Brief Motivational Intervention to Improve Adolescent Sexual Health Service Uptake: A Pilot Randomized Controlled Trial in the Emergency Department.

OBJECTIVE: To test the hypothesis that our motivational sexual health intervention (SexHealth) would increase health service uptake when compared with control. STUDY DESIGN: In a randomized controlled trial at a pediatric emergency department, sexually active adolescents received either the SexHealth intervention or printed materials (control). SexHealth, delivered by a health educator, was a tablet-based, interactive intervention that included motivational techniques to promote sexual health, condom skills training, and tailored service recommendations. We assessed feasibility (eg, intervention completion, recommendations discussed, intervention duration), acceptability (ie, proportion enrolled and rating intervention as satisfactory), and efficacy; secondary outcomes were sexual and care-seeking behaviors at 6 months. The efficacy outcome was completion of ≥1 service at the index visit (ie, counseling, condoms, emergency contraception for immediate or future use, pregnancy/sexually transmitted infection/HIV testing, sexually transmitted infection treatment, and clinic referral). RESULTS: We enrolled 91 participants (intervention = 44; control = 47). The intervention demonstrated high feasibility: 98% completed the intervention; 98% of recommendations were discussed; duration was 24.6 minutes, and acceptability: 87% of eligible adolescents enrolled and 93% rated the intervention as fairly to very satisfactory. Compared with controls, intervention participants were more likely to complete ≥1 service (98% vs 70%, P < .001) including HIV testing (33% vs 6%, P = .02) and emergency contraception (80% vs 0%, P = .01). There were no meaningful differences between arms in behaviors at follow-up. CONCLUSIONS: SexHealth was feasible to implement, acceptable to youth, and resulted in increased uptake of health services during the emergency department visit. Additional strategies may be needed to extend intervention effects over time. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; NCT03341975.

Universal Intimate-Partner Violence Assessment in the Pediatric Emergency Department and Urgent Care Setting: A Retrospective Review.

OBJECTIVE: The aim of this study was to examine universal intimate-partner violence (IPV) assessment in the pediatric acute care setting. METHODS: We reviewed universal IPV assessment over 1 year in 2 emergency departments and 3 urgent care centers within a children's hospital system. Written IPV assessment used 2 questions (ie, safety concerns at home, information desired); "yes" to either was considered positive. We identified positive assessments via preexisting quality report. We collected demographics, resource utilization, and reason for positive screen by chart review. Positive assessment for IPV was determined by chart documentation. RESULTS: Intimate-partner violence assessment was documented in 169,399 visits (96% of all visits); 511 (0.3%) were positive. Four hundred ninety cases were reviewed; 21 cases were excluded (incomplete data). One hundred twenty positive assessments were classified as misunderstood ("yes" marked in error); these were associated with nonwhite race (P < 0.001). We identified IPV in 169 (46%) of the remaining 370 positive assessments. Intimate-partner violence identification was associated with white race (P = 0.004), female caregiver (P < 0.001), and English as primary home language (P = 0.045). Non-IPV concerns triggered 239 positive assessments; concerns included child maltreatment (n = 125), mental/behavioral health (n = 46), other violence (n = 33), and parenting (n = 21). Intimate-partner violence was identified by social work in 82 cases triggered by non-IPV concerns. Resources utilized included social work (99%), non-IPV resources (59%), IPV advocate (21%), law enforcement (0.8%), and child protective services (1.6%). CONCLUSIONS: Universal IPV assessment in the pediatric acute care setting is feasible and may enable resource provision for IPV and non-IPV concerns.

Opioid Prescribing Practices in Pediatric Acute Care Settings.

OBJECTIVES: Deaths due to prescription opioid overdoses are at record-high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy. The purpose of this study was to describe the opioid prescribing practices in the emergency departments and urgent care sites of a Midwestern tertiary care children's hospital system. METHODS: This retrospective medical record review examined the visits from the 2 pediatric emergency departments and 2 pediatric urgent care sites in the system from June 1, 2012, to May 31, 2013, during which an outpatient opioid prescription was written. The primary outcome was number of days of opioid prescribed. Other data collected included patient demographics, diagnosis, and prescriber information; factors associated with prescriptions written for more than 5 days were identified. RESULTS: A total of 4075 opioid prescriptions were included in the 1-year study period, and 3991 of these had complete data for analysis. The median amount prescribed was 3.3 days with an interquartile range of 2.5 days. Odds of receiving a prescription of more than 5 days' duration were higher for children younger than 1 year (odds ratio [OR], 12.3; 95% confidence interval [CI], 7.3-21.0), 1 to 4 years of age (OR, 7.7; 95% CI, 5.5-10.8), and 5 to 9 years of age (OR, 2.4; 95% CI, 1.7-3.4); for children with noninjury diagnoses (OR, 1.4; 95% CI, 1.2-1.7); or if prescribed by a resident physician (OR, 1.4; 95% CI, 1.1-1.8) or from the urgent care (OR, 1.4; 95% CI, 1.1-1.7). CONCLUSIONS: Opioid prescriptions of more than 5 days were more frequently prescribed for younger patients, noninjury diagnoses, or if prescribed by a resident physician or from the urgent care. We need to focus on medical student, resident, and provider education as well as further opioid research in order to decrease unnecessary prescribing.

Comparative Performance of Pediatric Weight Estimation Techniques: A Human Factor Errors Analysis.

OBJECTIVE: We compared performance characteristics of 7 weight estimation methods examining predictive performance and human factors errors. METHODS: This was a prospective study of 80 emergency care providers (raters) and 80 children aged 2 months to 16 years. Raters estimated weights in 5 children with the following 7 strategies: visual estimation, Advanced Pediatric Life Support, Luscombe and Owens, Broselow tape, devised weight estimation method, 2D Mercy TAPE (2DT), and 3D Mercy TAPE (3DT). Quantitative errors were determined by checking rater values against values returned with optimal method use. RESULTS: Four hundred rater-child pairings generated 2800 weight estimates. For all methods, rater-estimated weights were less accurate than weights derived by optimal application. Skill-based, perception, and judgment/decision error were observed. For visual estimation, weights were underestimated in most children. For Advanced Pediatric Life Support/Luscombe and Owens, order of operations markedly impacted errors with 23% of calculations requiring addition first performed incorrectly versus 9% of calculations requiring multiplication first. For Broselow tape, only 63% of cases were eligible for estimation with this device, yet raters assigned a weight in 96% of cases. For Devised Weight Estimation Method, 96% of overweight and 48% of obese children were classified as slim or average. For 2DT/3DT, the 2DT was prone to more errors most commonly use of the wrong side of the device (24%). The impact of rater characteristics on error was most pronounced for methods requiring calculation. CONCLUSIONS: Skill-based, perception, or judgment errors were observed in more than 1 of 20 cases. No singular strategy was used with 100% accuracy.

Adapting an HIV Risk Reduction Curriculum: Processes and Outcomes.

Becoming a Responsible Teen (BART) is a community-based, HIV risk reduction curriculum shown to increase safer sex behaviors among African American adolescents. However, BART does not address common barriers to sexual health care access, which may limit program efficacy. We used a community-engaged adaptation process to maximize program relevance and health outcomes by incorporating a broad ecological perspective. Adolescent and staff advisory boards at a community-based organization recommended modifications (e.g., delete references to Kwanzaa, update language, localize incentives) and supported inclusion of critical on-site health services, such as sexually transmitted infection testing and condom provision. We conducted a trial of adapted BART (one session/week for 8 weeks) with 36 adolescents at two community organizations (mean age = 15.5 years, 52% female; 61% reported previous sexual intercourse). Most received on-site sexually transmitted infection testing (61%) and condoms (70%). Adolescents demonstrated significant improvements in self-efficacy for safer sexual practices (p < .02), AIDS risk knowledge (p < .001), condom knowledge (p < .001), and condom attitudes (p < .04). Adolescents and staff were satisfied with the revised curriculum and found on-site services acceptable. Based on improvements in constructs influencing behavior and the successful delivery of services essential for optimal health, future studies to assess efficacy and sustainability of the adapted curriculum appear warranted.

Brief Behavioral Intervention to Improve Adolescent Sexual Health: A Feasibility Study in the Emergency Department.

OBJECTIVE: Although emergency department (ED) visits offer an opportunity to deliver brief behavioral interventions to improve health, provision of ED-based interventions targeting adolescent sexual health is uncommon. The objectives for this study were to evaluate the feasibility and preliminary effects of a novel sexual health service intervention for adolescents. METHODS: In this cross-sectional feasibility study, sexually active patients aged 14 to 19 years presenting to a Midwestern pediatric ED were recruited to receive an intervention to improve sexual health. The intervention, based on motivational interviewing (MI), included agenda setting, exploration of behaviors, a decisional balance exercise, tailored feedback, and provision of personalized health services (including condoms, prescription for emergency contraception, urine testing for Chlamydia trachomatis and Neisseria gonorrheae, and referral to the hospital-affiliated adolescent clinic). Data were collected before and after intervention administration and at a 3-month follow-up telephone interview. Surveys assessed sexual risk behaviors, satisfaction with the intervention, health care use, and demographics. Feasibility criteria were (1) subject-rated interventionist fidelity to MI principles (Likert scale 1 [strongly agree] to 4 [strongly disagree]), (2) subject satisfaction (Likert scale 1 [not at all] to 5 [very]), and (3) session duration (minutes, recorded by the interventionist). A secondary outcome was the proportion of subjects who completed at least 1 health service. Services provided at the adolescent clinic were determined by an electronic medical record review. Comparisons of responses between sex subgroups were analyzed using Χ test. RESULTS: From August to November 2012, 69 adolescents were approached, 66 (96%) completed the screening survey, and 24 (37%) reported previous sexual activity. Of those, 20 (83%) agreed to participate. The mean (SD) age was 16.2 (1.4) years; 60% were female. Most (78%) reported that the interventionist maintained high fidelity to MI principles and most (80%) were very satisfied with the intervention. Mean (SD) intervention length was 15.7 (2.2) minutes. Most subjects (65%) accepted 1 or more health services, including 42% who completed clinic follow-up. In the ED or the referral clinic, the following services were provided to the subjects: condoms (n = 11), emergency contraception prescription (n = 5), C. trachomatis/N. gonorrheae testing (n = 4), hormonal birth control provision (n = 2), and human immunodeficiency virus testing (n = 3). Fifteen subjects (75%) were reached for the 3-month follow-up, and condom use was maintained by 67% of those reporting sexual activity. CONCLUSIONS: This study demonstrated the feasibility and potential utility of an MI-based service navigation intervention to connect youth with point-of-care services as well as resources for ongoing sexual health needs.

Family Adversity and Resilience Measures in Pediatric Acute Care Settings.

OBJECTIVE: Adverse childhood experiences (ACEs) impact health across the life course. The purpose of this study was to identify caregiver ACEs, current adversity, and resilience in families seeking care in pediatric acute care settings. Study aims included identifying demographic characteristics, current adversities, and resilience measures associated with caregiver ACEs ≥4. DESIGN AND SAMPLE: A cross-sectional survey study design was used and a convenience sample (n = 470) recruited at emergency and urgent care settings of a large Midwest pediatric hospital system. MEASURES: Measures were self-reported. The original 10-item ACEs questionnaire measured caregiver past adversity. Current adversity was measured using the 10-item IHELP. The six-item Brief Resiliency Scale measured resilience, and WHO-5 Well-Being Index was used to measure depressive affect. RESULTS: Compared to participants with ACEs score of 0-3 participants with ACEs ≥4 were more likely to have multiple current adversities, increased risk of depression, and lower resilience. CONCLUSIONS: Caregivers using pediatric acute care settings carry a high burden of ACEs and current adversities. Caregiver ACEs are associated with current child experiences of adversity. Caregivers socioeconomic status and education level may not be an accurate indicator of a family's risks or needs. Pediatric acute care settings offer opportunities to access, intervene, and prevent childhood adversity.

Supervision and risk of unintentional injury in young children.

OBJECTIVE: Assess the association between caregiver supervision and acute unintentional injury in young children; evaluate whether lower levels of supervision result in more severe injury. METHODS: A case cross-over study was conducted. Parents of children aged ≤4 years whose injuries required emergency department (ED sample) treatment or admission to the hospital (inpatient sample) were interviewed. Information on supervision (3 dimensions: proximity, attention, continuity) at the time of injury and 1 h before the injury (control time) was collected. An overall supervision score was created; a higher score indicates closer supervision. Hospital admission served as a proxy for injury severity. ORs and 95% CIs were calculated. RESULTS: Interviews were completed by 222 participants; 50 (23%) were in the inpatient sample. For each supervision dimension the inpatient sample had higher odds of injury, indicating effect modification requiring separate analyses for inpatient and ED samples. For both samples, proximity 'beyond reach' was associated with the highest odds of injury; compared with 1 h before injury, children were more likely to be beyond reach of their caregiver at the time of injury (inpatient sample: OR 11.5, 95% CI 2.7 to 48.8; ED sample: OR 2.9, 95% CI 1.8 to 4.9). Children with lower supervision scores had the greatest odds of injury (inpatient sample: OR 8.0, 95% CI 2.4 to 26.6; ED sample: OR 3.3, 95% CI 1.9 to 5.6). CONCLUSIONS: Lower levels of adult supervision are associated with higher odds of more severe injury in young children. Proximity is the most important supervision dimension for reducing injury risk.

Prevalence of 3 sexually transmitted infections in a pediatric emergency department.

OBJECTIVE: This study aimed to determine the prevalence of Chlamydia trachomatis, Neisseria gonorrheae, and Trichomonas vaginalis and to describe factors associated with sexually transmitted infection (STI) in a pediatric emergency department (ED). METHODS: Adolescents aged 14 to 19 years presenting to a Midwestern pediatric ED were asked to provide urine for STI testing and complete a survey about previous sexual activity (PSA), high-risk behaviors, demographics, and visit reason (reproductive: genitourinary complaints, abdominal pain, or a female with vomiting). Comparisons between subgroups were analyzed using Χ test. RESULTS: Among 200 subjects (64% of approached), mean age was 15.6 years; 63% were female. Eleven subjects (6%; 95% confidence interval, 2.3-8.7) tested positive for 1 or more STIs: 10 for C. trachomatis (one denied PSA), 3 for T. vaginalis (all coinfected with C. trachomatis), and 1 for N. gonorrheae. Half reported PSA; of these, 71% reported 1 or more high-risk behaviors, most commonly first sex before the age of 15 years (51%) and no condom at last sex (42%). Among those with PSA and nonreproductive visit (n = 73), 11.0% had 1 or more STIs (95% confidence interval, 3.4-18.1). Two factors were associated with greater likelihood of positive STI test result, namely, reporting PSA versus no PSA (10% vs 1%, P = 0.005) and last sex within 1 month or less versus more than 1 month (20% vs 0%, P = 0.001). In this sample, none of the following characteristics were associated with STI: insurance, race, high-risk behaviors, age, or ED visit reason. CONCLUSIONS: Approximately 1 in 10 sexually active adolescent ED patients without reproductive complaints had 1 or more STIs. This suggests the need for strategies to increase STI testing for this population.

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children.

OBJECTIVE: To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain. STUDY DESIGN: We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models. RESULTS: Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95). CONCLUSION: Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Acceptability of sexual health discussion and testing in the pediatric acute care setting.

OBJECTIVE: The objective of this study was to determine acceptability of sexual health discussion and testing among adolescents, parents, and health care providers (HCPs). METHODS: We conducted a cross-sectional study of acute care patients (aged 14-19 years), parents, nurses, and physicians/nurse practitioners. Subjects rated sexual health discussion, sexually transmitted disease and pregnancy testing as acceptable/unacceptable and verbally explained their reasoning. Reasons were transcribed verbatim, coded, and analyzed. Agreement with individual adolescent responses was determined. Controlling for visit type, logistic regression was used to evaluate association between location and acceptance with odds ratios (ORs). Visits were categorized as reproductive/nonreproductive. RESULTS: Subjects included 127 adolescents, 90 parents, and 190 HCP responses. Mean adolescent age was 15.5 years; 57% were female; 43% reported previous intercourse; 43% were black, and 39% were white. Most visits (76%) were nonreproductive. Adolescents and parents were highly accepting of discussion and testing and were more accepting than HCPs. Acceptance was more likely for reproductive versus nonreproductive visits (P ≤ 0.05). Emergency department HCPs were more likely to accept discussion (OR, 2.8) and sexually transmitted disease testing (OR, 3.1) than urgent care HCPs. Acceptance themes among adolescents were comfort with system/HCP, confidentiality concerns, and desire for good health; among parents, acceptance themes were identification as a safe place for disclosure and desire for adolescent good health and information; and among HCPs, these were relevance to chief complaint and perception of appropriate care. CONCLUSIONS: In contrast to HCPs, adolescents and parents expressed broad support for sexual health discussion and testing, which may inform HCP practice to improve access to care.

Evaluation of a firearm injury prevention web-based curriculum.

BACKGROUND: Firearm injury prevention training is lacking in pediatric residency programs. DESCRIPTION: This study aimed to evaluate a web-based curriculum teaching residents how to provide injury prevention anticipatory guidance, emphasizing firearm injury prevention. Ninety-two residents participated and completed pretesting. Residents in the intervention group completed the curriculum, posttesting, and 6-month follow-up testing. Residents in the nonintervention group completed 6-month follow-up testing. Pre- and posttest comparisons between and within each group were made. EVALUATION: Baseline knowledge of the participants was high, and no significant change in knowledge was shown in either group. Changes in attitude were noted regarding physician role in providing firearm injury anticipatory guidance in the intervention group, which persisted at 6 months. Participants completing the curriculum showed significant improvement for all self-efficacy questions in the immediate and 6-month follow-up testing. CONCLUSIONS: Participants reported changes in attitudes and in confidence in their ability to provide firearm injury prevention counseling after completion of a web-based curriculum.

Pediatric Emergency Department Challenges and Response to COVID-19.

Severe acute respiratory syndrome coronavirus 2, the virus causing the pandemic illness coronavirus disease 2019, was first detected in the United States in January 2020. As the illness spread across the country, all aspects and venues of health care were significantly impacted. This article explores the challenges and response of one children's emergency medicine division related to surge planning, personal protective equipment, screening, testing, staffing, and other operational challenges, and describes the impact and implications thus far. [Pediatr Ann. 2021;50(4):e172-e177.].

Patient characteristics and provider practice patterns for emergency contraception in a pediatric emergency department.

OBJECTIVES: To describe epidemiologic and clinical characteristics of patients receiving emergency contraception (EC) in a pediatric emergency department (ED), practice variations for EC, and ED return visits after EC. METHODS: This single-site study describes all patients who received oral EC (1.5-mg levonorgestrel) in the ED from January 1, 2003 to December 31, 2007. A chart review provided patient demographics, history, examination findings, treatment, and ED return visits within 7 days. RESULTS: There were 116 patients with a mean age of 13.7 years; half were white, and most (69.8%) had Medicaid. The most common presenting complaint was nonconsensual sex or sexual assault (87.9%). Most patients (89.6%) reported last sexual contact within 72 hours of presentation. Half of the patients (50%) received 1.5-mg levonorgestrel in a single dose, and there was a significant trend toward single-dose distribution during the study (P < 0.001). Patient presentation was most common from 8 pm to midnight (P < 0.001). Most received a pregnancy test (98.3%), a pelvic bimanual or speculum examination (81.9%), and prophylactic or immediate treatment of a sexually transmitted infection (88.8%). No prescriptions for future EC were given. One patient returned to the ED 1 day after receiving EC complaining of nausea and blurry vision. CONCLUSIONS: Reviewing recipients of EC from a pediatric ED suggests education is needed for both health care providers and adolescents. Although providers are generally following the most recent dosing guidelines, opportunities to prescribe EC to adolescent girls with complaints other than sexual assault seem to be missed.

The Relevance of Parental Adverse Childhood Experiences in Pediatric Practice.

Adverse childhood experiences affect a vast number of people, including the parents of the children we see as patients in our practices. Importantly, the trauma one experiences as a child affects not only health but also parenting style and ability, and thus is relevant in pediatric practice. Recent research has now established the significant relationship between adverse childhood experiences (ACEs) parents have before age 18 years and their children's health. However, considering a parent's past trauma and the toxic stress that may result is typically not considered by the pediatric health care provider. This article reviews new research investigating the relationship between parental ACEs and children, and its implications for pediatric practice. [Pediatr Ann. 2019;48(12):e463-e465.].

Choking in Children: What to Do and How to Prevent.

Choking happens when a child's airway is blocked by a foreign substance that impairs oxygenation and ventilation. It is one of the most frightening scenarios a parent can imagine. It happens suddenly and can have the direst of consequences. Small objects, such as food and candy, are the usual offenders. Child-related risk factors are largely developmental due to physical and cognitive immaturity. This article describes the magnitude of the problem, delineates some of the risks, and outlines prevention. [Pediatr Ann. 2019;48(9):e338-e340.].

Treatment and Prevention of Pediatric Sunburn.

Skin cancer is the most common cancer in the United States, and risk for melanoma is greatly increased with a serious sunburn in childhood or adolescence. Skin cancer also is one of the most preventable cancers, as sun exposure is an almost entirely modifiable risk factor. Proper skin protection should start early in life when infants begin to be exposed to the outdoors. [Pediatr Ann. 2019;48(6):e213-e214.].

Shared Decisions in Pediatrics.

Shared decision-making (SDM) is a structured approach to engaging patients in discussion in medical therapy when there is more than one viable option for care. SDM may decrease decisional conflict between providers and patients, increase trust, and possibly even help decrease health care costs. Much more is known about this approach in adult health care environments, but research on SDM in child health care settings is growing. This article explores unique features of SDM in pediatrics and gives examples of applications. [Pediatr Ann. 2019;48(3):e98-e100.].