Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study.

OBJECTIVE: The lack of evidence-based criteria to guide chest radiograph (CXR) use in young febrile infants results in variation in its use with resultant suboptimal quality of care. We sought to describe the features associated with radiographic pneumonias in young febrile infants. STUDY DESIGN: Secondary analysis of a prospective cohort study in 18 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from 2016 to 2019. Febrile (≥38°C) infants aged ≤60 days who received CXRs were included. CXR reports were categorised as 'no', 'possible' or 'definite' pneumonia. We compared demographics, clinical signs and laboratory tests among infants with and without pneumonias. RESULTS: Of 2612 infants, 568 (21.7%) had CXRs performed; 19 (3.3%) had definite and 34 (6%) had possible pneumonias. Patients with definite (4/19, 21.1%) or possible (11/34, 32.4%) pneumonias more frequently presented with respiratory distress compared with those without (77/515, 15.0%) pneumonias (adjusted OR 2.17; 95% CI 1.04 to 4.51). There were no differences in temperature or HR in infants with and without radiographic pneumonias. The median serum procalcitonin (PCT) level was higher in the definite (0.7 ng/mL (IQR 0.1, 1.5)) vs no pneumonia (0.1 ng/mL (IQR 0.1, 0.3)) groups, as was the median absolute neutrophil count (ANC) (definite, 5.8 K/mcL (IQR 3.9, 6.9) vs no pneumonia, 3.1 K/mcL (IQR 1.9, 5.3)). No infants with pneumonia had bacteraemia. Viral detection was frequent (no pneumonia (309/422, 73.2%), definite pneumonia (11/16, 68.8%), possible pneumonia (25/29, 86.2%)). Respiratory syncytial virus was the predominant pathogen in the pneumonia groups and rhinovirus in infants without pneumonias. CONCLUSIONS: Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonias, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias.

Rapid deployment of a telemedicine care model for genetics and metabolism during COVID-19.

The national importance of telemedicine for safe and effective patient care has been highlighted by the current COVID-19 pandemic. Prior to the 2020 pandemic the Division of Genetics and Metabolism piloted a telemedicine program focused on initial and follow-up visits in the patients' home. The goals were to increase access to care, decrease missed work, improve scheduling, and avoid the transport and exposure of medically fragile patients. Visits were conducted by physician medical geneticists, genetic counselors, and biochemical dietitians, together and separately. This allowed the program to develop detailed standard operating procedures. At the onset of the COVID-19 pandemic, this pilot-program was deployed by the full team of 22 providers in one business day. Two physicians remained on-site for patients requiring in-person evaluations. This model optimized patient safety and workforce preservation while providing full access to patients during a pandemic. We provide initial data on visit numbers, types of diagnoses, and no-show rates. Experience in this implementation before and during the pandemic has confirmed the effectiveness and value of telemedicine for a highly complex medical population. This program is a model that can and will be continued well-beyond the current crisis.

Radiographic Pneumonia in Febrile Infants 60 Days and Younger.

OBJECTIVE: Few prospective studies have assessed the occurrence of radiographic pneumonia in young febrile infants. We analyzed factors associated with radiographic pneumonias in febrile infants 60 days or younger evaluated in pediatric emergency departments. STUDY DESIGN: We conducted a planned secondary analysis of a prospective cohort study within 26 emergency departments in a pediatric research network from 2008 to 2013. Febrile (≥38°C) infants 60 days or younger who received chest radiographs were included. Chest radiograph reports were categorized as "no," "possible," or "definite" pneumonia. We compared demographics, Yale Observation Scale scores (>10 implying ill appearance), laboratory markers, blood cultures, and viral testing among groups. RESULTS: Of 4778 infants, 1724 (36.1%) had chest radiographs performed; 2.7% (n = 46) had definite pneumonias, and 3.9% (n = 67) had possible pneumonias. Patients with definite (13/46 [28.3%]) or possible (15/67 [22.7%]) pneumonias more frequently had Yale Observation Scale score >10 compared with those without pneumonias (210/1611 [13.2%], P = 0.002) in univariable and multivariable analyses. Median white blood cell count (WBC), absolute neutrophil count (ANC), and procalcitonin (PCT) were higher in the definite (WBC, 11.5 [interquartile range, 9.8-15.5]; ANC, 5.0 [3.2-7.6]; PCT, 0.4 [0.2-2.1]) versus no pneumonia (WBC, 10.0 [7.6-13.3]; ANC, 3.4 [2.1-5.4]; PCT, 0.2 [0.2-0.3]; WBC, P = 0.006; ANC, P = 0.002; PCT, P = 0.046) groups, but of unclear clinical significance. There were no cases of bacteremia in the definite pneumonia group. Viral infections were more frequent in groups with definite (25/38 [65.8%]) and possible (28/55 [50.9%]) pneumonias than no pneumonias (534/1185 [45.1%], P = 0.02). CONCLUSIONS: Radiographic pneumonias were uncommon, often had viruses detected, and were associated with ill appearance, but few other predictors, in febrile infants 60 days or younger.

Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger.

STUDY OBJECTIVE: To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). METHODS: We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. RESULTS: Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. CONCLUSION: The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

Acute-Onset Flaccid Hemiparesis in a 9-Year-Old Boy With Presumed Enteroviral Infection.

In the summer and autumn of 2014, a cluster of cases of flaccid paralysis were seen in the United States related to patients infected with enterovirus D68 (EV-D68). We present here a case of acute-onset flaccid hemiparesis in a previously healthy boy with altered mental status, hypothermia, and bowel incontinence.

Epidemiology of blunt head trauma in children in U.S. emergency departments.

Among more than 43,000 children treated in 25 emergency departments for blunt head trauma, traumatic brain injury was identified on CT scan in 7% of the patients. Falls were the most frequent injury mechanism for children under the age of 12 years.

Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.

STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.

Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger.

IMPORTANCE: Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach. OBJECTIVE: To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. EXPOSURE: RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. MAIN OUTCOMES AND MEASURES: Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. RESULTS: Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). CONCLUSIONS AND RELEVANCE: In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Sensitivity of plain pelvis radiography in children with blunt torso trauma.

STUDY OBJECTIVE: Plain anteroposterior pelvic radiographs are commonly used to screen children for pelvic fractures or dislocations after blunt torso trauma. The test sensitivity and utility, however, are unclear. We assessed the sensitivity of anteroposterior pelvic radiographs for identifying children with pelvic fractures or dislocations after blunt torso trauma. We hypothesized that anteroposterior pelvic radiographs fail to identify all children with pelvic fractures or dislocations, including patients undergoing operative intervention and those with hypotension. METHODS: We conducted a prospective multicenter observational study of children (<18 years) with blunt torso trauma in the Pediatric Emergency Care Applied Research Network. We compared plain anteroposterior pelvic radiographs to the final diagnosis of pelvic fractures or dislocations as documented by the orthopedic faculty physician before emergency department (ED)/hospital discharge. We described the data with descriptive statistics, including 95% confidence intervals (CIs). RESULTS: Of 12,044 patients enrolled in the parent study, 451 (3.7%; 95% CI 3.4% to 4.1%) had pelvic fractures or dislocations. Of these patients, 65 (14%; 95% CI 11% to 18%) underwent operative intervention and 21 (4.7%; 95% CI 2.9% to 7.0%) had age-adjusted hypotension on initial presentation. In the ED, 382 of the 451 patients underwent plain anteroposterior pelvic radiographs, with a sensitivity of 297 of 382 (78%; 95% CI 73% to 82%) for patients with pelvic fractures or dislocations, 55 of 60 (92%; 95% CI 82% to 97%) for patients undergoing operative intervention, and 14 of 17 (82%; 95% CI 57% to 96%) for patients with hypotension. CONCLUSION: Plain anteroposterior pelvic radiographs have a limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma, including patients undergoing operative intervention and those with hypotension.

Emergency department practice variation in computed tomography use for children with minor blunt head trauma.

OBJECTIVE: To describe factors associated with computed tomography (CT) use for children with minor blunt head trauma that are evaluated in emergency departments. STUDY DESIGN: Planned secondary analysis of a prospective observational study of children <18 years with minor blunt head trauma between 2004 and 2006 at 25 emergency departments. CT scans were obtained at the discretion of treating clinicians. We risk-adjusted patients for clinically important traumatic brain injuries and performed multivariable regression analyses. Outcome measures were rates of CT use by hospital and by clinician training type. RESULTS: CT rates varied between 19.2% and 69.2% across hospitals. Risk adjustment had little effect on the differential rate of CT use. In low- and middle-risk patients, clinicians obtained CTs more frequently at suburban and nonfreestanding children's hospitals. Physicians with emergency medicine (EM) residency training obtained CTs at greater rates than physicians with pediatric residency or pediatric EM training. In multivariable analyses, compared with pediatric EM-trained physicians, the OR for CT use among EM-trained physicians in children <2 years was 1.24 (95% CI 1.04-1.46), and for children >2 years was 1.68 (95% CI 1.50-1.89). Physicians of all training backgrounds, however, overused CT scans in low-risk children. CONCLUSIONS: Substantial variation exists in the use of CT for children with minor blunt head trauma not explained by patient severity or rates of positive CT scans or clinically important traumatic brain injuries.

Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries.

OBJECTIVE: To determine the accuracy of complaints of abdominal pain and findings of abdominal tenderness for identifying children with intra-abdominal injury (IAI) stratified by Glasgow Coma Scale (GCS) score. STUDY DESIGN: This was a prospective, multicenter observational study of children with blunt torso trauma and a GCS score ≥13. We calculated the sensitivity of abdominal findings for IAI with 95% CI stratified by GCS score. We examined the association of isolated abdominal pain or tenderness with IAI and that undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of intravenous fluid therapy). RESULTS: Among the 12 044 patients evaluated, 11 277 (94%) had a GCS score of ≥13 and were included in this analysis. Sensitivity of abdominal pain for IAI was 79% (95% CI, 76%-83%) for patients with a GCS score of 15, 51% (95% CI, 37%-65%) for patients with a GCS score of 14, and 32% (95% CI, 14%-55%) for patients with a GCS score of 13. Sensitivity of abdominal tenderness for IAI also decreased with decreasing GCS score: 79% (95% CI, 75%-82%) for a GCS score of 15, 57% (95% CI, 42%-70%) for a GCS score of 14, and 37% (95% CI, 19%-58%) for a GCS score of 13. Among patients with isolated abdominal pain and/or tenderness, the rate of IAI was 8% (95% CI, 6%-9%) and the rate of IAI undergoing acute intervention was 1% (95% CI, 1%-2%). CONCLUSION: The sensitivity of abdominal findings for IAI decreases as GCS score decreases. Although abdominal computed tomography is not mandatory, the risk of IAI is sufficiently high that diagnostic evaluation is warranted in children with isolated abdominal pain or tenderness.

Association of traumatic brain injuries with vomiting in children with blunt head trauma.

STUDY OBJECTIVE: We aimed to determine the prevalence of traumatic brain injuries in children who vomit after minor blunt head trauma, particularly when the vomiting occurs without other findings suggestive of traumatic brain injury (ie, isolated vomiting). We also aimed to determine the relationship between the timing and degree of vomiting and traumatic brain injury prevalence. METHODS: This was a secondary analysis of children younger than 18 years with minor blunt head trauma. Clinicians assessed for history and characteristics of vomiting at the initial evaluation. We assessed for the prevalence of clinically important traumatic brain injury and traumatic brain injury on computed tomography (CT). RESULTS: Of 42,112 children enrolled, 5,557 (13.2%) had a history of vomiting, of whom 815 of 5,392 (15.1%) with complete data had isolated vomiting. Clinically important traumatic brain injury occurred in 2 of 815 patients (0.2%; 95% confidence interval [CI] 0% to 0.9%) with isolated vomiting compared with 114 of 4,577 (2.5%; 95% CI 2.1% to 3.0%) with nonisolated vomiting (difference -2.3%, 95% CI -2.8% to -1.5%). Of patients with isolated vomiting for whom CT was performed, traumatic brain injury on CT occurred in 5 of 298 (1.7%; 95% CI 0.5% to 3.9%) compared with 211 of 3,284 (6.4%; 95% CI 5.6% to 7.3%) with nonisolated vomiting (difference -4.7%; 95% CI -6.0% to -2.4%). We found no significant independent associations between prevalence of clinically important traumatic brain injury and traumatic brain injury on CT with either the timing of onset or time since the last episode of vomiting. CONCLUSION: Traumatic brain injury on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for many of these children.

Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas.

STUDY OBJECTIVE: We aimed to determine the association between scalp hematoma characteristics and traumatic brain injuries in young children with blunt head trauma who have no other symptoms or signs suggestive of traumatic brain injuries (defined as "isolated scalp hematomas"). METHODS: This was a secondary analysis of children younger than 24 months with minor blunt head trauma from a prospective cohort study in 25 Pediatric Emergency Care Applied Research Network emergency departments. Treating clinicians completed a structured data form. For children with isolated scalp hematomas, we determined the prevalence of and association between scalp hematoma characteristics and (1) clinically important traumatic brain injury (death, neurosurgery for traumatic brain injury, intubation >24 hours for traumatic brain injury, or positive computed tomography (CT) scan in association with hospitalization ≥2 nights for traumatic brain injury); and (2) traumatic brain injury on CT. RESULTS: Of 10,659 patients younger than 24 months were enrolled, 2,998 of 10,463 (28.7%) with complete data had isolated scalp hematomas. Clinically important traumatic brain injuries occurred in 12 patients (0.4%; 95% confidence interval [CI] 0.2% to 0.7%); none underwent neurosurgery (95% CI 0% to 0.1%). Of 570 patients (19.0%) for whom CTs were obtained, 50 (8.8%; 95% CI 6.6% to 11.4%) had traumatic brain injuries on CT. Younger age, non-frontal scalp hematoma location, increased scalp hematoma size, and severe injury mechanism were independently associated with traumatic brain injury on CT. CONCLUSION: In patients younger than 24 months with isolated scalp hematomas, a minority received CTs. Despite the occasional presence of traumatic brain injuries on CT, the prevalence of clinically important traumatic brain injuries was very low, with no patient requiring neurosurgery. Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to help determine which otherwise asymptomatic children should undergo neuroimaging after minor head trauma.

Cranial computed tomography utilization for suspected ventriculoperitoneal shunt malfunction in a pediatric emergency department.

BACKGROUND: Computed tomography (CT) scan, the largest medical source of ionizing radiation in the United States, is used to test for failure of ventricular peritoneal shunts. STUDY OBJECTIVES: To quantify the exposure to cranial CT scans in pediatric patients presenting with symptoms of shunt malfunction, and to measure the association of signs and symptoms with clinical shunt malfunction and the need for neurosurgical intervention within 30 days of presentation. METHOD: This was a quality improvement study evaluating a pathway used by providers in a tertiary care pediatric emergency department with 85,000 patient visits per year, by retrospective chart review of 223 patient visits for suspected shunt malfunction. We determined the median CT scan per patient per year and the association of signs and symptoms on the pathway with radiological signs of shunt failure and neurosurgical intervention within 30 days of scan. RESULTS: The median exposure was 2.6 (interquartile range 1.44-4.63) scans per patient per year. Among 11 signs and symptoms, none was associated with radiologic shunt failure. Neurosurgical intervention within 30 days was positively associated with bulging fontanelle (adjusted odds ratio [AOR] 11.78; 95% confidence interval [CI] 1.67-83.0) and behavioral change (AOR 3.01; 95% CI 1.14-7.93), and negatively associated with seizure (AOR 0.13; 95% CI 0.02-0.79) and fever (AOR 0.15; 95% CI 0.04-0.55). CONCLUSIONS: Patients with ventricular peritoneal shunts underwent many cranial CT scans each year. None of the signs or symptoms included on the clinical pathway was predictive of changes on CT scan.

Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma.

OBJECTIVE: Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children. METHODS: We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14. RESULTS: Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients' characteristics were as follows: median age, 1.7 years (interquartile range, 1.1-2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%-21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%-12%): laryngospasm 1 (0.2%; 95% CI, 0%-1.1%), failed sedation 31 (6%; 95% CI, 4%-8%), vomiting 6 (1%; 95% CI, 0.4%-2%), hypotension 13 (4%; 95% CI, 2%-7%), and hypoxia 1 (0.2%; 95% CI, 0%-2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate. CONCLUSIONS: Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.

Direct-to-patient telemedicine: Expanding access to regional pediatric specialty care.

Telemedicine is seen as a useful tool in reducing gaps in health care but this technology-enabled care can also exacerbate health inequity if not implemented with a focus on inclusivity. Though many studies have reported improvements as well as exacerbation of disparities in access to care in their telehealth programs, there does not exist a common evaluation tool to assess these programs. To mitigate the impact of COVID-19 on health care workers and protect medically vulnerable children, in March 2020 we expanded our pre-established specialty and subspecialty direct-to-patient pediatric telemedicine program in a high volume urban pediatric health system. Our program aimed to prevent disparities in pediatric health care. In this study, using a "Pillars of Access" approach as a model to evaluate impact and access to care of our direct-to-patient telemedicine program, we analyzed the patients that were seen pre-COVID versus post-COVID. Our study demonstrated an increase in telemedicine visits for patients from diverse socioeconomic and racial backgrounds, and geographically underserved communities. We also observed an increase in telemedicine visits for mental health complaints and for certain categories of high-risk patients. This study was not designed to identify language and cultural barriers to telemedicine. Future identification of these specific barriers is needed. The tool to evaluate telehealth impact/access to care through a "Pillars of Access" approach presented here could serve as a model for implementation of telehealth programs. Our study highlights telemedicine programs as a mechanism to address healthcare inequity and overcome barriers to care.

Results of phase II levetiracetam trial following acute head injury in children at risk for posttraumatic epilepsy.

Posttraumatic seizures develop in up to 20% of children following severe traumatic brain injury (TBI). Children ages 6-17 years with one or more risk factors for the development of posttraumatic epilepsy, including presence of intracranial hemorrhage, depressed skull fracture, penetrating injury, or occurrence of posttraumatic seizure were recruited into this phase II study. Treatment subjects received levetiracetam 55 mg/kg/day, b.i.d., for 30 days, starting within 8 h postinjury. The recruitment goal was 20 treated patients. Twenty patients who presented within 8-24 h post-TBI and otherwise met eligibility criteria were recruited for observation. Follow-up was for 2 years. Forty-five patients screened within 8 h of head injury met eligibility criteria and 20 were recruited into the treatment arm. The most common risk factor present for pediatric inclusion following TBI was an immediate seizure. Medication compliance was 95%. No patients died; 19 of 20 treatment patients were retained and one observation patient was lost to follow-up. The most common severe adverse events in treatment subjects were headache, fatigue, drowsiness, and irritability. There was no higher incidence of infection, mood changes, or behavior problems among treatment subjects compared to observation subjects. Only 1 (2.5%) of 40 subjects developed posttraumatic epilepsy (defined as seizures >7 days after trauma). This study demonstrates the feasibility of a pediatric posttraumatic epilepsy prevention study in an at-risk traumatic brain injury population. Levetiracetam was safe and well tolerated in this population. This study sets the stage for implementation of a prospective study to prevent posttraumatic epilepsy in an at-risk population.

The prevalence of traumatic brain injuries after minor blunt head trauma in children with ventricular shunts.

STUDY OBJECTIVE: We compare the prevalence of clinically important traumatic brain injuries and the use of cranial computed tomography (CT) in children with minor blunt head trauma with and without ventricular shunts. METHODS: We performed a secondary analysis of a prospective observational cohort study of children with blunt head trauma presenting to a participating Pediatric Emergency Care Applied Research Network emergency department. For children with Glasgow Coma Scale (GCS) scores greater than or equal to 14, we compared the rates of clinically important traumatic brain injuries (defined as a traumatic brain injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights for management of traumatic brain injury in association with positive CT scan) and use of cranial CT for children with and without ventricular shunts. RESULTS: Of the 39,732 children with blunt head trauma and GCS scores greater than or equal to 14, we identified 98 (0.2%) children with ventricular shunts. Children with ventricular shunts had more frequent CT use: (45/98 [46%] with shunts versus 13,858/39,634 [35%] without; difference 11%; 95% confidence interval 1% to 21%) but a similar rate of clinically important traumatic brain injuries (1/98 [1%] with shunts versus 346/39,619 [0.9%] without; difference 0.1%; 95% confidence interval -0.3% to 5%). The one child with a ventricular shunt who had a clinically important traumatic brain injury had a known chronic subdural hematoma that was larger after the head trauma compared with previous CT; the child underwent hematoma evacuation. CONCLUSION: Children with ventricular shunts had higher CT use with similar rates of clinically important traumatic brain injuries after minor blunt head trauma compared with children without ventricular shunts.

Identifying children at very low risk of clinically important blunt abdominal injuries.

STUDY OBJECTIVE: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

The role of telehealth in pediatric emergency care.

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.