Minnesota Chapter of the American Academy of Pediatrics

Child Safety

<h3 class="wp-block-heading">What is a work group?</h3>



The MNAAP work groups were formed as part of the chapter’s strategic priorities plan to address areas in which change or improvement would benefit the lives of Minnesota’s youth. During a work group meeting, members often identify opportunities for collaboration, potential projects to take on, or other ways to advocate for their cause. Email Bethany Venable (venable@mnaap.org) for more information.



Anti-Racism &amp; Disparities



The Anti-Racism &amp; Disparities work group is looking ahead to spring with plans to host a retreat to bring members together in an energizing session of planning and visioning. The group is also the chapter’s point of contact for a new contract initiated with the YWCA to help further embed diversity, equity, accessibility and inclusion in the MNAAP culture and operations. The Anti-Racism &amp; Disparities Work Group next meeting is set for Monday, Dec. 11, from 12:15 to 1 p.m. via Zoom.



Early Childhood



It has been a monumental year for investment in the littlest Minnesotans, thanks in part, to all the MNAAP members who spoke up for children who can’t speak for themselves. Yet, all this positive change yields more opportunity and more work to do! This year, our chapter will have monthly meetings or lectures about the ways we can advocate at the policy level for prenatal to five health and investment. We will also talk about how we can bring important programming into our daily practice. Our next meeting is Oct. 27, at 12:10 p.m. via Zoom.&nbsp; If you believe in the power of the first 1,000 days to change a life course, then please join us!



Behavioral/Mental Health



The Behavioral/Mental Health work group continues to work on the Minnesota Pediatric Mental Health Access Program MOC 4 focused on depression screening in LGBTQ+ and BIPOC communities. We are looking forward to learning more about how we can have open, affirming screening and supportive conversations around mental health from the youth in our community partnerships. 



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MNAAP Work Group News | Fall 2023

The recent tragic news in Minnesota that <a href="https://r20.rs6.net/tn.jsp?f=0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdH9drxlntk3sjgVdRhIrIKUHO4peIwlBJgJ3ZHQvzbsihYcz1ONSrVXW6eVu0xSpRbbgeeu8mscFvdy27J4s2w2pQ2pEb8FXW-KgiXlqDRz4xhvqwkaxgZkCiGInpEVxtGor5RYYbZYAXuhmCJEXUySRAdBDkv8Xiwgs-GhTIJITxCrXoEDoKx_zvWRW1YbTLdLNETpqNUcg6A3YIisn5NT4kWNthKuOq3uadLyJ2W-I=&amp;c=T8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw==&amp;ch=paVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ==" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://r20.rs6.net/tn.jsp?f%3D0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdH9drxlntk3sjgVdRhIrIKUHO4peIwlBJgJ3ZHQvzbsihYcz1ONSrVXW6eVu0xSpRbbgeeu8mscFvdy27J4s2w2pQ2pEb8FXW-KgiXlqDRz4xhvqwkaxgZkCiGInpEVxtGor5RYYbZYAXuhmCJEXUySRAdBDkv8Xiwgs-GhTIJITxCrXoEDoKx_zvWRW1YbTLdLNETpqNUcg6A3YIisn5NT4kWNthKuOq3uadLyJ2W-I%3D%26c%3DT8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw%3D%3D%26ch%3DpaVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ%3D%3D&amp;source=gmail&amp;ust=1692108799005000&amp;usg=AOvVaw1dxToHWnS7_8dOuT9carWu">two young lives </a>were lost in separate <a href="https://r20.rs6.net/tn.jsp?f=0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdra2cVP-R86Hn70o8WTsmPGVUs-GuNr0zmdXHlwNL01CBiYfew4Q0Sbv5xkieZdLoSrakXoEcy7kjsG2d16s3Gp4pdXXFdDFwdQdl2bPiiZVHpKpwXvhbe2E_4zzkpJBsr_5t1tvvuFgOh4DIwc7ikvozq01vy9PqoNXCfwcPGXnWEqQwBPBjih1ARnfkK41k1kHtfn-pUPrhVx6wLZzQw27lVqC5jYktb00o8FCxSIitiDP4vy_FVK5BCIiBTQ4m92duncp4jFvsJ0esMa5T4Q==&amp;c=T8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw==&amp;ch=paVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ==" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://r20.rs6.net/tn.jsp?f%3D0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdra2cVP-R86Hn70o8WTsmPGVUs-GuNr0zmdXHlwNL01CBiYfew4Q0Sbv5xkieZdLoSrakXoEcy7kjsG2d16s3Gp4pdXXFdDFwdQdl2bPiiZVHpKpwXvhbe2E_4zzkpJBsr_5t1tvvuFgOh4DIwc7ikvozq01vy9PqoNXCfwcPGXnWEqQwBPBjih1ARnfkK41k1kHtfn-pUPrhVx6wLZzQw27lVqC5jYktb00o8FCxSIitiDP4vy_FVK5BCIiBTQ4m92duncp4jFvsJ0esMa5T4Q%3D%3D%26c%3DT8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw%3D%3D%26ch%3DpaVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ%3D%3D&amp;source=gmail&amp;ust=1692108799005000&amp;usg=AOvVaw1v48Dx1YlrU80NruYA7xD1">accidental firearm deaths</a> underscores the importance of discussing safety with patients and families. MNAAP has long advocated for firearm violence prevention measures, and while some progress is being made at the legislative level, much of the prevention and awareness begins at home.
The American Academy of Pediatrics&#8217; website <a href="https://r20.rs6.net/tn.jsp?f=0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdeXrBl5uFfFmbCEiXndkis8DtiM5efUUJitCOITzhXrtvaPuF1YK-7KNB8v_Q5lD2lFlHpGa5MDZqc8TKmgx0sExxC8kyX9fj8qxPZADoQ2gjGbW6CQQ41VeegcNeG0y_doKWY4P0NMy0DUxdzzXUkbKFT-foG-Zw6WX9PESEa-KdVqN-K_nwkSyiyLGVPHR5&amp;c=T8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw==&amp;ch=paVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ==" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://r20.rs6.net/tn.jsp?f%3D0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdeXrBl5uFfFmbCEiXndkis8DtiM5efUUJitCOITzhXrtvaPuF1YK-7KNB8v_Q5lD2lFlHpGa5MDZqc8TKmgx0sExxC8kyX9fj8qxPZADoQ2gjGbW6CQQ41VeegcNeG0y_doKWY4P0NMy0DUxdzzXUkbKFT-foG-Zw6WX9PESEa-KdVqN-K_nwkSyiyLGVPHR5%26c%3DT8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw%3D%3D%26ch%3DpaVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ%3D%3D&amp;source=gmail&amp;ust=1692108799006000&amp;usg=AOvVaw0_F_cmC_KmdMdVS-MoE6wu">HealthyChildren.org</a> has extensive resources for families to learn more about the safe storage of firearms, how to keep kids safe at home and in other people&#8217;s homes, and how to discuss firearm violence with children.
Additionally, MNAAP offers the recorded webinar, &#8220;<a href="https://r20.rs6.net/tn.jsp?f=0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdY6YJpacsRm4cvGgPtfmWL8_yZvReS4EMqAQH5dk5hIeQ7C8UW2ZHksxapMZp1v0FelFOXpCbHjwP-1RRN6LvXQ==&amp;c=T8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw==&amp;ch=paVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ==" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://r20.rs6.net/tn.jsp?f%3D0012VVuDtn17Y1Dg_SZXEIPGLkaehMwuNBh7WktBmZQQHNbMQZs5sN4tbnl2MyVnJwdY6YJpacsRm4cvGgPtfmWL8_yZvReS4EMqAQH5dk5hIeQ7C8UW2ZHksxapMZp1v0FelFOXpCbHjwP-1RRN6LvXQ%3D%3D%26c%3DT8S1M1qaC1JblWla1dwxkyJhWIfhzKw9aTL8b11WvEHtO6WaJptuJw%3D%3D%26ch%3DpaVVyKEyn0b2vlgFe8S-kmyVIraiZ4eT9S8oSXV7DsZ4uANNMmlHIQ%3D%3D&amp;source=gmail&amp;ust=1692108799006000&amp;usg=AOvVaw1j9USpAcWSzQ-LA_uoOwPR">Firearm Violence Prevention: Counseling Parents about Safe Gun Storage Practices at the Practice Level</a>&#8221; which was presented by Andrew Kiragu, MD, FAAP, Sheldon Berkowitz, MD, FAAP, and Gretchen Karstens, MD, FAAP in January 2020.

Talk with Families About Safe Firearm Storage

Suicide prevention and firearm violence prevention are among the top concerns and areas of interest for MNAAP pediatricians, according to the results of last year’s member survey. An upcoming project through a coalition that includes the Minnesota Medical Association (MMA) and Protect Minnesota offers pediatricians an opportunity to examine the role that firearms play in suicides.



The coalition has brought together physician groups and community stakeholders from across Minnesota, and together, they are working to raise their voices on firearm safety.



As part of these efforts, the coalition is planning to conduct physician interviews, to learn more about the experience of physicians in counseling patients about gun safety, and learn about the barriers they might be facing.



In addition,&nbsp;the coalition is planning to conduct pilot projects at 4-5 clinics in rural Minnesota. The coalition will provide trigger locks and messaging for the physicians – to assist in conversations about gun safety, and suicide prevention with patients.&nbsp;&nbsp;



If you are interested in participating in a physician interview, or you know of a rural clinic that might be interested in participating in the pilot project,&nbsp;please use the links below to provide your name and email, and staff from the MMA will be in contact with you.



<ul class="wp-block-list"><li><a rel="noreferrer noopener" aria-label=" (opens in a new tab)" href="https://docs.google.com/forms/d/e/1FAIpQLSeInG6btSvRjTrQmxDLJVRCGSy4ztED8vYccqpWo7Oh4S3JFA/viewform" target="_blank">Minnesota Firearm Safety and Suicide Prevention Coalition &#8211; Physician Interviews: Interest Form</a></li><li><a href="https://docs.google.com/forms/d/e/1FAIpQLScalIfmZ63woE6TwMHMAWoe0S21fG988qcJyW13g_nd9W99VA/viewform">Minnesota Firearm Safety and Suicide Prevention Coalition &#8211; Pilot Project: Rural Clinic Interest Form</a></li></ul>

Coalition to Examine Suicide Prevention Through Physician Interviews, Pilot Projects

By Lisa Guetzko, MD, HealthPartners Central Minnesota Clinic
<a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/11/LisaGuetzko.jpg"><img loading="lazy" decoding="async" class="alignleft size-thumbnail wp-image-507" style="margin: 5px;" alt="LisaGuetzko" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/11/LisaGuetzko-150x150.jpg" width="150" height="150" /></a>Diagnosing and reporting suspected child abuse or neglect is one of the greatest challenges a pediatrician must face. Besides the obvious primary concern for the child’s welfare, there are numerous other considerations that can affect our decisions about whether or not to file a child protection report. Time constraints, diagnostic uncertainty, logistical barriers, lack of knowledge about proper reporting protocol, and fear of alienating the patient’s family or losing them to follow up may all play a role in the clinician’s decision. Although we are all aware that we are mandated reporters, it is often unclear exactly when, why, and how to report a suspicion of child abuse.

As a pediatrician who practices in a city that spans three different counties, I have encountered significant variability in the reporting, investigation, and responses to child abuse reports. One county is particularly efficient in filing reports over the phone, processing written documentation, and notifying the clinician after an outcome has been determined. Other counties have presented additional barriers that have made the reporting process more difficult for families and clinicians.
For example, I was told by one child protection employee that they could not file my report of suspected sexual abuse of a 12 year-old boy who had repeatedly sexually abused his two younger siblings and attacked his older sibling with a weed whacker. The children had been seen by law enforcement in the home, and by physicians in the ER repeatedly, where it had even been documented that the 12 year-old who perpetrated the sexual abuse was showing red flags that he, too, had been abused. But because I could not tell child protection services exactly who was the suspected abuser, the county refused to file my report. I subsequently spent another four hours on the phone, being redirected to various agencies until I reached someone in law enforcement who appropriately filed and responded to my report.
I am thankful that my persistence paid off, as none of the other medical providers who had seen the 12 year-old ever reported their concerns that he was the victim of abuse. This was especially surprising to me because I had spoken directly with ER staff during one of his visits there, and they had assured me that their suspicion of abuse against the child would be reported. The child has since been removed from the home and placed with his grandparents while the case is under investigation. After intensive psychotherapy and numerous legal proceedings, the child did finally identify his abuser and additional protective measures can now be implemented.
Although the reporting process can be daunting and frustrating at times, there are some helpful guidelines I would like to offer to the clinician who suspects child abuse or neglect:
<ul>
<li>Trust your clinical judgment. If you suspect child abuse or neglect, make a verbal report to the appropriate agency within 24 hours. Follow up with a written report as soon as possible. It is better to report your concerns than to ignore them or talk yourself out of them.</li>
<li>Consult with an expert if needed. If you are uncertain about your concerns or what to do next, consult with a child abuse specialist. Their wealth of expertise can help guide you through the process. Contact information is available at: <a href="https://www2.aap.org/sections/childabuseneglect/Minnesota.cfm" target="_blank" rel="noopener">https://www2.aap.org/sections/childabuseneglect/Minnesota.cfm</a></li>
<li>Don’t assume that anyone else has filed a report. Even when a patient has been seen by multiple providers before you, there is no guarantee that any of them have reported a concern of child abuse. You may be the child’s only hope in obtaining the necessary investigation, intervention or services.</li>
<li>Document your findings and impressions thoroughly. Your history, physical, assessment, and even photographs of your patient are extremely valuable in the investigative process.</li>
<li>Utilize a team approach. While you are carefully documenting your findings and concerns, you can enlist your nurse or rooming staff to assist with contacting the authorities. Although you have to make the actual report yourself, your staff can assist by contacting the appropriate agency and providing them with basic information such as patient demographics.</li>
<li>Communicate with the patient’s family. We all worry that we may alienate a patient’s family by filing a report of suspected child abuse. But parental estrangement is not inevitable. When appropriate, you can express your concerns to the child’s caretaker and explain why these concerns need to be addressed. You may be surprised at how grateful they are for your care.</li>
<li>Make sure to follow up. You should expect to receive written communication from the county regarding the outcome of any inquiry or investigation resulting from your report. You may also be asked to provide additional feedback or documentation, depending on the situation. Child Protection Services personnel have told me on more than one occasion that most physicians are hesitant to stand by their original concerns by providing additional written documentation such as letters or more detailed impressions to be used in court. Remember that you might be your patient’s sole medical advocate in these situations, and your medical opinions are both valid and absolutely necessary.</li>
</ul>
Above all, remember that any suspicion of child abuse or neglect should be reported. You are protecting both yourself and your patient by doing so. You may even be saving a child’s life.
&nbsp;

Suspicions of Child Abuse or Neglect Must Be Reported

By Alice Swenson, MD, FAAP, Children’s Hospitals and Clinics of Minnesota; Chris Derauf, MD, FAAP, Mayo Clinic; and Sarah Lucken, MD, FAAP, Hennepin County Medical Center
One of the toughest challenges that primary care physicians face is what to do when confronted with a child who may have been maltreated. This may occur in the inpatient setting when a child is hospitalized with suspicious injuries or failure to thrive. Or it may occur in an outpatient setting, such as an emergency room or clinic, derailing an otherwise routine day and requiring immediate action.
Physicians often have questions about who is mandated to report, which acts trigger mandated reporting, and to whom a mandated report must be made. These topics are addressed in more detail in the Minnesota Reporting of Maltreatment of Minors Act in Minnesota (Statute 626.556).

Who is a mandated reporter? 
Anyone can voluntarily report suspected maltreatment. However, physicians, medical care providers, and other professionals who work with children are legally required to report cases of child maltreatment or neglect that are suspected, ongoing, or have occurred in the past three years. They also must report cases involving maltreatment of two or more children unrelated to the perpetrator that have occurred in the past 10 years.
Those making reports in good faith are legally immune from criminal and civil liability. However, a mandated reporter who does not report a case of suspected child maltreatment or neglect is guilty of a misdemeanor.
Which acts trigger mandated reporting?
Acts that would be considered reportable under the statute are broadly defined as physical abuse, sexual abuse, and neglect. 
Physical abuse means “any physical injury, mental injury, or threatened injury inflicted by a person responsible for the child’s care.” This may include, but is not limited to, throwing, kicking, burning, biting, cutting, striking with a closed fist, shaking a child under 3 years of age, inflicting any injury on a child 18 months old or younger, interfering with a child’s breathing, threatening a child with a weapon, striking a child under 1 year old in the face or head, and unreasonable physical confinement. It is noted that abuse “does not include reasonable and moderate physical discipline of a child administered by a parent or legal guardian that does not result in injury.”
Sexual abuse includes sexual assault, rape, prostitution, and statutory crimes in which a child who is under the age of 16 becomes involved in sexual activity. Although specific laws governing sexual conduct for teens may be confusing to the mandated reporter, it is clear that an adult who is in a caregiving role is guilty of sexual abuse if he or she engages in sexual conduct with the child, regardless of age.
Neglect includes medical, nutritional, educational, and other forms or acts of omission or commission that result in inadequate care and potential or actual harm. Minnesota is one of many states that allow for religious exemptions from routine medical care, but not if the lack of medical care may cause serious danger to the child’s health.
To whom must a mandated report be made?
When maltreatment is suspected, a verbal report should be made to the local child protective services (CPS) and/or the law enforcement agency. A follow-up written report must be submitted within 72 hours (exclusive of weekends and holidays). CPS then takes on the responsibility for investigating the report, ascertaining the child’s safety, and implementing a safety plan during the investigatory period.
If CPS cannot be reached and there is immediate concern about the patient’s safety or the safety of other minor children in the home or daycare setting, the physician should call 911; ask for the police, in particular the child abuse unit; and make a report. 
What should a physician consider before reporting child maltreatment?
Try to determine whether the child has been abused or neglected. Take a careful history from the child’s caretaker, carefully delineating this firsthand account from other histories that may have come secondhand. The physician also should use trained interpreters when taking histories from non-English speakers in order to be as accurate as possible. If the child is developmentally capable and medically able, the physician also should ask the child directly what happened; depending on the situation, this may occur either with or without the caregiver present. Children often can spontaneously give many corroborating details about how their injuries occurred. A physician also may partner with an experienced social worker to help obtain this information. 
A thorough physical exam should be done to look for any injuries/physical findings in addition to the presenting complaint. Additional lab tests and X-rays may be ordered if indicated.
The physician then must attempt to determine if the physical findings and test results fit with the history given by the caregiver. In some cases this may be easy. For example, a nonmobile infant would not sustain a broken femur and posterior rib fractures from rolling off a bed. In other cases it may be more challenging. A pattern injury, such as an iron burn, may occur when a toddler trips over an iron left on the floor or it may have been inflicted.
The physician also should look for other red flags. Has the child had suspicious injuries before? Was there a delay in seeking care and why? Are there different histories about how the injury happened, including a changing history from the caregiver? 
The most important question the physician then must address is: What are the immediate safety needs of the child? Can the child safely be discharged home with the parents/guardians, particularly if they are possible perpetrators of the injury? If they are not the perpetrators, can they protect the child?
The safety and health of the child must come first. It must take priority over consideration of the family’s and provider’s reputations, and the family’s relationship with the physician.
Is there a protocol to follow when evaluating a possibly maltreated child?
Depending on the type of abuse and age of the child, there are standard workups that occur for children who may have been physically abused. For example, an infant with suspected abusive head trauma would typically have a careful history and physical exam, head CT, skeletal survey, and ophthalmologic exam performed, as well as liver function tests, amylase, lipase, and urinalysis to screen for possible abdominal trauma.
A child suspected of having been sexually abused would typically undergo a careful history and physical exam, and evaluation that might include laboratory tests for sexually transmitted infections, and a colposcopic and forensic exam depending on the age of the child, the type of sexual abuse, and how long ago it occurred.
For the child with “failure to thrive,” most often the causes are multifactorial. A careful history and physical exam, examination of growth charts, and diagnostic testing can help rule out significant medical etiologies at the same time the physician initiates close monitoring of feeding practices of the child, including calorie counts.
The latter workup can occur in an outpatient setting but may require inpatient admission for management. In these cases, it is the cooperation and concern of the caregiver and their ability to follow up with medical recommendations that determines whether neglect is present.
What options do physicians have if they suspect that abuse and/or neglect may have occurred, but cannot make a definitive determination with the information at hand and do not know whether to file a report?
The physician can always call the appropriate social services agency, such as Child Protection Services (CPS), and run the case by a screener for advice—in essence, to find out whether CPS would most likely open a case and to help determine whether the child can safely go home.
For situations in which there is concern for serious injury, threatened harm, child abduction, flight, or where the child needs ongoing medical care, the provider can send the child to the nearest emergency room or admit the child to the hospital for treatment and further medical evaluation and testing.
How should parents be informed?
Many parents, though upset, are able to understand if one explains to them the laws about mandated reporting and the need to put the child’s safety first when uncertainty about the circumstances of an injury occurs. When the time is right, caregivers can be informed of the need to make a report to CPS using some variant of the following: “Ms. Johnson, I want to thank you for all your patience this afternoon—I know it has been a long day for you and that you have been really concerned about Jenny. I’m concerned, too. As you know, we discovered that she has a broken arm. Unfortunately, we don’t know how this happened, and when I see an injury like this in a child her age, one of the possibilities is that someone might have caused this injury to her. Because of this, I’m required to make a report to Child Protective Services so that together we can do our best to make sure she is safe. I know you want the best for her; so do I. And, I’m going to do my best to help you and Jenny through this situation.”
The caregiver then should be told what to expect from the CPS worker, and that the physician’s role will be to help CPS understand the medical findings and provide any needed medical background or pertinent social information. Using language like the above usually (but not always) sets the stage to allow the physician to maintain an ongoing working relationship with the family. 
What if the family is not cooperative and wishes to leave immediately with the child?
If there is concern that the child is potentially in immediate danger, hospital/clinic security should be called if available and a 911 call placed to police, who can then place a 72-hour police hold on the child. The child may either then be admitted or put into foster care while awaiting the CPS/police investigation.
Does patient confidentiality enter into reporting abuse?
The Health Insurance Portability and Accountability Act (HIPAA) allows for the disclosure of protected health information without the consent of the child’s caregiver or legal guardian in situations where abuse or neglect is suspected. Ideally, the parent or guardian should be made aware of this disclosure unless the disclosure could place the child’s safety in jeopardy.
Can the reporter of the abuse remain anonymous?
Technically, yes—the reporter’s name is confidential unless she/he consents to be named; however, CPS and police will most likely need to receive additional historical and medical information from the physician after the initial report and the physician can ultimately be subpoenaed to testify if the case goes to court.
Caring for children who are suspected of being abused or neglected can be challenging even for experienced practitioners. Physicians should understand mandated reporting laws, know how to contact CPS, prioritize child safety, and when needed, seek consultation from a physician trained in child abuse pediatrics.

Reporting Child Maltreatment and Abuse: FAQs

<img loading="lazy" decoding="async" class="alignleft" style="margin: 2px 5px; border: 0px;" alt="" src="http://webresources.childrensmn.org/images/staff/4589.jpg" width="117" height="175" />Where did you grow up and complete your training? Why did you decide to pursue a subspecialty in child abuse pediatrics? 
I grew up in Two Harbors, Minnesota. I attended undergraduate at the University of Wisconsin Green Bay and Medical school at the University of Minnesota. I stayed at the U of M for my pediatrics residency. Following residency I spent two years in a child abuse pediatrics fellowship with Carolyn Levitt, MD and Rich Kaplan, MD at Midwest Children’s Resource Center at Children’s Hospitals and Clinics of Minnesota.
Most of my career decisions occurred relatively late. In medical school I found that I enjoyed my pediatrics rotations more than any of my other rotations. Not only did I enjoy working with children but I also enjoyed the pediatricians. In residency I did an elective rotation in child abuse and found it very interesting. As residency was coming to an end, I didn’t really know what I wanted to do with my career, but I didn’t feel ready to get a job. Child abuse pediatrics was not yet a recognized subspecialty, which allowed me to spend the next two years creating my own fellowship.

Describe a typical day for you. What do you enjoy most and least about your job?
My days are quite varied and this is one aspect that I really enjoy. From a clinical perspective I see a mix of outpatient patients with concerns related to sexual or minor physical abuse and inpatient consults with more serious injuries. I spend a significant amount of time consulting with child protection, law enforcement and county attorneys. I have the opportunity to provide court testimony one or two times per month. I also get the opportunity to teach quite frequently. My least favorite part of my job is the paperwork involved.
Outside of seeing patients, describe your work with the Governor’s Task Force. If you could suggest and enforce 3 changes to the child protection system, what would they be? 
Over the past decade Minnesota’s Child Protection has evolved into a system where there is little emphasis on identifying if a child is a victim of maltreatment and who has maltreated a child. This is done under the false pretense that children are safer and parents will be engaged in making changes if parents are not confronted about maltreatment. The first change I would enforce is a fundamental change in approach such that there is an emphasis on establishing if a child has been the victim of maltreatment and who is responsible. An increased focus on investigation is often equated with a desire to punish parents, but I don’t believe this is necessarily true. I believe an increased emphasis on investigation and fact finding is critical for effective safety planning.
Second, I believe we should work toward a system that acknowledges and treats the trauma and lifelong consequences of abuse. The Task Force has recommended increased trauma screening in the Child Protection system and I believe this is a crucial first step in moving to a system that focuses on the consequences of early trauma related to maltreatment.
Third, over the past decade Minnesota has seen massive cuts in Child Protection funding. Minnesota provides some of the lowest state funding in the country. If we want a system that effectively protects children, we need to invest in that system.
What is one thing people would be surprised to know about you? What hobbies or activities do you enjoy?
During residency I built a kayak and a wooden motorboat. I enjoy woodworking and I’m currently working on an addition to our home.
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Member Profile: Mark Hudson, MD, FAAP

By Pediatric Emergency Medicine Physicians Jeffrey P. Louie, MD, FAAP, and Ronald A. Furnival, MD, FAAP, 
 University of Minnesota Masonic Children’s Hospital
In 2013, the Centers for Disease Control (CDC) listed the leading causes of unintentional pediatric deaths: suffocation, (under age 1); drowning (ages 1 to 4); and motor vehicle accidents (ages 5 to 19). The Minnesota Department of Health (MDH) also publishes data on the leading causes of death, and not surprisingly, the groups are identical. Between 2004 and 2013, there were 169 suffocation deaths, 36 drowning deaths, and 1,085 deaths from motor vehicle crashes among children in Minnesota.

The Minnesota State Trauma Advisory Council (STAC) was established in 2005 within MDH to supervise and improve trauma care across the state. Of 130 medical facilities across Minnesota (128 hospitals and 2 free-standing emergency centers), a total of 123 are designated trauma centers, certified to accept and treat injured patients. In 2014, the Minnesota STAC published its most recent annual report on all injury hospitalizations in the state. For children 15 and younger, trauma centers treated 1,880 admissions, with 28 percent injured from falls, and 12 percent from motor vehicle accidents. The most common type of injury was a fracture of the shoulder or upper arm (11 percent). followed by traumatic brain injuries (8 percent), forearm and elbow fractures (8 percent), and upper leg and thigh fractures (7 percent). Nine percent of Minnesota pediatric trauma victims were classified as severe (defined as an Injury Severity Score of 25 or greater) and death occurred in fewer than 1 percent of all cases.
Head Injuries
In 2013, there were approximately 3,600 Emergency Department visits in Minnesota for pediatric head injury. Appropriate utilization of head CT for diagnosis, and reducing pediatric radiation exposure with its subsequent cancer risk, has been a treatment goal for many years. A 2009 multi-center benchmark study by Kupperman, et al in Lancet, defined clinical guidelines for CT use in children. These CT guidelines included mechanism of the head injury, age, and symptoms, and were very effective for identifying children at risk for a CiTBI (clinically important traumatic brain injury) defined as the following: children who die, who require neurosurgery intervention, who are intubated, or require two nights in the hospital for observation. With negative predictive values as high as 99 percent, these guidelines help health care providers manage head-injured children without unnecessarily exposing them to radiation, while also directing the use of CT scans only for those children who are at the most risk for a CiTBi.
Child Abuse
Child abuse is one of the leading causes of infant mortality in Minnesota, and its prevention and detection is a responsibility for all pediatric care providers. In 2012, there were 4,820 substantiated cases, 51 (1.1 percent) for medical neglect, 3,070 (63.7 percent) for non-medical neglect, 815 (16.9 percent) for physical abuse, 30 (0.6 percent) for psychological maltreatment, and 854 (17.7 percent) for sexual abuse. Minnesota has four facilities statewide offering child abuse and neglect expertise, which can be found on the AAP website (www2.aap.org/sections/childabuseneglect/Minnesota.cfm). In the Twin Cities metro area, Dr. Nancy Harper is developing a new collaboration among the University of Minnesota Masonic Children’s Hospital, Hennepin County Medical Center and Children’s Hospitals and Clinics of Minnesota to coordinate and unify child maltreatment evaluations and care.
Anticipatory Guidance
Improved Minnesota trauma system organization and trauma care can only go so far. Anticipatory guidance and injury prevention is the only real antidote for pediatric trauma. Parental education must start early and address the most frequent preventable causes of pediatric death and injury. Suffocation, the most common traumatic cause of death for infants under 1 year of age, can be reduced with safe sleep positioning, the use of safe bedding, and by avoiding co-sleeping. Toddlers and school-age children are most frequently killed or injured as pedestrians, in motor vehicle crashes, from drowning, and from falls from height. Educating parents and children about car seats, seat belts, pedestrian safety, water safety (including the bathroom), and secure windows and stairways can reduce these common injuries. Parents of older children and adolescents can be encouraged to promote bike safety and helmet use, as well as helmet use in sports, and to prevent distracted driving, the most frequent preventable causes of injury and deaths for children as they mature.
Advocacy
What else can we pediatricians do to reduce injury among Minnesota’s children? In 2012, MDH produced a plan for injury reduction: &#8220;Preventing unintentional injury in Minnesota: A working plan for 2020&#8221; (www.minnesotasafetycouncil.org/2020Plan/). We can become involved in hospital and community education and injury prevention efforts; we can speak on behalf of our patients for improved regulation, legislation, and allocation of resources for childhood safety; and we can become more involved in the care of injured children in our local settings as the pediatric experts. We must not be complacent. We need to be proactive. Child safety is not someone else’s responsibility; we all need to watch out for the safety of every child.

Pediatric Trauma in Minnesota: How are our Children Doing?

By Andrew Kiragu, MD, FAAP, Medical Director, Pediatric Intensive Care Unit, Hennepin County Medical Center, and Assistant Professor of Pediatrics, University of Minnesota
Almost invariably, with warmer weather comes plenty of Emergency Department and physician office visits for management of childhood injuries.
Trauma is the leading preventable health problem for children. According to data from the Centers for Disease Control and Prevention (CDC), unintentional injuries are the leading cause of death in the United States among children and teens aged 1–19 years. In fact, injuries kill more children than all other diseases combined, accounting for 37 percent of all deaths in this age group in 2009.
The economic toll is great; injuries are the leading cause of health care spending for children age 5 to 14 years. Annual lifetime cost of all injuries were estimated at $406 billion in 2006. While these numbers are high, the personal cost to children and families from a debilitating injury or death is immeasurable. The high incidence and preventable nature of child and adolescent unintentional injuries highlight the need for public health action.
There is much that we, as pediatricians, can do to aid in this effort and this principally revolves around talking to our patients and their families about injury prevention.

Safety Equipment
Discussion about the need for proper safety equipment like bike helmets is key. It is important that parents also model proper use of these safety devices since children take their cues regarding personal safety from their parents and because these devices can be life saving.
Last summer we admitted a teenage boy who was struck while riding his bicycle across a busy street. He sustained a mild traumatic brain injury and a number of cuts and bruises. The entire incident was caught on camera by a neighbor’s CCTV cameras. A review of the footage revealed what a horrible crash it had been. What is most remarkable about this story is that our patient was able to go home the following day because he had been wearing a bicycle helmet, which bore the brunt of the impact. At the very least, it prevented a more severe brain injury and at most, it saved his life.
Children in motor vehicles should use age-appropriate safety restraints, including child car seats and booster seats.
Safety while playing organized sports is also important. The importance of proper equipment and training in order to minimize the risk of serious injury cannot be overstated. To prevent and better recognize sports-related brain injuries, the CDC’s Heads Up Campaign provides athletes, parents and coach’s information about the recognition of sports-related concussions and advice about what to do when a concussion has occurred. Indeed, efforts by professional sports organizations to protect their players and move away from the previous almost nonchalant approach to sports-related concussions have increased societal recognition of these injuries.
Water Safety
With summer approaching, water safety is also very important. Drowning is a leading cause of injury-related death in children. About 20 percent of those who die from drowning are children ages 14 and younger. For every child who dies from drowning, another five receive emergency department care for nonfatal submersion injuries.
As educators and advocates, pediatricians can play an important role in the prevention of drowning through direct counseling, educational material and other resources. Pediatricians should also emphasize the need for close, non-distracted adult supervision of young children near any body of water.
Adequate fencing for pools, drain covers and other pools construction techniques to prevent entanglement and swimming lessons are other ways that drownings can be prevented.
The AAP recommends swimming lessons for children 4 years or older and no longer issues an advisory against swimming lessons or other aquatic experiences for children of any specific age. As part of the counseling of parents and adolescents, information should be shared with them about the risks associated with drug and alcohol use during any activity, especially water-related activities.
There is a lot more that can be done to protect our children including increased efforts in education about safety while engaged in recreational activities, work to prevent traumatic brain injury (especially those related to organized sports), engineering to improve the vehicles we drive in, safety equipment we use, and so on. There are also enforcement and legislative aspects to injury prevention. Our nation’s laws have been instrumental in helping to protect the most vulnerable in our society and we, as pediatricians, should play an integral role in encouraging our legislators to formulate laws that protect children.
Have a wonderful and safe summer!
References: 
Morbidity and Mortality Weekly Report; April 16, 2012 Centers for Disease Control and Prevention; Unintentional Drowning: Get the Facts 
AAP Committee on Injury, Violence, and Poison Prevention. Prevention of Drowning; Pediatrics 2010 126: e253 -e262

Summer Safety Reminders for Families

Grand Itasca Clinic & Hospital is seeking a board certified/board eligible outpatient Pediatric Physician to join our busy and growing primary care clinic practice. Grand Itasca is a fully integrated multi-specialty clinic and hospital located in Grand Rapids, Minnesota.

Pediatric Physician

Partners in Pediatrics, Ltd. is seeking a full time BC/BE Pediatrician. The standard work week for a full-time pediatrician is 4 days a week plus a rotation of nights and weekends. Night and weekend shifts are shared equally among all providers. The salary package is competitive. You will have paid time off (PTO) and be given a CME allowance as well as CME days to further your medical education. We offer health, dental, disability and life insurance. You will also be eligible for a lucrative profit sharing 401(k). For inquiries, please contact our recruiting leads, Dr. Lisa Irvin at lirvin@pipstop.com and Dr. Megan Camerino at mcarmerino@pipstop.com

BC/BE Pediatrician

We’re excited to announce an opening for a Communications Manager at the Minnesota Chapter of the American Academy of Pediatrics (MNAAP). This part-time, remote role is a unique opportunity for a communications professional with at least five years of experience, who is passionate about advancing child health through advocacy, education, and special projects.

Child Safety Updates