happen?" The medical records and radiographs of 215 children younger than the age of 3 with fractures evaluated by a pediatric service during a 5-year period were retrospectively reviewed in an attempt to elucidate the mechanism of childhood fractures. Based on these reviews, two clinicians and two pediatric radiologists rated the likelihood that the fracture was either accidental or due to child abuse. Long-bone fractures were strongly associated with abuse. This report focuses on the 39 children with either humeral or femoral fractures. Fourteen children had humerus fractures. Eleven were considered to be the result of child abuse, and 3 the result of accidents. The latter 3 were supracondylar elbow fractures in children who fell from a tricycle, a rocking horse, or downstairs. Humerus fractures other than supracondylar fractures were all found to be due to abuse. There were 25 femur fractures. Nine were found to be from abuse, 14 were found to be from accidents, and 2 could not be rated. Sixty percent of femur fractions in infants younger than 1 year of age were due to abuse. Although it is taught that femur fractures in young children are inflicted unless proven otherwise, in this study it was found that femur fractures often are accidental and that the femur can be fractured when the running child trips and falls.

Accidental Falls↗
PubMed1990

Predictors of recurrent febrile seizures: a metaanalytic review.

The 1980 National Institutes of Health Consensus Development Conference on Febrile Seizures identified five circumstances in which it might be appropriate to consider anticonvulsant prophylaxis after a first febrile seizure: (1) a focal or prolonged seizure, (2) neurologic abnormalities, (3) afebrile seizures in a first-degree relative, (4) age less than 1 year, and (5) multiple seizures occurring within 24 hours. We performed a metaanalysis of 14 published reports to evaluate the strength of association between each of these indications and recurrent febrile seizures. Young age at onset (less than or equal to 1 year) and a family history of febrile seizures (not listed in the recommendations) each distinguished between groups with approximately a 30% versus a 50% risk of recurrence. Family history of afebrile seizures was not consistently associated with an increased risk. Focal, prolonged, and multiple seizures were associated with only a small increment in risk of recurrence. The data were not adequate to assess the risk associated with neurologic abnormalities. By considering children with combinations of risk factors, some studies were able to distinguish between groups with very low and very high recurrence risks. Only age at onset was consistently predictive of having more than one recurrence. These results suggest that the great majority of children who have a febrile seizure do not need anticonvulsant treatment even if one of the factors listed in the Consensus Statement is present, and that the rationale and indications for treating febrile seizures need to be reconsidered.

Age Factors↗
PubMed1990

Relationship between infant feeding and infectious illness: a prospective study of infants during the first year of life.

Prior studies investigating the relationship between infant feeding and infectious illnesses in developed countries have provided conflicting data about whether breast-feeding protects against common infectious illnesses early in life. These conflicts may in part be due to the failure to consider the following methodologic issues: (1) collecting data prospectively at frequent intervals for active surveillance of the detection of infections and of feeding practices, (2) specifying what is meant by infectious illnesses and breast-feeding, (3) controlling for confounding variables such as social class or presence of siblings in the household, and (4) applying appropriate analytical strategies to a population in which both feeding and exposure to illness change over time. A total of 500 infants born consecutively in a university-affiliated community hospital in Copenhagen, Denmark, were studied prospectively for the first 12 months of life by means of a detailed, monthly, mailed questionnaire that focused on feeding practices and illnesses (overall response rate, 73%). The percentage of infants who were completely or mostly breast-fed decreased from 88% at 1 month to 20% at 12 months of age. After adjustment for major covariates, no statistically significant relationship was found between the type of infant feeding and the incidence of four categories of infectious illnesses: gastroenteritis, upper respiratory illness, otitis media, and lower respiratory illness. The adjusted incidence density ratio for gastroenteritis was 1.067 (95% confidence interval = 0.982, 1.226) and for upper respiratory illnesses 0.984 (95% confidence interval = 0.883, 1.096).(ABSTRACT TRUNCATED AT 250 WORDS)

Algorithms↗
PubMed1989

Identification during the postpartum period of infants who are at high risk of child maltreatment.

To determine whether clinicians correctly identify newborn infants who are at high risk of child maltreatment, we examined the outcomes of high-risk and non-high-risk children. Infants who were born at Yale-New Haven Hospital from 1979 to 1981 and who were referred by clinicians during the postpartum period to the hospital's child abuse registry because they were considered at high risk of child abuse or neglect became the high-risk group. For each high-risk infant, a comparison infant was selected and matched according to date of birth, gender, race, and method of payment for the hospitalization. For both groups, the occurrence of maltreatment was ascertained by reviewing the medical records until the child's fourth birthday. Each injury for which medical care was sought was classified into one of seven categories (from definite child abuse to accident) by a pediatrician who was unaware of the child's risk status. Information also was recorded about nonorganic failure to thrive and changes in the child's caretaker. Maltreatment (defined as abuse or neglect) occurred more frequently in the high-risk group than the comparison group (adjusted matched odds ratio = 4.3; 95% confidence interval = 1.41, 6.93; p less than 0.001), as did poor weight gain from a nonorganic cause (matched odds ratio = 7.0; 95% confidence interval = 1.59, 30.79; p less than 0.01) and changes in the child's caretaker (matched odds ratio = 9.0; 95% confidence interval = 3.80; 20.55; p less than 0.001). We conclude that as early as the postpartum period, clinicians can identify some families who are at high risk of maltreatment and other major adverse outcomes resulting from poor parenting.

Child Abuse↗
PubMed1989

Anatomically correct dolls used in interviews of young children suspected of having been sexually abused.

To determine the value of using anatomically correct dolls in diagnostic interviews of young children suspected of being sexually abused, the records of 83 children who were less than 7 years of age and who were evaluated at Yale-New Haven Hospital because of a suspicion of sexual abuse were reviewed. The dolls were used in 60 cases (72%). When the dolls were used, children provided significantly more information than by interview alone about what had happened and about the identity of the suspected perpetrator. Children less than 3 years of age, however, were unable to provide details about the abuse despite the use of the dolls. The ratings of the likelihood that sexual abuse had occurred were based on all of the information in the case including that obtained through the diagnostic interview with the dolls. When these ratings were compared with the ratings based on evidence obtained solely from noninterview data, the likelihood of abuse was higher in 35% of the cases. It was concluded that substantially more information is provided by young children when anatomically correct dolls are used and that the likelihood of detection of abuse is increased when information from the child is included in the assessment.

Child↗
PubMed1988

Cigarette smoking and alcohol consumption during pregnancy by Danish women and their spouses--a potential source of fetal morbidity.

The relationship between cigarette smoking and alcohol consumption behavior during pregnancy was examined in a select group of Danish women and their spouses. Five-hundred consecutive women who had uncomplicated pregnancies and delivered full-term babies were interviewed 3+ days postpartum. Information was collected about smoking and drinking behavior of all household members during pregnancy. We found (1) a high percentage of Danish women (70%) and their spouses (80%) consume alcohol during pregnancy, and (2) a significant correlation between maternal and paternal smoking (r = .25, P .0001) and maternal and paternal drinking (r = .35, P .0001). These data suggest that even though the potential dangers of cigarette smoking and alcohol consumption during pregnancy have been well publicized, there is still a high percentage of women who participate in such behaviors. There may also exist an important role for the father in affecting these two behaviors and therefore indirectly affecting fetal development.

Adolescent↗
PubMed1988

Have there been changes in the epidemiology of sexual abuse of children during the 20th century?

Have there been changes in the epidemiology of sexual abuse of children during the 20th century? To explore this question, a comparison was made between the results of the survey conducted by Alfred Kinsey and colleagues in the 1940s of women in the United States, the majority of whom were born between 1900 and 1929, and the results of more recent studies of the epidemiology of sexual abuse. In Kinsey's study, 24% of 4,441 women reported at least one episode of sexual abuse before adolescence; in 49% of the episodes, the perpetrator was not known to the child and, in 50%, the abuse did not involve bodily contact. These findings are compared to the results of more recent epidemiologic surveys, particularly Russell's study conducted in San Francisco in 1978. Although there are important differences in the methodologies used by Kinsey and Russell, it is likely that changes have occurred in the prevalence and nature of sexual abuse in the 20th century. Russell described a higher prevalence of sexual abuse, a greater proportion of perpetrators who were relatives or adults known to the child, and a greater proportion of serious types of sexual abuse.

Adolescent↗
PubMed1987

Usefulness of chest radiographs in children with acute lower respiratory tract disease.

To determine how frequently and under what circumstances the chest radiograph changes pre-x-ray diagnoses and plans for management of suspected acute lower respiratory tract disease, experienced pediatricians performed a three-phased sequential evaluation (observation, history, physical examination), determined an initial diagnosis and the need for a chest radiograph after each phase, and recorded pre- and post-x-ray diagnoses and plans of management. Of the 102 children evaluated, the chest radiograph resulted in a change of the pre-x-ray diagnosis in 21% and pre-x-ray management plans in 16%. In the majority of these cases, a diagnosis previously considered less likely was "ruled in" or therapy was instituted rather than withheld. More important, when the pattern of decision making was consistent, with the initial diagnosis and the need for a chest radiograph remaining the same throughout all phases, the chest radiograph resulted in a change of pre-x-ray diagnosis in five (10%) of 48 patients, compared with a change in 16 (30%) of 54 when the pattern was inconsistent (P less than 0.02). Similarly, when the pattern was consistent, the pre-x-ray management was modified in only three (6%) of 48 patients versus 13 (24%) of 54 inconsistent cases (P less than 0.015). Chest radiographs are least useful when information from sequential observation, history, and physical examination is consistent in suggesting the same diagnosis and need for a chest radiograph. Radiographs appear to have greater impact on diagnosis and management when any inconsistencies arise.

Acute Disease↗
PubMed1987

Is intrauterine growth retardation a risk factor for child abuse?

A case-control study was conducted to determine whether infants with intrauterine growth retardation are at an increased risk of child abuse. Case children were those who had been born at Yale-New Haven Hospital and were reported to the hospital's child abuse committee because they had been physically abused. For each case, one control child was chosen from the hospital's log of births and matched to the case child by age, gender, race of the mother, method of payment for the hospitalization, and the provider of the child's health care at the time of birth. Infants were defined as having intrauterine growth retardation if they had either a ponderal index or a birth weight that was less than the tenth percentile for gestational age using the Kansas City or Denver growth standards. We identified 117 case-control pairs that met those criteria. The matched odds ratios for each of the four definitions of intrauterine growth retardation were less than one, indicating that infants with intrauterine growth retardation are at a decreased risk of abuse. The matched odds ratio for a low ponderal index according to the Kansas City standard was 0.4 (95% confidence interval 0.19, 0.83). This result was not affected by such possible confounding factors as the mother's age. We conclude that infants with intrauterine growth retardation are not at an increased risk and may be at a decreased risk of physical abuse.

Child↗
PubMed1986

Effect of passive smoking on birth-weight.

500 consecutive Danish women who had full-term babies were interviewed on the third or fourth day post partum and asked about smoking in all household members. Exposure to smoking by the mother was found to reduce birth-weight, and indirect or passive exposure to smoking by the father had nearly as large (66%) an effect. On average, birth-weight was reduced by 120 g per pack of cigarettes (or cigar/pipe equivalent) smoked per day by the father. This relation remained statistically significant after controlling for mother's age, parity, alcohol and tobacco consumption during pregnancy, illness during pregnancy, and social class and sex of the baby. The effect of passive smoking was greatest in the lower social classes.

Adult↗
PubMed1986

Studies of breast-feeding and infections. How good is the evidence?

We assessed the extent to which studies of the association between breast-feeding and infection met four important methodological standards that relate to both the scientific validity and the generalizability of the studies. Of the 20 studies (14 cohort, six case-control), only six met three or four of the methodological standards. Four of these six studies found that breast-feeding was not protective against infections and two found that breast-feeding was protective against infections. In the three studies in which statistical adjustments were made for three additional potentially important confounding variables--size of the family, smoking of cigarettes by the mother, and the mother's level of education-the apparent protective effect of breast-feeding against respiratory tract infections disappeared after the adjustments were made. We found that most of the studies have major methodological flaws that may have compromised their conclusions. The studies that met important methodological standards and controlled for confounding variables suggest that breast-feeding has at most a minimal protective effect in industrialized countries.

Breast Feeding↗
PubMed1986

Clinical data used by pediatric residents to assess parenting.

To determine how pediatricians assess parenting at well-child visits, pediatric residents were interviewed following the well-child visit of a child less than 24 months of age. Using a structured format, the residents were interviewed about their judgments concerning the characteristics of the mother just seen and the data used to make these judgments. In addition, ratings were made of the quality of the descriptions of the parents. Fifty interviews, 2 each with 25 residents, were completed. Residents described the parenting abilities of 82% of the mothers in predominantly positive terms and 18% in negative terms. To make these judgments, residents relied on one or more of five categories of data: how mothers used the medical system (98%); observations during the office visit of the mother-child interactions (96%), of the child (74%), and of the mother (68%); and information obtained by interview about the mother's caregiving skills and her feelings toward the child (50%). In 30% of cases the residents' descriptions of the mother contained only minimal information. We conclude that residents rely more on observational data than data acquired during the interview. These findings suggest that residency training programs should sharpen the residents' ability to make behavioral observations and teach more effectively the process of interviewing so that residents will be able to make appropriate assessments of parenting skills.

Adult↗
PubMed1986

Does breast-feeding protect against infections in infants less than 3 months of age?

To determine whether breast-feeding protects infants from infections, a case-control study was conducted. The cases were previously healthy children who were admitted to Yale-New Haven Hospital for an infectious illness at or before 90 days of age. The controls were chosen from the log of births and matched to the cases for five important demographic variables. In addition, logistic regression models were used to adjust the results for other potential confounders. To minimize the potential surveillance bias that might occur if formula-fed and breast-fed infants with the same degree of illness have a different probability of being hospitalized, the case-control pairs were stratified by the severity of the medical condition of the case at the time of hospitalization. For the 281 case-control pairs, the matched odds ratio was .50 (95% confidence interval .32, .77; P less than .005), which indicates that breast-feeding is protective against infections. However, this apparent protective effect was diminished substantially when the data were stratified according to the severity of illness: the matched odds ratio for the 164 infants with serious illnesses was .79 (.47, 1.32; P less than .50), and for the 117 infants with mild illnesses it was .17 (.03, .44; P less than .001). These stratified results suggest that breast-feeding protects infants from hospitalization rather than from infections. Failure to consider the problem of surveillance bias may lead to erroneous conclusions about the protective effect of breast-feeding.

Bacterial Infections↗