Epidemiology and clinical characteristics of drowning patients presenting to a pediatric emergency department from 2017 to 2020.

BACKGROUND: Drowning is a common mechanism of injury in the pediatric population that often requires hospitalization. The primary objective of this study was to describe the epidemiology and clinical characteristics of pediatric drowning patients evaluated in a pediatric emergency department (PED), including the clinical interventions and outcomes of this patient population. METHODS: A retrospective cohort study was conducted of pediatric patients evaluated in a mid-Atlantic urban pediatric emergency department from January 2017 to December 2020 after a drowning event. RESULTS: Eighty patients ages 0-18 were identified, representing 57 79 unintentional events and 1 intentional self-injury event. The majority of patients (50%) were 1-4 years of age. The majority (65%) of patients 4 years of age or younger were White, whereas racial/ethnic minority patients accounted for the majority (73%) of patients 5 years of age or older. Most drowning events (74%) occurred in a pool, on Friday through Saturday (66%) and during the summer (73%). Oxygen was used in 54% of admitted patients and only in 9% of discharged patients. Cardiopulmonary resuscitation (CPR) was performed in 74% of admitted patients and 33% of discharged patients. CONCLUSIONS: Drowning can be an intentional or unintentional source of injury in pediatric patients. Among the patients who presented to the emergency department for drowning, more than half received CPR and/or were admitted, suggesting high acuity and severity of these events. In this study population, outdoor pools, summer season and weekends are potential high yield targets for drowning prevention efforts.

"Before I Could Get Him, He Fell": Experiences, Concerns, and Fall Prevention Strategies of Parents With Young Children.

Little is known about parents' perceptions and prevention strategies regarding childhood falls. In this qualitative study using semi-structured interviews, we sought to describe parental reports of child fall experiences, concerns, and prevention strategies in the home. Sixteen parents with at least one child younger than 18 months were asked about their awareness of fall risks, falls experienced by the child, fall concerns, prevention strategies, and where in the home the child spends time throughout the day. Seven themes emerged: (1) "falls are unexpected," (2) "role of the physical environment," (3) "children's temperament and developmental stage," (4) "physical barriers and baby products," (5) "addressing walking surfaces," (6) "modifying the height of a fall," and (7) "supervision." Parents are aware of in-home fall hazards and actively use strategies to lessen fall risk. Anticipatory guidance should promote evidence-based and evidence-informed prevention strategies and augment effective strategies some parents use to lower fall risk.

A review of state regulations for child care: Preventing, recognizing and reporting child maltreatment.

BACKGROUND: Prior to the COVID-19 pandemic, nearly 60% of children under 5 years of age were cared for in out-of-home child care arrangements in the United States. Thus, child care provides an opportunity to identify and address potential child maltreatment. However, during the pandemic, rates of reporting child maltreatment decreased-likely because children spent less time in the presence of mandated reporters. As children return to child care, states must have regulations in place to help child care providers prevent, recognize and report child maltreatment. However, little is known about the extent to which state regulations address child maltreatment. Therefore, the purpose of this cross-sectional study was to assess state regulations related to child maltreatment and compare them to national standards. METHOD: We reviewed state regulations for all 50 states and the District of Columbia for child care centres ('centres') and family child care homes ('homes') through 31 July 2021 and compared these regulations to eight national health and safety standards on child maltreatment. We coded regulations as either not meeting, partially meeting or fully meeting each standard. RESULTS: Three states (Colorado, Utah and Washington) had regulations for centres, and one state (Washington) had regulations for homes that at least partially met all eight national standards. Nearly all states had regulations consistent with the standards requiring that caregivers and teachers are mandated reporters of child maltreatment and requiring that they be trained in preventing, recognizing and reporting child maltreatment. One state (Hawaii) did not have regulations consistent with any of the national standards for either centres or homes. CONCLUSIONS: Generally, states lacked regulations related to the prevention, recognition and reporting of child maltreatment for both centres and homes. Encouraging states to adopt regulations that meet national standards and further exploring their impact on child welfare are important next steps.

Impact of the COVID-19 pandemic on pediatric emergency department utilization for head injuries.

Head injuries are a leading cause of death and disability in children, accounting for numerous emergency department (ED) visits. It is unclear how the COVID-19 pandemic has influenced healthcare utilization for pediatric head injuries. We hypothesize that the proportion of ED visits attributable to head injury and severity will increase during the COVID-19 era. Retrospective study using electronic health record data to compare proportion and severity of head injury for children 0-21 years of age from three urban mid-Atlantic EDs in the pre-COVID-19 era (March-June 2019) and COVID-19 era (March-June 2020). Controlling for confounders, logistic regression analyses assessed ORs of head injury outcomes. The χ2 analyses identified differences in patient characteristics. The proportion of head injury visits within the ED population significantly increased during the COVID-19 era (adjusted OR (aOR)=1.2, 95% CI 1.1 to 1.4). Proportion of visits requiring hospitalization for head injury increased by more than twofold in the COVID-19 era (aOR=2.3, 95% CI 1.3 to 4.3). Use of head CT imaging did not significantly change in the COVID-19 era (aOR=1.0, 95% CI 0.7 to 1.6). The proportion of ED visits and hospitalizations for head injury increased during the COVID-19 era. This could be due to changes in the level of supervision and risk exposures in the home that occurred during the pandemic, as well as differences in postinjury care, level of awareness regarding injury severity, and threshold for seeking care, all of which may have influenced pediatric healthcare utilization for head injuries.

State and city laws governing the use of child restraint systems in rideshare vehicles and taxicabs: requirements and responsibility.

OBJECTIVES: To identify, describe and critique state and local policies related to child passenger safety in for-hire motor vehicles including ridesharing and taxis. METHODS: We used standard legal research methods to collect policies governing the use of child restraint systems (CRS) in rideshare and taxi vehicles for all 50 states and the 50 largest cities in the USA. We abstracted the collected policies to determine whether the policy applies to specific vehicles, requires specific safety restraints in those vehicles, lists specific requirements for use of those safety restraints, seeks to enhance compliance and punishes noncompliance. RESULTS: All 50 states have policies that require the use of CRS for children under a certain age, weight or height. Seven states exempt rideshare vehicles and 28 states exempt taxis from their CRS requirements. Twelve cities have relevant policies with eight requiring CRS in rideshare vehicles, but not taxis, and two cities requiring CRS use in both rideshare vehicles and taxis. CONCLUSION: Most states require CRS use in rideshare vehicles, but not as many require CRS use in taxis. Though states describe penalties for drivers who fail to comply with CRS requirements, these penalties do not actually facilitate the use of CRS in rideshare or taxis. Furthermore, there is ambiguity in the laws about who is responsible for the provision and installation of the restraints. To prevent serious or fatal injuries in children, policy-makers should adopt policies that require, incentivise and facilitate the use of CRS in rideshare vehicles and taxis.

Child Housing Assessment for a Safe Environment (CHASE): a new tool for injury prevention inside the home.

OBJECTIVE: To develop a tool to assess the safety of the home environment that could produce valid measures of a child's risk of suffering an injury. METHODS: Tool development: A four-step process was used to develop the CHASE (Child Housing Assessment for a Safe Environment) tool, including (1) a literature scan, (2) reviewing of existing housing inspection tools, (3) key informants interviews, and (4) reviewing the National Electronic Injury Surveillance System to determine the leading housing elements associated with paediatric injury. Retrospective case-control study to validate the CHASE tool: Recruitment included case (injured) and control (sick but not injured) children and their families from a large, urban paediatric emergency department in Baltimore, Maryland in 2012. Trained inspectors applied both the well-known Home Quality Standard (HQS) and the CHASE tool to each enrollee's home, and we compared scores on individual and summary items between cases and controls. RESULTS: Twenty-five items organised around 12 subdomains were included on the CHASE tool. 71 matched pairs were enrolled and included in the analytic sample. Comparisons between cases and controls revealed statistically significant differences in scores on individual items of the CHASE tool as well as on the overall score, with the cases systematically having worse scores. No differences were found between groups on the HQS measures. CONCLUSION: Programmes conducting housing inspections in the homes of children should consider including the CHASE tool as part of their inspection measures. Future study of the CHASE inspection tool in a prospective trial would help assess its efficacy in preventing injuries and reducing medical costs.

Content of Infant Safe Sleep Counseling and Maternal Reported Practices in an Urban Clinic.

OBJECTIVE: Sudden Infant Death Syndrome is a leading cause of mortality in infants, and pediatric providers can influence caregiver infant safe sleep practices. We described the content of safe sleep counseling by pediatric providers and examined pediatric provider and caregiver factors that may be related to the delivery of safe sleep counseling. METHODS: A sample of mothers and providers enrolled in the Safe Start Study, a randomized controlled trial assessing a safe sleep intervention, were audio-recorded during the 2-week well child visits (WCV) at a large urban pediatric practice in Baltimore, Maryland from October 2015 to April 2017. Provider counseling content related to infant sleep was transcribed and coded based on American Academy of Pediatrics (AAP) policy statement Grade A recommendations. Maternal reported infant sleep practices were defined by items on an interviewer administered survey. Multivariate logistic regression analyses were used to examine the relation between maternal reported infant sleep practices and provider counseling. RESULTS: Most, 92%, of WCVs included at least 1 safe sleep topic, but there was inconsistency in content delivered based on AAP recommendations. Yet, only 12% of WCVs included all 4 components of ABC counseling. Maternal report of infant sleeping with a person or an object in sleep space was associated with decreased odds of receiving counseling on alone no person, no objects (adjusted odds ratio: 0.34, 95% confidence interval: 0.13, 0.90). CONCLUSIONS: Pediatric provider counseling on safe sleep is inconsistent across AAP recommendations demonstrating a need for enhanced provider education and a more standardized approach to assess infant sleep practices.

Characteristics of opioid prescriptions for discharged pediatric emergency department patients with acute injuries.

This study describes the characteristics of opioid prescriptions for pediatric patients discharged from the emergency department (ED) with acute injuries, including type, formulation, quantity dispensed, and associations with patient age group and prescriber level of training. This retrospective cohort study enrolled all acutely injured patients receiving opioid prescriptions at discharge from an urban academic pediatric ED in a 1-year period. Electronic medical records were reviewed to abstract clinical and prescription data and prescriber level of training. Descriptive statistics were used for analysis. We identified 254 patients with injuries who received opioid prescriptions at ED discharge during the study period (mean age 9.5 years, 65% male). The most common injury was fracture (71%). Oxycodone was the opioid most frequently prescribed (96.1%). Liquid formulations were prescribed in 51.6% of cases. The median number of doses prescribed per prescription was 12 (SD±9.1), with a range of 1-50. Residents wrote 72.9% of prescriptions and prescribed more doses than non-residents (15.5 vs 12.2, p=0.01). Post-graduate year 2 (PGY2) residents prescribed more doses than PGY1 or PGY3+ residents. Our data show wide variation in the number of opioid doses prescribed to acutely injured pediatric patients at ED discharge and frequent use of liquid formulation; both factors may place this population at risk for accidental ingestion. These findings also support the development of pediatric clinical guidelines to define appropriate quantities of opioids to prescribe, promote poisoning prevention strategies, and design post-graduate education for medical trainees about safe prescribing practices.

Preventing unintentional injuries in US early care and education: Are state regulations sufficient?

Unintentional injuries are currently the leading cause of death among US children older than one. As many children spend significant time in non-parental child care, these injuries often occur outside of the home. This study examined US state early care and education (ECE) regulations related to injury prevention. We reviewed ECE regulations for child care centers and family child care homes through August 2018 for all 50 states and DC ("states"). We compared these regulations to six components from two national health and safety standards on injury prevention ("standards"). One state had regulations that met all six standards for both centers and homes; sixteen states had regulations that met at least five for both. Most states required child care providers to be trained in emergency preparedness (42 for centers; 38 for homes) or first aid including CPR (50 for centers; 46 for homes). Additionally, most states required providers in centers and homes to notify parents (47 and 41, respectively) and the state (40 and 41, respectively) when a child was injured; these requirements varied greatly in both the timing and manner of notification. Two-thirds of states required that providers keep copies of a completed injury form on the premises. However, few states (5 for centers, 3 for homes) required providers to take corrective action after an injury. Although most states had some injury prevention regulations, they varied greatly across states. More states should require corrective action after an injury to help prevent future injuries from occurring.

Utilizing Facebook and Automated Telephone Calls to Increase Adoption of a Local Smoke Alarm Installation Program.

CONTEXT: Innovative strategies are needed to improve the prevalence of working smoke alarms in homes. To our knowledge, this is the first study to report on the effectiveness of Facebook advertising and automated telephone calls as population-level strategies to encourage an injury prevention behavior. OBJECTIVE: We examine the effectiveness of Facebook advertising and automated telephone calls as strategies to enroll individuals in Baltimore City's Fire Department's free smoke alarm installation program. PARTICIPANTS: We directed our advertising efforts toward Facebook users eligible for the Baltimore City Fire Department's free smoke alarm installation program and all homes with a residential phone line included in Baltimore City's automated call system. DESIGN: The Facebook campaign targeted Baltimore City residents 18 years of age and older. In total, an estimated 300 000 Facebook users met the eligibility criteria. Facebook advertisements were delivered to users' desktop and mobile device newsfeeds. A prerecorded message was sent to all residential landlines listed in the city's automated call system. RESULTS: By the end of the campaign, the 3 advertisements generated 456 666 impressions reaching 130 264 Facebook users. Of the users reached, 4367 individuals (1.3%) clicked the advertisement. The automated call system included approximately 90 000 residential phone numbers. Participants attributed 25 smoke alarm installation requests to Facebook and 458 to the automated call. CONCLUSION: Facebook advertisements are a novel approach to promoting smoke alarms and appear to be effective in exposing individuals to injury prevention messages. However, converting Facebook message recipients to users of a smoke alarm installation program occurred infrequently in this study. Residents who participated in the smoke alarm installation program were more likely to cite the automated call as the impetus for their participation. Additional research is needed to understand the circumstances and strategies to effectively use the social networking site as a tool to convert passive users into active participants.

Health education intervention promoting infant safe sleep in paediatric primary care: randomised controlled trial.

BACKGROUND: Few randomised controlled trials (RCTs) have been conducted to improve infant sleep practices. There is limited research on how best to integrate safe sleep information into routine paediatric anticipatory guidance delivered at well child visits (WCVs). This protocol paper describes the design of the Safe Start Study, which aims to evaluate the impact of safe sleep interventions on parents' knowledge, beliefs and behaviours related to creating and maintaining a safe sleep environment for their infants. METHODS: Safe Start is a three-group RCT comparing a safe sleep health education intervention delivered as part of the 2-week WCV, an attention-matched control group that receives a scald burn prevention intervention, and a standard of care group. A baseline survey is completed at the 2-week WCV; follow-up surveys and observations are completed in the home at 2-4 weeks and 2-3 months. Participants include mother-baby dyads attending a large urban paediatric primary care practice and their paediatricians. Primary outcomes are self-reported behaviours (baby sleeps alone, on back, in crib and in a smoke-free environment), observations of the sleep environment, paediatricians' anticipatory guidance counselling about safe sleep and participants' reported exposure to an existing city-wide safe sleep campaign. DISCUSSION: Providing a theory-driven and evidenced-based safe sleep intervention is both a research and a clinical practice priority. This study will advance the application of educational and environmental interventions in the primary care setting to improve the safety of infant sleep environments in high-risk families. TRIAL REGISTRATION NUMBER: NCT03070639; Pre-results.

Cell Phone and Computer Use Among Parents Visiting an Urban Pediatric Emergency Department.

OBJECTIVES: The objectives of this study were to estimate the prevalence of cell phone and computer use among urban families bringing their children to an emergency department and to determine which technologies parents prefer to use to receive health information. METHODS: We visited 2 pediatric emergency departments in Baltimore, Md, and Little Rock, Ark. A convenience sample of parents of children 8 years old or younger completed a self-administered survey in the waiting area. RESULTS: Two hundred thirty-eight surveys were completed. Respondents were primarily female (83%), less than 35 years old (74%), and had at least a high school diploma or General Educational Development (94%). Forty-three percent were employed full time. A majority (95%) of respondents reported owning a cell phone, with most (88%) owning a smartphone and 96% reported having some internet access. Of cell phone owners, 91% reported daily text messaging activity. Over half (63%) of respondents reported having computer internet access at home; 31% reported having internet access at work. Patterns of behavior and preferences emerged for both cell phone and computer use. Respondents were more likely to check their email (75% vs 50%, P < 0.0001) and access the internet (78% vs 67%, P = 0.002) with a smartphone rather than their computer. CONCLUSIONS: Both cell phones and computers are prevalent and used among urban families seen in pediatric emergency departments, offering new ways to deliver health information to these often underserved populations. Providers aiming to deliver health information should consider smartphone applications, text message-based programs, and email to communicate with their patients.

Results of an RCT in Two Pediatric Emergency Departments to Evaluate the Efficacy of an m-Health Educational App on Car Seat Use.

INTRODUCTION: The growing interest in incorporating prevention into emergency health care make it timely to examine the use of computer technology to efficiently deliver effective education in this setting. STUDY DESIGN: This RCT compared results from an intervention group (n=367) that received child passenger safety information, to an attention-matched control (n=375). A baseline survey and two follow-up surveys at 3 and 6 months were conducted. SETTING/PARTICIPANTS: Data were collected from June 2014 to September 2016 from a sample of parents with children aged 4-7 years recruited from a pediatric emergency department in an East Coast urban area and one in a Midwest semi-rural area. INTERVENTION: A theory-based, stage-tailored educational program, Safety in Seconds v2.0TM, delivered on a mobile app. MAIN OUTCOME MEASURES: Four car seat behaviors: (1) having the correct restraint for the child's age and weight; (2) having the child ride in the backseat all the time; (3) buckling up the child all the time; and (4) having the child's restraint inspected by a child passenger safety technician. RESULTS: At 3 months, adjusting for baseline behaviors and attrition, the odds of reporting the correct behavior by the intervention group relative to the control group was 2.07 (p<0.01) for using the correct car seat; 2.37 (p<0.05) times for having the child ride in the back seat; 1.04 (nonsignificant) for riding buckled up all the time; and 1.99 (p<0.01) times for having the car seat inspected. At 6 months, there were statistically significant effects for reporting use of the correct car seat (OR=1.84, p<0.01) and having the car seat inspected (OR=1.73, p<0.01). CONCLUSIONS: Mobile apps hold promise for reaching large populations with individually tailored child passenger safety education. TRIAL REGISTRATION: Clinical Trial Registration # NCT02345941.

Pilot Study of a Novel Partnership for Installing Smoke Alarms.

Objectives To demonstrate the feasibility of partnering fire department personnel and home visiting nurses to increase the number of low-income homes protected by smoke alarms. Methods During a regularly scheduled home visit, nurses at the Nurse-Family Partnership of Maricopa County (NFP) informed their clients about an opportunity to have smoke alarms installed in their homes for free. For interested families, nurses sent a referral to the Phoenix Fire Department (PFD), scheduled an appointment, and accompanied the PFD volunteers during the installation. During the appointment, PFD personnel installed alarms and provided safety education. Clients completed a follow-up survey 1-3 months after the installation visit. In-depth interviews were completed with key informants from NFP and PFD to solicit feedback on the program. Results Fifty-two smoke alarm installation visits were completed. Before the fire department arrived, 55% of homes had no working smoke alarm. Almost all (94%) homes received at least one new smoke alarm, and every home had at least one working smoke alarm at the end of the fire department visit. At follow-up, all homes maintained at least one working smoke alarm. Members from both organizations were enthusiastic about, and supportive of the project. NFP nurses appreciated the skill and knowledge of the firefighters; PFD representatives noted that the nurses' relationships with clients made it easier for them to gain access to families who are often described as "hard-to-reach". Conclusions Partnering home visiting nurses and fire departments can be successful to increase the number of vulnerable homes with smoke alarms.

Primary Care Opportunities to Prevent Unintentional Home Injuries: A Focus on Children and Older Adults.

Unintentional injuries are a persistent public health problem in the United States. A new health care landscape has the potential to create a clinical environment that fosters greater involvement by health care providers in injury prevention. The aim of this article is to provide evidence supporting the need for engagement by primary care providers in unintentional home injury prevention along with examples of how this could be accomplished. We know a great deal about what population groups are at risk for certain types of injuries. We also know that many injuries can be prevented through policies, programs, and resources that ensure safe environments and promote safe behaviors. For example, the Centers for Disease Control and Prevention's STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative comprises clinical decision support tools and educational materials for health care providers. Two effective interventions that have demonstrated a reduction in falls among children are the redesign of baby walkers (engineering) and the mandated use of window guards (enforcement). Primary care clinicians can play a key role in promoting their patient's safety. Taken collectively, a focused attention on preventing unintentional home injuries by primary care providers can contribute to the reduction of injuries and result in optimal health for all.

Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children.

OBJECTIVES: To describe safe storage practices and beliefs among adults who have used a prescription opioid pain reliever (OPR) in the past year; to compare practices and beliefs among those living with younger (<7 years) versus older children (7-17 years). METHODS: A survey was administered to a nationally representative sample of adults reporting OPR use in the previous 12 months and who had children <18 years old living with them. We used Health Belief Model-derived items to measure beliefs. Safe storage was defined as locked or latched for younger children and as locked for older children. Regression models examined the association between beliefs and safe storage practices. RESULTS: Among 681 adults who completed our survey and reported having children in their home, safe storage was reported by 32.6% (95% confidence interval [CI], 21.4-43.8) of those with only young children, 11.7% (95% CI, 7.2-16.2) among those with only older children, and 29.0% (95% CI, 18.3-39.8) among those with children in both age groups. Among those asked to answer survey questions thinking about only their oldest child, the odds of reporting safe storage decreased by half as perceived barriers increased (0.505; 95% CI, 0.369-0.692), increased twofold as efficacy increased (2.112; 95% CI, 1.390-3.210), and increased (1.728; 95% CI, 1.374-2.174) as worry increased. CONCLUSIONS: OPRs are stored unsafely in many households with children. Educational messages should address perceived barriers related to safe storage while emphasizing how it may reduce OPR access among children.

Does Health Literacy Level Influence the Effectiveness of a Kiosk-Based Intervention Delivered in the Pediatric Emergency Department?

OBJECTIVE: This study assesses parents' literacy skills and evaluates how literacy levels influenced the effectiveness of a health communication intervention designed to improve safety knowledge in low-income, urban families. METHODS: A total of n = 450 parents of children aged 4 to 66 months completed the Rapid Estimate of Adult Literacy in Medicine (REALM) and participated in a randomized trial of an injury prevention intervention delivered via computer kiosk in a pediatric emergency department. A safety knowledge test was administered by telephone 2 to 4 weeks later. RESULTS: More than one-third of parents were assessed by the REALM to have marginal (30%) or inadequate (8%) reading levels; the remaining 62% of parents had adequate reading levels. REALM scores were independently associated with knowledge gains for poison storage and smoke alarms. CONCLUSIONS: Participants reading level had an independent and significant effect on safety knowledge outcomes. Literacy level should be considered in all patient education efforts.