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Originally published by 2 Minute Medicine® (view original article). Reused on AccessPediatrics with permission.

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Infants classified as very high risk for substantiated maltreatment had a higher relative risk of overall mortality, death through unintentional and inflicted injury, and sudden unexpected infant death. This high risk group also had higher relative risk for hospitalization.

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Evidence Rating Level: 1 (Excellent)

Study Rundown:

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Maltreatment of children – defined by the authors in this study as physical and emotional abuse, and neglect – remains a considerable problem in the United States. In this retrospective study, researchers aimed to evaluate the association between adverse health outcomes and risk status for substantiated maltreatment through a predictive risk model (PRM). After creating PRMs based on both birth and maternal factors, subjects were grouped into a very high risk group (top 10%). Their data showed that these infants had significantly higher relative risk of mortality compared to lower risk children. Those in the top 10% group were at the highest risk of mortality through unintentional injury followed by inflicted injury and sudden unexpected infant death (SUID). Additionally, the relative risk of hospitalization was higher in the top 10% group, with maltreatment-related injuries by age 2 being the most common cause, followed by fracture of long bones and ambulatory sensitive hospitalizations, or hospitalizations with selected discharge codes that suggested a potentially preventable admission. Their study noted several limitations, including analysis limited to only 2 birth cohorts consisting of children born in New Zealand, not accounting for immigrant children. For providers, this study suggests that PRMs may help identify children at greater risk for more adverse health outcomes who might benefit from more intensive services.

In-Depth [retrospective cohort]:

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Subjects included all live births in 2010 (N=61 476) and 2011 (N=60 006) with health, welfare, child protection and justice registry data available through the Integrated Child Dataset in New Zealand. Subjects receiving Family Start, a home visiting program, and subjects who had only sexual abuse as a substantiated finding, were excluded. Researchers used the 2010 cohort to generate predictors of maltreatment and applied those predictors to the 2011 cohort to estimate the risk of substantiated maltreatment by age 2. Researchers selected 15 predictors of maltreatment, which included both birth factors (i.e. preterm birth, ≥3 children in the family) and maternal factors (i.e. history of mental health or substance abuse, history of childhood maltreatment). Logistic model regression was used to assess probability of maltreatment by age 2, and subjects in the 2010 cohort were risk stratified as either very high risk (top 10%, N=6009) or high risk (top 20%, N=12 096).

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Primary outcomes included injury hospitalizations and overall infant mortality, further stratified as inflicted injury deaths, unintentional injury deaths, and SUID. All relative risk mortality ratios were higher in the top 10% group. Overall, infants in the top 10% group were more likely to die in infancy compared to other children (RR=4.8; 95% CI:3.2-7.2). The largest relative risk was seen in postneonatal inflicted injury deaths (RR=9.9; 95% CI:4.2-23.3) followed by unintentional injury deaths (RR=9; 95% CI:3.9-20.7) and SUID (RR=8.5; 95% CI:4.4-16.5). Additionally, hospitalization outcomes were higher in the top 10% group. The risk of injury in the top 10% group was double that of other children (RR=2; 95% CI:1.8-2.2). The largest relative risk was seen in hospitalization for maltreatment-related injuries (RR=9.6; 95% CI:5.8-15.8) followed by fracture of long bones (RR=2.6; 95% CI:1.7-4.0) and then ambulatory sensitive hospitalizations (RR=1.6; 95%CI=1.5-1.7).

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