Cindy W Christian

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (64)276.2 Total impact

  • Clinical Infectious Diseases 12/2015; 61(suppl 8):S856-S864. DOI:10.1093/cid/civ786 · 8.89 Impact Factor
  • Katie K Lockwood · Susan Friedman · Cindy W Christian ·
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    ABSTRACT: Each year over 20,000 youth age out of the child welfare system without reaching a permanent placement in a family. Certain children, such as those spending extended time in foster care, with a diagnosed disability, or adolescents, are at the highest risk for aging out. As young adults, this population is at and increased risk of incarceration; food, housing, and income insecurity; unemployment; educational deficits; receipt of public assistance; and mental health disorders. We reviewed the literature on foster care legislation, permanency, outcomes, and interventions. The outcomes of children who age out of the child welfare system are poor. Interventions to increase permanency include training programs for youth and foster parents, age extension for foster care and insurance coverage, an adoption tax credit, and specialized services and programs that support youth preparing for their transition to adulthood. Future ideas include expanding mentoring, educational support, mental health services, and post-permanency services to foster stability in foster care placements and encourage permanency planning. Children in the child welfare system are at a high risk for physical, mental, and emotional health problems that can lead to placement instability and create barriers to achieving permanency. Failure to reach the permanency of a family leads to poor outcomes, which have negative effects on the individual and society. Supporting youth in foster care throughout transitions may mediate the negative outcomes that have historically followed placement in out-of-home care.
    Current problems in pediatric and adolescent health care 09/2015; 45(10). DOI:10.1016/j.cppeds.2015.08.005 · 1.63 Impact Factor
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    ABSTRACT: Vaccinations have been proposed as a cause of retinal hemorrhage in children, primarily as part of a defense strategy in high-stakes abusive head trauma cases. If vaccination injections cause retinal hemorrhage, this consideration would affect the evaluation of children for suspected child abuse. To describe the prevalence and causes of retinal hemorrhage among infants and young children in an outpatient ophthalmology clinic and to test the hypothesis that, if vaccination injections cause retinal hemorrhage, then retinal hemorrhage would be seen frequently and be temporally associated with immunization. Retrospective cohort study between June 1, 2009, and August 30, 2012, at The Children's Hospital of Philadelphia pediatric ophthalmology clinics among 5177 children 1 to 23 months old undergoing a dilated fundus examination as an outpatient for any reason. Children with intraocular surgery or active retinal neovascularization were excluded from the study. The prevalence and causes of retinal hemorrhage, as well as the temporal association between vaccination injection within 7, 14, or 21 days preceding examination and retinal hemorrhage. Among 7675 outpatient fundus examinations, 9 of 5177 children had retinal hemorrhage for a prevalence of 0.17% (95% CI, 0.09%-0.33%). All 9 had abusive head trauma diagnosable with nonocular findings. Among a subset of 2210 children who had complete immunization records and underwent 3425 fundoscopic examinations, 163 children had an eye examination within 7 days of vaccination, 323 within 14 days, and 494 within 21 days. No children had retinal hemorrhage within 7 days of vaccination, 1 child had hemorrhage within 14 days, and no additional child had hemorrhage within 21 days. There was no temporal association between vaccination injection and retinal hemorrhage in the prior 7 days (P > .99), 14 days (P = .33), or 21 days (P = .46). Retinal hemorrhage was rare among outpatients younger than 2 years. Considering both immediate and delayed effects, no temporal association existed between vaccination injection and retinal hemorrhage. Vaccination injections should not be considered a potential cause of retinal hemorrhage in children, and this unsupported theory should not be accepted clinically or in legal proceedings. Ophthalmologists noting incidental retinal hemorrhage on an outpatient examination should consider a child abuse evaluation in the absence of other known ocular or medical disease.
    Jama Ophthalmology 09/2015; DOI:10.1001/jamaophthalmol.2015.2868 · 3.32 Impact Factor
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    Cindy W Christian ·
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    ABSTRACT: Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children. Copyright © 2015 by the American Academy of Pediatrics.
    PEDIATRICS 04/2015; 135(5). DOI:10.1542/peds.2015-0356 · 5.47 Impact Factor
  • Howard Dubowitz · Cindy W Christian · Kent Hymel · Nancy D Kellogg ·
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    ABSTRACT: Physicians play an important role in the forensic evaluation of suspected child abuse and neglect. There has been considerable progress in the medical field, helping distinguish findings related to maltreatment from other conditions or circumstances. Nevertheless, important questions remain. This article covers several of these questions and proposes a research agenda concerning five main topics: sexual abuse, neglect, fractures, abusive head trauma, and physicians work in interdisciplinary settings. The suggestions are hardly inclusive, but offer suggestions the authors think are priorities, and ones that research could reasonably address. By providing some background to gaps in our knowledge, this paper should be of interest to a broader audience than just medical professionals.
    Child Abuse & Neglect 09/2014; 38(11). DOI:10.1016/j.chiabu.2014.07.012 · 2.47 Impact Factor

  • Samantha Schilling · Cindy W Christian ·
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    ABSTRACT: This article provides an overview of child physical abuse and neglect, and describes the magnitude of the problem and the triggers and factors that place children at risk for abuse and neglect. After examining the legal and clinical definitions of child abuse and neglect, common clinical outcomes and therapeutic strategies are reviewed, including the lifelong poor physical and mental health of victims and evidence-supported treatment interventions. Mandated reporting laws, and facilitating collaboration among child welfare, judicial, and health care systems are considered. Important tools and resources for addressing child maltreatment in clinical practice are discussed, and future approaches posited.
    Child and adolescent psychiatric clinics of North America 04/2014; 23(2):309-319. DOI:10.1016/j.chc.2014.01.001 · 2.88 Impact Factor
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    ABSTRACT: To evaluate associations between retinal hemorrhage severity and hypoxic-ischemic brain injury (HII) patterns by diffusion-weighted magnetic resonance imaging (DW-MRI) in young children with head trauma. DW-MRI images of a consecutive cohort study of children under age 3 years with inflicted or accidental head trauma who had eye examinations were analyzed by two independent masked examiners for type, severity, and location of primary lesions attributable to trauma, HII secondary to trauma, and mixed injury patterns. Retinal hemorrhage was graded retrospectively on a scale from 1 (none) to 5 (severe). Retinal hemorrhage score was 3-5 in 6 of 7 patients with predominantly post-traumatic HII pattern and 4 of 32 who had traumatic injury without HII (P < 0.001) on DW-MRI imaging. Severe retinal hemorrhage was observed in absence of HII but only in inflicted injury. Retinal hemorrhage severity was correlated with HII severity (ρ = 0.53, P < 0.001) but not traumatic injury severity (ρ = -0.10, P = 0.50). HII severity was associated with retinal hemorrhage score 3-5 (P = 0.01), but traumatic injury severity was not (P = 0.37). During inflicted head injury, a distinct type of trauma occurs causing more global brain injury with HII and more severe retinal hemorrhages. HII is not a necessary factor for severe retinal hemorrhage to develop from inflicted trauma.
    Journal of AAPOS: the official publication of the American Association for Pediatric Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology and Strabismus 11/2013; 17(6). DOI:10.1016/j.jaapos.2013.09.002 · 1.00 Impact Factor
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    ABSTRACT: The objectives of this study were to describe the experience of a novel pediatric sexual assault response team (SART) program in the first 3 years of implementation and compare patient characteristics, evaluation, and treatment among subpopulations of patients. This was a retrospective chart review of a consecutive sample of patients evaluated at a pediatric emergency department (ED) who met institutional criteria for a SART evaluation. Associations of evaluation and treatment with sex, menarchal status, and presence of injuries were measured using logistic regression. One hundred eighty-four patients met criteria for SART evaluation, of whom 87.5% were female; mean age was 10.1 (SD, 4.6) years. The majority of patients underwent forensic evidence collection (89.1%), which varied by menarchal status among girls (P < 0.01), but not by sex. Evidence of acute anogenital injury on physical examination was found in 20.6% of patients. As per the Centers for Disease Control and Prevention guidelines for acute sexual assault evaluations in pediatric patients, menarchal girls were more likely to undergo testing for sexually transmitted infections and pregnancy (P < 0.01) and to be offered pregnancy, sexually transmitted infection, and HIV prophylaxis (P < 0.01). In an effort to improve quality and consistency of acute sexual assault examinations in a pediatric ED, development of a SART program supported the majority of eligible patients undergoing forensic evidence collection. Furthermore, a substantial number of patients had evidence of injury on examination. These findings underscore the importance of having properly trained personnel to support ED care for pediatric victims of acute sexual assault.
    Pediatric emergency care 08/2013; 29(9). DOI:10.1097/PEC.0b013e3182a21a0d · 1.05 Impact Factor

  • Clinical Toxicology 08/2013; 51(7):593-594. · 3.67 Impact Factor
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    ABSTRACT: Objective: Raised intracranial pressure (ICP) has been proposed as an isolated cause of retinal hemorrhages (RHs) in children with suspected traumatic head injury. We examined the incidence and patterns of RHs associated with increased ICP in children without trauma, measured by lumbar puncture (LP). Methods: Children undergoing LP as part of their routine clinical care were studied prospectively at the Children's Hospital of Philadelphia and retrospectively at Nationwide Children's Hospital. Inclusion criteria were absence of trauma, LP opening pressure (OP) ≥ 20 cm of water (cm H2O), and a dilated fundus examination by an ophthalmologist or neuro-ophthalmologist. Results: One hundred children were studied (mean age: 12 years; range: 3-17 years). Mean OP was 35 cm H2O (range: 20-56 cm H2O); 68 (68%) children had OP >28 cm H2O. The most frequent etiology was idiopathic intracranial hypertension (70%). Seventy-four children had papilledema. Sixteen children had RH: 8 had superficial intraretinal peripapillary RH adjacent to a swollen optic disc, and 8 had only splinter hemorrhages directly on a swollen disc. All had significantly elevated OP (mean: 42 cm H2O). Conclusions: Only a small proportion of children with nontraumatic elevated ICP have RHs. When present, RHs are associated with markedly elevated OP, intraretinal, and invariably located adjacent to a swollen optic disc. This peripapillary pattern is distinct from the multilayered, widespread pattern of RH in abusive head trauma. When RHs are numerous, multilayered, or not near a swollen optic disc (eg, elsewhere in the posterior pole or in the retinal periphery), increased ICP alone is unlikely to be the cause.
    PEDIATRICS 07/2013; 132(2). DOI:10.1542/peds.2013-0262 · 5.47 Impact Factor
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    ABSTRACT: To determine the prevalence of nonconvulsive seizures in children with abusive head trauma. Retrospective study of children with abusive head trauma undergoing clinically indicated continuous electroencephalographic monitoring. PICU of a tertiary care hospital. Children less than or equal to 2 years old with evidence of abusive head trauma determined by neuroimaging, physical examination, and determination of abuse by the Child Protection Team. None. Thirty-two children with abusive head trauma were identified with a median age of 4 months (interquartile range 3, 5.5 months). Twenty-one of 32 children (66%) underwent electroencephalographic monitoring. Those monitored were more likely to have a lower admission Glasgow Coma Scale (8 vs 15, p = 0.05) and be intubated (16 vs 2, p= 0.002). Electrographic seizures occurred in 12 of 21 children (57%) and constituted electrographic status epilepticus in 8 of 12 children (67%). Electrographic seizures were entirely nonconvulsive in 8 of 12 children (67%). Electroencephalographic background category (discontinuous and slow-disorganized) (p=0.02) and neuroimaging evidence of ischemia were associated with the presence of electrographic seizures (p = 0.05). Subjects who had electrographic seizures were no more likely to have clinical seizures at admission (67% electrographic seizures vs 33% none, p = 0.6), parenchymal imaging abnormalities (61% electrographic seizures vs 39% none, p = 0.40), or extra-axial imaging abnormalities (56% electrographic seizures vs 44% none, p = 0.72). Four of 21 (19%) children died prior to discharge; none had electrographic seizures, but all had attenuated-featureless electroencephalographic backgrounds. Follow-up outcome data were available for 16 of 17 survivors at a median duration of 9.5 months following PICU admission, and the presence of electrographic seizures or electrographic status epilepticus was not associated with the Glasgow Outcome Scale score (p = 0.10). Electrographic seizures and electrographic status epilepticus are common in children with abusive head trauma. Most seizures have no clinical correlate. Further study is needed to determine whether seizure identification and management improves outcome.
    Pediatric Critical Care Medicine 07/2013; 14(7). DOI:10.1097/PCC.0b013e3182917b83 · 2.34 Impact Factor
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    ABSTRACT: Object: Enlargement of the subarachnoid spaces has been theorized as a risk factor for the development of subdural hemorrhage (SDH). As the finding of unexplained SDH in children often raises suspicion for nonaccidental trauma, the possibility of increased risk of SDH in children with enlargement of the subarachnoid spaces has important clinical, social, and legal implications. Therefore, the authors evaluated the frequency of SDH in a cohort of children with enlargement of the subarachnoid spaces. Methods: The authors identified children younger than 2 years of age who were diagnosed with enlargement of the subarachnoid spaces on MRI or CT scanning in a large primary care network between July 2001 and January 2008. The authors excluded children who had enlargement of the subarachnoid spaces diagnosed on imaging performed for trauma or developmental delay, as well as children with a history of prematurity, diagnosis of intracranial pathology, or metabolic or genetic disorders. Chart review recovered the following data: patient demographics, head circumference, history of head trauma, and head imaging results. For the subset of children with SDH, information regarding evaluation for other injuries, including skeletal survey, ophthalmological examination, and child protection team evaluation, was abstracted. Results: There were 177 children with enlargement of the subarachnoid spaces who met the inclusion criteria. Subdural hemorrhage was identified in 4 (2.3%) of the 177 children. All of the children with SDH underwent evaluations for suspected nonaccidental trauma, which included consultation by the child protection team, skeletal survey, and ophthalmological examination. Additional injuries (healing rib fractures) were identified in 1 of 4 patients. None of the 4 children had retinal hemorrhages. Only the child with rib fractures was reported to child protective services due to concerns for abuse. Conclusions: Only a small minority of the patients with enlargement of the subarachnoid spaces had SDH. Evidence of additional injuries concerning for physical abuse were identified in a quarter of the children with enlargement of the subarachnoid spaces and SDH, suggesting that an evaluation for suspected nonaccidental trauma including occult injury screening should be performed in cases of SDH with enlargement of the subarachnoid spaces. In the absence of additional injuries, however, the presence of an unexplained SDH in the setting of enlargement of the subarachnoid spaces may be insufficient to support a diagnosis of nonaccidental trauma.
    Journal of Neurosurgery Pediatrics 02/2013; 11(4). DOI:10.3171/2012.12.PEDS12289 · 1.48 Impact Factor
  • Hiu-Fai Fong · Cindy W Christian ·
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    ABSTRACT: CME EDUCATIONAL OBJECTIVES1.Review the definition, epidemiology, risk factors, and consequences of neglect.2.Provide a step-wise approach to the assessment of neglect, highlighting situations in which a report to child protective services is necessary.3.Describe promising strategies to help prevent child neglect. Child neglect, the most commonly reported form of maltreatment, can significantly impact a child's long-term development. Pediatricians must understand how to recognize and respond to neglect. This article reviews the definition, epidemiology, risk factors, and consequences of neglect. It provides a step-wise approach to the assessment of neglect, highlighting the situations in which a report to child protective services is necessary. Additionally, promising strategies for child neglect prevention are described.
    Pediatric Annals 12/2012; 41(12):e1-5. DOI:10.3928/00904481-20121126-08 · 0.61 Impact Factor
  • Hiu-fai Fong · Cindy W. Christian ·
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    ABSTRACT: Testing for sexually transmitted infections (STIs) is an important component of the medical evaluation for sexually abused children. Selective screening of this population with culture or microscopy-based techniques has been the traditional approach, particularly in younger children who have a lower prevalence of STIs compared with adolescents. However, newer testing methodologies (nucleic acid amplification tests) that use noninvasively collected specimens enable more widespread screening in children. This article provides an updated review of recommended STI testing and interpretation in children who present with suspected sexual abuse, focusing on these emerging methodologies and the evidence to support their use.
    Clinical Pediatric Emergency Medicine 09/2012; 13(3):202–212. DOI:10.1016/j.cpem.2012.06.004
  • Joanne N Wood · Lydia H Pecker · Michael E Russo · Fred Henretig · Cindy W Christian ·
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    ABSTRACT: Although the majority of poisonings in young children are due to exploratory ingestions and might be prevented through improved caregiver supervision, the circumstances that warrant evaluation for suspected maltreatment and referral to Child Protective Services (CPS) are unclear. Therefore the objective of this study was to determine the percentage and characteristics of young poisoning victims who were evaluated for child maltreatment by the hospital team (social work and/or child protection team) and/or referred to CPS. Retrospective study of poisoning victims<6 years old seen at an urban children's hospital from 2006 to 2008. Logistic regression was performed to evaluate the associations between the outcomes (evaluation for maltreatment by hospital team and/or referral to CPS) and predictor variables (demographics and circumstances, type and severity of poisoning). Among 928 poisonings, 41% were from household products, 20% from over-the-counter drugs, 7% from prescription narcotics/sedatives, 29% from other prescription drugs, and ≤ 1% each from ethanol, illicit drugs, or other substances. Most children were asymptomatic (69%) or stable (28%); 3% were critically ill. Only 13% were evaluated by the hospital team and 4% were referred to CPS. Demographic characteristics were not associated with referral to CPS. Higher clinical severity was associated with increased referral (p<0.001). Compared to poisonings with over-the-counter drugs, referrals were more likely for poisonings with ethanol and prescription narcotics/sedatives, but not other prescription drugs or household products (p<0.001). All illicit drug poisonings and 44% of ethanol poisonings were referred. The majority of referrals to CPS were for concerns for illicit drugs, poor supervision or multiple forms of maltreatment; 6% were secondary to concerns for intentional poisoning. Evaluations and referrals to CPS for maltreatment are uncommon in young poisoning victims. Referrals occurred consistently for illicit drugs but not ethanol. Although referrals were more likely for higher severity poisonings, it is unclear if the severity of poisoning is associated with the level of supervisory neglect or a marker of ongoing risk to the child. These findings suggest the need to identify risk factors for ongoing harm and the development of clinical guidelines used to determine which poisoning victims should be referred to Child Protective Services.
    Child abuse & neglect 05/2012; 36(4):362-9. DOI:10.1016/j.chiabu.2012.01.001 · 2.34 Impact Factor
  • Caitlin Farrell · David M Rubin · Kevin Downes · John Dormans · Cindy W Christian ·
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    ABSTRACT: Delay in seeking medical care is one criterion used to identify victims of abuse. However, typical symptoms of accidental fractures in young children and the time between injury and the seeking of medical care have not been reported. We describe patient and injury characteristics that influence the time from injury to medical care. Parental interviews were conducted for children <6 years old with accidental extremity fractures. Demographic characteristics, signs and symptoms of the injury, and fracture location and severity were described and examined for their association with a delay (>8 hours) in seeking medical care. Among 206 children, 69% had upper extremity fractures. The median time to the first medical evaluation was 1 hour, but 21% were seen at >8 hours after injury. Although 91% of children cried after the injury, only 83% were irritable for >30 minutes. Parents observed no external sign of injury in 15% of children, and 12% used the injured extremity normally. However, all parents noted at least 1 sign or symptom. Minority children (odds ratio [OR]: 2.54 [95% confidence interval [CI]: 1.18-5.47), those with lower extremity injuries (OR: 2.23 [95% CI: 1.01-4.90]), those without external signs of injury (OR: 3.40 [95% CI: 1.36-8.51]), and those with continued extremity use (OR: 3.26 [95% CI: 1.22-8.76]) were more likely to delay seeking medical care. Although some children did not manifest all expected responses, no child with an accidental fracture was asymptomatic. Delay in seeking medical care was associated with more subtle signs of injury; however, delays identified in minority patients are unexplained.
    PEDIATRICS 12/2011; 129(1):e128-33. DOI:10.1542/peds.2010-0691 · 5.47 Impact Factor
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    Nicole G Ibrahim · Joanne Wood · Susan S Margulies · Cindy W Christian ·
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    ABSTRACT: Age-based differences in fall type and neuroanatomy in infants and toddlers may affect clinical presentations and injury patterns. Our goal is to understand the influence of fall type and age on injuries to help guide clinical evaluation. Retrospectively, 285 children 0-48 months with accidental head injury from a fall and brain imaging between 2000 and 2006 were categorized by age (infant ≤1 year and toddler=1-4 years) and fall type: low (≤3 ft), intermediate (>3 and <10 ft), high height falls (≥10 ft) and stair falls. Clinical manifestations were noted and head injuries separated into primary (bleeding) and secondary (hypoxia, edema). The influence of age and fall type on head injuries sustained was evaluated. Injury patterns in children <4 years varied with age. Despite similar injury severity scores, infants sustained more skull fractures than toddlers (71% vs. 39%). Of children with skull fractures, 11% had no evidence of scalp/facial soft tissue swelling. Of the patients with primary intracranial injury, 30% had no skull fracture and 8% had neither skull fracture nor cranial soft tissue injury. Low height falls resulted in primary intracranial injury without soft tissue or skull injury in infants (6%) and toddlers (16%). Within a given fall type, age-related differences in injuries exist between infants and toddlers. When interpreting a fall history, clinicians must consider the fall type and influence of age on resulting injury. For young children, intracranial injury is not always accompanied by external manifestations of their injury.
    International journal of developmental neuroscience: the official journal of the International Society for Developmental Neuroscience 10/2011; 30(3):201-6. DOI:10.1016/j.ijdevneu.2011.10.007 · 2.58 Impact Factor
  • Cindy W Christian ·
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    ABSTRACT: The medical examination of the sexually abused child may have evidentiary, medical, and therapeutic purposes, and the timing of the examination requires consideration of each of these objectives. In cases of acute sexual assault, emergent examinations may be needed to identify injury, collect forensic evidence, and provide infection and pregnancy prophylaxis. Alternately, most sexually abused children are not identified immediately after assault, and the timing of the examination needs to balance physical and emotional issues with the availability of qualified examiners. In all cases, the best interests of the child should be paramount.
    Journal of Child Sexual Abuse 09/2011; 20(5):505-20. DOI:10.1080/10538712.2011.607424 · 0.75 Impact Factor
  • Cindy W. Christian · Kenneth W. Feldman ·

    Pediatrics 08/2011; 128(2). DOI:10.1542/peds.2011-1244 · 5.47 Impact Factor

Publication Stats

2k Citations
276.20 Total Impact Points


  • 2001-2015
    • University of Pennsylvania
      • • Perelman School of Medicine
      • • Department of Pediatrics
      Filadelfia, Pennsylvania, United States
  • 2010-2014
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 1995-2014
    • The Children's Hospital of Philadelphia
      • • Division of General Pediatrics
      • • Department of Pediatrics
      • • Department of Emergency Medicine
      Filadelfia, Pennsylvania, United States
  • 2011
    • Robert Wood Johnson Foundation
      Princeton, New Jersey, United States
  • 2008
    • Children's Medical Center Dallas
      Dallas, Texas, United States