Child Protection System Interactions for Children With Positive Urine Screens for Illicit Drugs.

Importance: Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive. Objective: To document the child protection system involvement and the characteristics of children who test positive for illicit substances. Design, Setting, and Participants: This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children's Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024. Exposure: Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine. Main Measures and Outcomes: CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements. Results: A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 [51.3%] were female; 309 [60.5%] were age 6 years or younger; fewer than 10 [<3.0%] were American Indian or Alaska Native; 252 [49.3%] were Hispanic [any race], 20 [3.9%] were non-Hispanic Asian, 56 [11.0%] were non-Hispanic Black, 143 [28.0%] were non-Hispanic White, 36 [7.0%] had other or unknown race and ethnicity; 233 [43.6%] had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 [9.8]) compared with prior to the pandemic onset (16.5 [4.7]); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 [4.7] vs 5.7 [2.9]). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk [RR], 2.91 [95% CI, 2.21-3.83]) and child protection case openings (RR, 1.71 [95% CI, 1.07-2.72]) than encounters involving older children. Conclusions and Relevance: In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.

Presentation, Management, and Child Protective Service Reporting of Children Who Test Positive for Cannabis in an Emergency Room Setting.

OBJECTIVES: Rates of cannabis ingestion among young children are increasing. Small studies have evaluated symptomatology of these children. The literature lacks research regarding factors influencing medical management. Our goal was to 1) understand circumstances leading to exposure over time and 2) gain insight into factors that may influence emergency room management and Child Protective Services reporting over time. METHODS: Retrospective cross-sectional study on children younger than 10 years with cannabis-positive urine drug screens in the emergency room setting. Single-factor analysis of variance and Fisher exact tests were used to assess for trends. Two-tailed t tests and Fisher exact tests were used to compare management of children presenting to the emergency room with chief complaint (CC) "ingestion" versus those without. RESULTS: Of the 179 children, the mean age was 3.7 years and 48% were boys. We observed a significant increase over time in cannabis-positive children. The most common location of exposure was the primary residence (54%), with parents as the most frequent users (46%). In the emergency department, the most common CC was ingestion followed by altered mental status and fatigue. Children with an "ingestion" CC were managed with less testing than those with other CCs. They received fewer needle sticks (43% vs 91%), less imaging (5% vs 56% computed tomography heads), and fewer procedures (0% vs 8% lumbar punctures). Children with "ingestion" CC were less likely to be reported to Child Protective Services. CONCLUSIONS: Pediatric cannabis exposures are increasing and have a wide array of clinical presentations that complicate emergency room management. Parental report of cannabis ingestion seems to impact and reduce potentially unnecessary testing.

Ingestion of Illicit Substances by Young Children Before and During the COVID-19 Pandemic.

Importance: Information about the trend in illicit substance ingestions among young children during the pandemic is limited. Objectives: To assess immediate and sustained changes in overall illicit substance ingestion rates among children younger than 6 years before and during the COVID-19 pandemic and to examine changes by substance type (amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids) while controlling for differing statewide medicinal and recreational cannabis legalization policies. Design, Setting, and Participants: Retrospective cross-sectional study using an interrupted time series at 46 tertiary care children's hospitals within the Pediatric Health Information System (PHIS). Participants were children younger than 6 years who presented to a PHIS hospital for an illicit substance(s) ingestion between January 1, 2017, and December 31, 2021. Data were analyzed in February 2023. Exposure: Absence or presence of the COVID-19 pandemic. Main Outcome(s) and Measure(s): The primary outcome was the monthly rate of encounters for illicit substance ingestions among children younger than 6 years defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code(s) for poisoning by amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids. The secondary outcomes were the monthly rate of encounters for individual substances. Results: Among 7659 children presenting with ingestions, the mean (SD) age was 2.2 (1.3) years and 5825 (76.0%) were Medicaid insured/self-pay. There was a 25.6% (95% CI, 13.2%-39.4%) immediate increase in overall ingestions at the onset of the pandemic compared with the prepandemic period, which was attributed to cannabis, opioid, and ethanol ingestions. There was a 1.8% (95% CI, 1.1%-2.4%) sustained monthly relative increase compared with prepandemic trends in overall ingestions which was due to opioids. There was no association between medicinal or recreational cannabis legalization and the rate of cannabis ingestion encounters. Conclusions and Relevance: In this study of illicit substance ingestions in young children before and during the COVID-19 pandemic, there was an immediate and sustained increase in illicit substance ingestions during the pandemic. Additional studies are needed to contextualize these findings in the setting of pandemic-related stress and to identify interventions to prevent ingestions in face of such stress, such as improved parental mental health and substance treatment services, accessible childcare, and increased substance storage education.

Extensive Tongue Laceration in an Edentulous Infant: Is It Child Abuse?

It is important for medical providers to distinguish between accidental and abusive mechanisms of injury in children. In the absence of a serious trauma, an isolated tongue laceration and oromaxillofacial trauma in a young, edentulous infant raises significant concern for abuse. The presented case demonstrates a unique injury pattern and serves as an opportunity to explore the multidisciplinary approach to infant trauma in Otolaryngology. Presented is an edentulous infant who sustained a deep splitting laceration of the oral tongue as a result of being dropped a short distance onto carpeted floor. This injury pattern, in the absence of other trauma, raised concern for abuse. Hospital social work and Child Abuse Pediatrics further investigated the matter. A surveillance camera video was produced which demonstrated the blunt force of the fall, coupled with the friction sliding on the floor, ripped open the infant's tongue and left a pattern otherwise suspicious for sharp object laceration. To our knowledge, this is the first report describing a full-thickness tongue laceration after a fall from a caregiver's arms onto carpeted ground. This case underscores the responsibility of the astute provider coupled with a multidisciplinary team to identify or rule out potential child abuse.

Delivering Urgent Care Using Telemedicine: Insights from Experienced Clinicians at Academic Medical Centers.

BACKGROUND: Care delivered using telemedicine has been steadily growing in the USA but represented a small fraction of overall visits before the COVID-19 pandemic as few clinicians had been providing care using telemedicine. Understanding how experienced clinicians have practiced telemedicine can help guide today's exponential adoption of telemedicine. OBJECTIVE: The objective of this study was to explore barriers and facilitators to providing effective, high-quality urgent care using telemedicine ("tele-urgent care") from the perspective of clinicians experienced in telemedicine. APPROACH: We conducted semi-structured interviews between July 2018 and March 2019 of clinicians who had been providing tele-urgent care services to patients as a part of their routine clinical practice. Themes were identified using content analysis with a constant comparative coding approach. KEY RESULTS: Among the 20 clinicians interviewed, the majority were female (90%) and nurse practitioners (65%). We identified four themes related to barriers and facilitators to providing effective, high-quality tele-urgent care. Workplace factors such as a strong information technology (IT) infrastructure, real-time IT support, an electronic health record, and a collegial work environment, often virtual, were necessary standards. Communication and exam techniques from in-person encounters were adapted to tele-urgent care including active listening skills and teaching patients to conduct specific exam maneuvers virtually. The convenience of tele-urgent care should be preserved to support improvements in access to care. Finally, patients and clinicians occasionally had mismatched expectations about what could or would be provided during a tele-urgent care encounter. Managing the added tension that can occur during a telemedicine encounter was important. CONCLUSION: As telemedicine becomes an integral part of the care continuum, incorporating and accounting for these key insights when we train and support clinicians will be necessary to provide effective, high-quality care to patients in the future.

Methamphetamine-associated pulseless electrical activity in a young child.

This is a case report of a 19-month-old female who presented to the emergency department in cardiac arrest after methamphetamine exposure. Prior to presentation, she had seizure-like activity and then became unresponsive. On arrival, she had dilated pupils, intermittent clonus, and pulseless electrical activity. She was found to have full thickness circumferential burns of her bilateral lower extremities. She received 12 doses of epinephrine, cardiopulmonary resuscitation, and volume resuscitation after which she had return of spontaneous circulation and was transferred to the intensive care unit on an epinephrine drip. Initial laboratory studies showed a mixed metabolic and respiratory acidosis and hyperglycemia. An initial urine immunoassay for drugs of abuse was negative, however, 5 h later, a second urine immunoassay was positive for amphetamine. The first specimen was also sent for liquid chromatography-mass spectrometry analysis that later returned positive for methamphetamine and amphetamine. In retrospect, the initial urine screen was found to have evidence of amphetamine below the threshold for positivity (500 ng/mL), and the second urine specimen was highly positive, with an amphetamine level of >1450 ng/mL. In this case, what turned out to be a sub-threshold rather than undetectable level was clinically significant, highlighting the challenges of urine screening in cases of suspected poisoning syndromes with atypical presentations. Our case also suggests the possibility of PEA as a presentation of methamphetamine toxicity in a child.