Is Underimmunization Associated With Child Maltreatment? Melissa S. Stockwell, MD, MPH; Jocelyn Brown, MD, MPH; Shaofu Chen, MD, PhD; Roger D. Vaughan, DrPH, MS; Matilde Irigoyen, MD Objective.—To assess the relationship between underimmuniza- tion and child maltreatment among children referred to a child advocacy center for a child maltreatment evaluation. Methods.—We conducted a secondary data analysis of 399 chil- dren aged 3 to 48 months who were referred to a child advocacy center at an academic medical center. The primary independent variable was age-appropriate immunization status. The dependent variable was maltreatment (confirmed, suspected, or ruled out). Multivariate models were used to control for insurance, race/eth- nicity, and maternal education. Results.—At 3 and 7 months of age, underimmunized children were significantly more likely to have confirmed maltreatment than children whose immunizations were up to date (at 3 months, 32.0% vs 17.6%, P < .05; at 7 months, 23.7% vs 8.6%, P < .01). At 19 months, rates were not significantly different (16.1% vs 24.1%, P ¼ .33). In multivariate analyses, children underimmu- nized at 3 or 7 months of age were 4 times more likely to have confirmed maltreatment compared with children whose immuni- zations were up to date (at 3 months, adjusted odds ratio [AOR], 3.97, 95% confidence interval [95% CI], 1.67–9.49; at 7 months, AOR, 4.79, 95% CI, 1.47–15.66). This relationship was statisti- cally significant for children evaluated for physical abuse (AOR, 4.34, 95% CI, 1.18–16.02), but not for sexual abuse. Conclusions.—Underimmunization at 3 and 7 months of age was associated with confirmed maltreatment, specifically physical abuse, in children evaluated for child maltreatment. The associa- tion between underimmunization and child abuse in the general population deserves further study. KEY WORDS: child abuse; health services needs; immuniza- tion; vaccination Ambulatory Pediatrics 2008;8:210–213 C hild maltreatment is an unsolved public health issue. 1 The nearly 1 million children who are vic- tims of child maltreatment annually are at risk for behavioral, psychological, and adverse health outcomes that last through adulthood. 2–4 Primary pediatric care may play a role in preventing child maltreatment or in amelio- rating long-term morbidity. 5–7 There is some evidence of a relationship between inad- equate primary care and child maltreatment, at least in chil- dren referred for evaluation of maltreatment. We recently showed an association between lacking a primary care pro- vider and physical abuse. 8 Furthermore, children with sus- pected or confirmed child maltreatment have been shown to have unmet primary care needs such as underimmuniza- tion. 9–13 However, the observed relationship between child maltreatment and primary care needs such as underimmu- nization may have been confounded by poverty and decreased access to care. 9–17 Therefore, it remains to be determined whether an independent association exists. To understand whether underimmunization is associated with child maltreatment among young children referred for maltreatment evaluation, we assessed maltreatment out- comes for children grouped by their immunization status while controlling for the common sociodemographic variables of race/ethnicity, insurance status, and maternal education. METHODS Study Design We conducted a secondary data analysis of an existing patient database maintained by a child advocacy center (CAC) at an urban academic medical center. The study was approved by the Institutional Review Board of Colum- bia University Medical Center. Study Setting The CAC evaluates approximately 500 children annu- ally for maltreatment (sexual abuse, physical abuse, and/ or neglect). Most children are referred to the CAC from the emergency department, from primary care providers, or from child protective services primarily for a forensic evaluation of physical or sexual abuse. Children seen in the CAC range in age from 0 to 20 years old, with From the Division of General Pediatrics, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY (Dr Stockwell, Dr Brown, Dr Chen, and Dr Irigoyen); the Department of Biostatistics (Dr Vaughan) and the Heilbrunn Department of Population and Family Health (Dr Irigoyen and Dr Stockwell), Mailman School of Public Health, Columbia University, New York, NY. Presented in part as a poster at the Pediatric Academic Societies’ An- nual Meeting, San Francisco, Calif, April 2006; and at the Eastern Society for Pediatric Research Annual Meeting, Greenwich, Conn, March 2006. Address correspondence to Melissa S. Stockwell, MD, MPH, Division of General Pediatrics, Columbia University, 622 W 168th St, VC 402, New York, New York 10032 (e-mail: mss2112@columbia.edu). Received for publication August 13, 2007; accepted January 14, 2008. AMBULATORY PEDIATRICS Volume 8, Number 3 Copyright Ó 2008 by Academic Pediatric Association 210 May–June 2008