Because parents assume the primary responsibility for providing ambulatory post-transplant care to pediatric patients, pretransplant psychosocial evaluation in these recipients is usually focused on parents rather than on patients themselves. We sought to determine whether pretransplant parental psychosocial evaluation predicts post-transplant medical outcome at current levels of psychosocial support. We compared relative risk (RR) of rejection and hospitalizations (days of all-cause hospitalization) following initial discharge in patients in 'risk' and 'control' groups defined by their pretransplant parental psychosocial evaluation. We also compared the two groups of patients for the proportion of all outpatient trough cyclosporine A (CSA) or tacrolimus (FK) levels that were < 50% of the target level (defined as the mid-therapeutic range level). There were seven patients in the 'risk' group with a median age 0.25 yr (range 0.19-14.7 yr) and total follow up 20.5 patient-yr. There were 21 patients in the 'control' groups with a median age of 2.1 yr (range 0.05-16.2 yr) and total follow up of 71.3 patient-yr. There was no significant difference between the groups in rejection-risk or days of all-cause hospitalization early after transplant (first six months). During the late period (after the first six months), there were 11 rejection episodes in the 'risk' group over 17.4 patient-yr and four rejection episodes in control group over 61.8 patient-yr of follow up. After adjustment for age and race, patients in the 'risk' category had a RR of 3.4 for developing a rejection episode (p = 0.06) and 3.1 for being inpatient (p < 0.001) during the late period. Patients in the risk group were 2.9 times more likely to have subtherapeutic trough levels (< 50% target level) of calcineurin inhibitor (CSA or FK) during both early and late periods (p < 0.01 for both periods) after adjustment for patient age and race. We conclude that pretransplant parental psychosocial risk assessment is associated with post-transplant morbidity in children after cardiac transplantation. These patients may benefit from closer outpatient monitoring and a higher level of psychosocial support.

No child with normal neurologic findings had a clinically important abnormality depicted at CT. CT scans did not alter clinical management, clinical outcome, or legal outcome. Thus, routine CT of all patients with skull fractures in this population may be unnecessary.

Shaken baby syndrome (SBS) is a term denoting a particularly harmful form of child abuse. By definition, 1 these infants have intracranial and retinal hemorrhages in the absence of signs of head trauma or skull fracture. Most SBS victims appear to have significant neurologic damage at the time of diagnosis.2,3 The medical literature, however, does not describe these children as they grow older. A 1986 article4 called for follow-up studies on these children, but a computerized literature search turned up only one paper on long-term follow-up in SBS. Sinal and Ball5 described cranial computerized tomog-raphic (CT) and clinical follow-up in 24 brain-injured children, 17 of whom had SBS. They followed the 15 surviving shaken infants for about 4 years: seven had severe handicaps, and only one was normal.

Our study may have underestimated children's climbing abilities because of the absence of a shower curtain to help with balance and the distracting presence of strangers. The diagnosis of abuse is in part based on a described mechanism being inconsistent with the observed pattern of injury. This has severe repercussions for the child and his or her family. Our study brings into question previously held beliefs that these injuries could only be sustained by direct immersion.