Prediction of child abuse in an ambulatory setting.

A prospective random study was performed on 476 patients, up to 2 years of age, by full-time registered nurses in the emergency room. The parent (caretaker) and child were assessed in an effort to predict child abuse. The incidence of abuse rose from 2.5% to 15.2% if one or more abnormal features were present in parent or child (p less than .0003). Abuse developed in 19% of unkempt children and 28% of children with abnormal bruises, burns, or bites. The incidence of abuse increased to 42% (P less than .002) when these factors were present together. An unkempt child with an abnormal parenting pattern and a 30% chance of being abused (P = .007).

Comparison of cocaine and opiate exposures between young urban and suburban children.

OBJECTIVE: To determine the prevalence of cocaine and opiate metabolites in the urine of young urban and suburban children. DESIGN: Survey. SETTING: Urban and suburban emergency departments and private pediatric practices. PATIENTS: A convenience sample of 1469 children between 1 and 60 months of age who required a urinalysis for investigation of the chief complaint. INTERVENTION: None. MAIN OUTCOME MEASURES: Urine was screened for benzoylecogonine and opiates using an enzyme-multiplied immunoassay technique and a fluorescence-polarization immunoassay, both with a sensitivity of 50 ng/mL. RESULTS: Benzoylecogonine was identified in the urine of 45 children (3.1%) (95% CI, 2.2% to 3.9%) and opiates in the urine of 38 children (2.6%) (95% CI, 1.8% to 3.4%). No difference was observed between urban and suburban health care facilities in the percentage of patients whose urine tested positive for benzoylecgonine (29 of 1011 vs 16 of 458, P = .6) or opiates (28 of 1011 vs 10 of 458, P = .6). CONCLUSION: Exposure to illicit drugs, as reflected by urinary metabolites, is similar for urban and suburban children.

Three quantitative approaches to the diagnosis of abdominal pain in children: practical applications of decision theory.

BACKGROUND/PURPOSE: The authors compared 3 quantitative methods for assisting clinicians in the differential diagnosis of abdominal pain in children, where the most common important endpoint is whether the patient has appendicitis. Pretest probability in different age and sex groups were determined to perform Bayesian analysis, binary logistic regression was used to determine which variables were statistically significantly likely to contribute to a diagnosis, and recursive partitioning was used to build decision trees with quantitative endpoints. METHODS: The records of all children (1,208) seen at a large urban emergency department (ED) with a chief complaint of abdominal pain were immediately reviewed retrospectively (24 to 72 hours after the encounter). Attempts were made to contact all the patients' families to determine an accurate final diagnosis. A total of 1,008 (83%) families were contacted. Data were analyzed by calculation of the posttest probability, recursive partitioning, and binary logistic regression. RESULTS: In all groups the most common diagnosis was abdominal pain (ICD-9 Code 789). After this, however, the order of the most common final diagnoses for abdominal pain varied significantly. The entire group had a pretest probability of appendicitis of 0.06. This varied with age and sex from 0.02 in boys 2 to 5 years old to 0.16 in boys older than 12 years. In boys age 5 to 12, recursive partitioning and binary logistic regression agreed on guarding and anorexia as important variables. Guarding and tenderness were important in girls age 5 to 12. In boys age greater than 12, both agreed on guarding and anorexia. Using sensitivities and specificities from the literature, computed tomography improved the posttest probability for the group from.06 to.33; ultrasound improved it from.06 to.48; and barium enema improved it from.06 to.58. CONCLUSIONS: Knowing the pretest probabilities in a specific population allows the physician to evaluate the likely diagnoses first. Other quantitative methods can help judge how much importance a certain criterion should have in the decision making and how much a particular test is likely to influence the probability of a correct diagnosis. It now should be possible to make these sophisticated quantitative methods readily available to clinicians via the computer.

MADYMO simulation of children in cycle accidents: a novel approach in risk assessment.

Head injuries are a significant cause of death and injury to child cyclists both on and off the road. Current evaluations of the effectiveness of cycle helmets rely on simplified mechanical testing or the analysis of aggregated accident statistics. This paper presents a direct evaluation of helmet efficacy by using computational modelling to simulate a range of realistic accident scenarios, including loss of control, collision with static objects and vehicle impact. A 6-year-old cyclist was modelled (as a Hybrid III 6-year-old dummy), in addition to a typical children's bicycle and a vehicle using the MADYMO dynamics software package. Simulations were performed using ranges of cyclist position, cycle speed and vehicle speed with and without a helmet that meets current standards. Wearing a cycle helmet was found to reduce the probability of head injuries, reducing the average probability of fatality over the scenarios studied from 40% to 0.3%. Similarly, helmet wearing reduced the probability of neck injuries (average probability of fatality reduced from 11% to 1%). There was no evidence that helmet wearing increased the severity of brain or neck injuries caused by rotational accelerations; in fact these were slightly reduced. Similarly, there was no evidence that increased cycling speed, such as might result from helmet related risk compensation, increased the probability of head injury.

Pediatric cardiopulmonary arrest in the emergency department.

A prospective observation of cardiopulmonary resuscitation was made at an active municipal pediatric emergency department. Pediatric cardiorespiratory arrest, documented in only 26 patients over a 12-month period, was unusual. Fifteen were less than 1 year old, and four children survived to discharge. Asystole was present in 24 of 26 patients with cardiac arrest. Congenital abnormalities were present in 23% of patients; however, these accounted for 50% of the survivors. The overall survival rate was 15.4%. Suggestions for termination of resuscitation are given.

Congenital syphilis: an emerging emergency.

Is a condition such as congenital syphilis within the purview of pediatric emergency medicine? The following case histories would suggest that it is.

Incidence of infection in pediatric patients with laceration.

Lacerations are common in emergency departments. A review of pediatric patients was carried out to determine the infection rate. During a three-month period, from August to October, 415 patients were prospectively evaluated to determine the occurrence of infections in sutured lacerations. Sixty-nine patients (16%) were lost to follow-up. Seven patients (2%) developed infections. The infection rate in the lower extremities was 8.5% (P less than 0.0001). Six lacerations (5.3%) greater than 3 cm in size became infected, compared to one (0.4%) that was smaller than 3 cm (P less than 0.0001). Falls accounted for 61% of the injuries. The infection rate in children is less than that in adults. However, large lacerations in the lower extremities are at greater risk.

Frequency of suspected abuse/neglect in burn patients.

This study was conducted to determine the frequency of suspected abuse/neglect in pediatric patients with burns presenting to an emergency department. Criteria were established for the suspicion of abuse/neglect. During a 12-month period, 431 patients were evaluated. Eighty-four (19.5%) were suspected of being abused or neglected. The frequency of suspected abuse/neglect in single-parent families was 22%, compared to 10% for married couples (P = 0.027). There was no significant difference in the rate of suspected abuse/neglect in patients seen fewer than or more than 24 hours after the injury occurred. Seventy-five children (17%) had more than two burn sites, with 24 (32%) appearing to be a result of abuse/neglect (P = 0.01). One hundred twenty-eight patients (30%) were admitted to the hospital, with 34% suspected of being abused/neglected, compared to 13% who were treated on an ambulatory basis (P = 0.00005). Fifty-eight (69%) of the suspected abused/neglected patients were diagnosed based on the history and/or physical examination. The medical records of 31% revealed previous abuse/neglect, ingestion, failure to thrive, or old burns. We conclude that abuse or neglect is a significant factor in pediatric burn patients and that the child's previous medical record must be reviewed. Other associated factors include a single parent family or the child with greater than two burn sites. The actual incidence of abuse/neglect could not be determined, owing to laws regarding confidentiality.

Clinical indicators for lumbar puncture.

This study was conducted to demonstrate that experienced pediatricians using standard clinical indications for performing a lumbar puncture should have a higher yield of positive spinal taps than previously reported and also can detect bacterial meningitis. These indicators included temperature elevation, inability to be consoled, level of alertness, nuchal rigidity, bulging fontanel, decreased appetite, rash, referral, and febrile seizures. Eighty-two of 381 (22%) lumbar punctures were positive for pleocytosis and/or organisms. Patients were divided into two groups, consisting of those with one indicator (low risk) and those with greater than one indicator (high risk). Thirteen of 14 patients with bacterial meningitis were placed in the high risk group. The single patient in the low risk group had been pretreated with antibiotics. The positive predictive value in bacterial meningitis for a score greater than one was 5%. The average number of clinical indicators in bacterial meningitis was 3.7, versus 2.4 in viral meningitis and 1.6 without meningitis. These findings suggest that, in the absence of prior antibiotic therapy, an experienced pediatrician can clinically detect patients at high risk for bacterial meningitis. Nonbacterial meningitis cannot be as readily detected clinically.

A fatal case of colic.

The potential causes of excessive, prolonged crying in early infancy represent a broad range of conditions. The underlying etiology causing an acute episode of crying may not be recognized in a single emergency department encounter. An adverse outcome may result when an infant with unexplained crying is discharged with a diagnosis of colic.

Use of topical lidocaine in pediatric laceration repair: a review of topical anesthetics.

OBJECTIVE: To determine whether application of topical aqueous lidocaine to a laceration attenuates the pain from the subsequent lidocaine injection in children. DESIGN: Prospective, double-blind study. SETTING: A large, urban, tertiary care children's hospital emergency department. PATIENTS: A convenience sample of 100 children, five to 16 years of age, presenting with simple lacerations over a six-month period. INTERVENTIONS: An unlabelled 3-ml solution of either 1% lidocaine or placebo (saline) was used to soak a Telfa pad (Kendall, Mansfield, MA) and then placed onto the laceration for 10 minutes. The wound was then injected with 1% lidocaine, irrigated, and sutured per standard emergency department protocol. Independent pain response was elicited from the patient and parent four times: before any intervention, after the soak, after the injection, and at the end of the procedure. Blood pressure and heart rates were recorded at the same intervals. RESULTS: Four patients were excluded. Of the 96 remaining patients, 46 received the placebo and 50 received lidocaine. Age, sex, race, and laceration length and location were similar between groups. Physiologic parameters did not differ between groups. For all four pain ratings, the independent variables of age, sex, race, and laceration length or location did not differ between groups. Topical lidocaine was ineffective in relieving pain from the injection. When groups were combined, a significant negative correlation was noted for age versus injection pain (P = .035), with older children reporting less pain from injection than younger children. CONCLUSION: For children, soaking a simple laceration with 1% lidocaine does not decrease pain from the subsequent lidocaine injection.

Pediatric emergency department walk-outs.

The objectives of this study were to determine reasons for leaving a pediatric emergency department before physician evaluation, any adverse outcomes of those leaving, and to assess whether the presence of an ombudsman altered the pattern. This was a prospective follow-up study of all patients who left the pediatric emergency department of the Children's Hospital of Michigan before physician evaluation between October 24, 1991 and January 30, 1992. Information was obtained from medical records and a telephone questionnaire with the parent or guardian one week later. A control group of patients (n = 150) evaluated in the same period were randomly selected for comparison and matched for triage acuity score, shift, and weekday/weekend visit. Five hundred and twelve patients left during this period. Contact was made with 82% (419). Forty-three percent of patients left only because of a long wait, and an additional 19% included a long wait as one of the reasons for leaving. There was a significantly longer waiting time for walk-outs compared with controls (188 +/- 76.4 vs 93.6 +/- 64.9 minutes, P < 0.0001). Of the 419 patients followed, 256 (61%) were seen by a physician within seven days, and seven (1.7%) were hospitalized. Three hundred one (72%) were reported to be well; 108 (26%) were better. No deaths occurred. Hospitalization rates were significantly lower for patients who left compared with patients who stayed over the same period of time (7/419 vs 1931/16,990, P < 0.0001). The presence of an ombudsman was associated with an increase in walk-outs.(ABSTRACT TRUNCATED AT 250 WORDS)

Jaw mass in a pediatric patient.

The aneurysmal bone cyst is an unusual cause of a jaw mass in children. Left untreated, this relatively benign lesion can lead to deformity and destructive bone changes. We report a nine-year-old patient with a large untreated aneurysmal bone cyst, and briefly discuss the differential diagnosis of head and neck masses in children.

Seizures associated with meningitis.

The records of 187 patients with bacterial meningitis were reviewed. Seizures were a presenting manifestation in 25 (13%). Seven (28%) of the patients with a presenting seizure had been taking antibiotics prior to the diagnosis. Four of seven pretreated patients did not have additional signs or symptoms with the seizure, while all 18 patients without treatment had additional findings (P less than 0.01). Patients developing seizures while hospitalized had a poorer outcome than those without seizures. Patients with bacterial meningitis may present with only a seizure if they have been taking oral antibiotics; therefore, all patients taking antibiotics who develop a seizure require a lumbar puncture to exclude meningitis.

Occult cocaine exposure in children.

We determined the prevalence of cocaine and cannabinoid exposure among young children presenting to an urban pediatric emergency department without signs or symptoms suggestive of the exposure. The study included 460 children between 1 and 60 months of age in whom urinalysis was required for investigation of routine pediatric complaints. Anonymously and without informed consent, an aliquot of urine was screened for cocaine metabolite (benzoylecgonine) and 11- or delta-9-tetrahydrocannabinol-9 carboxylic acid with the enzyme multiplied immunoassay technique. Positive specimens were rescreened with a radioimmunoassay and confirmed with gas chromatography/mass spectrometry, if a sufficient quantity of urine was available. Benzoylecgonine was identified in 25 patients (5.4%) by both screening techniques. Enough urine was available for confirmatory testing in eight patients, and all eight urine specimens contained benzoylecgonine. Neither 11- nor delta-9-tetrahydrocannabinol-9 carboxylic acid was detected in any patient. We documented the magnitude of the problem of occult passive cocaine exposure in young children living in an urban environment. Such exposure has serious implications for the assessment of outcomes in postnatal follow-up studies of prenatally exposed children as well as potential risks to children living in household environments where occult cocaine exposure occurs.

Soft tissue swelling with fractures: abuse versus nonintentional.

The objectives were to 1) define the amount of postfracture swelling at presentation in long bone fractures, and 2) to study the relationship between suspected abuse and/or neglect (A/N) and degree of postfracture swelling at presentation. This was a prospective study of 37 patients less than 11 years of age presenting with long bone fractures to the emergency department (ED) of the Children's Hospital of Michigan between August 1992 and December 1992. Data were recorded at the time of the ED visit and from medical records which were reviewed four to six months later. Of the patients enrolled in the study, eight were categorized as A/N and 29 as nonintentional. There was no difference in reported injury age between the two groups (15.5 +/- 24.5 hours vs 14.0 +/- 17.7, P = 0.8). At presentation the mean increase in circumference from post-fracture swelling was 9.6 +/- 7.1%, using the uninjured extremity as the control. The abuse group had a lesser increase in circumference compared to the nonintentional group, even after adjusting for injury age (3.8 +/- 3.6% vs 11.2 +/- 7.0%, P < 0.006). We concluded that patients with long bone fractures had a mean swelling of 9.6 +/- 7.1% at presentation. Injuries induced by A/N present with less swelling than similar injuries sustained nonintentionally, and we speculate that this difference indicates that the history and/or time of injury may not be reliable.

Occult cocaine and opiate exposure in children and associated physical findings.

We determined the prevalence of cocaine and opiate exposure and the association of exposure with objective physical findings in children presenting to an urban pediatric emergency department. The study included 942 children between one and 60 months of age who required urinalysis for investigation of their chief complaint. Anonymously and without informed consent, urine was screened for benzoylecgonine (BE) and opiates, using an enzyme multiplied immunoassay technique (EMIT) with sensitivity of 50 ng/ml. EMIT-positive samples were rescreened using a fluorescence polarization immunoassay (FPIA). Specimens positive by both EMIT and FPIA were confirmed by gas chromatography/mass spectrometry (GC/MS) if sufficient quantity of urine was available. BE was identified in 41 (4.4%) and opiates in 46 (4.9%) patients by both EMIT and FPIA. The presence of BE or opiate was confirmed by GC/MS in all 34 cases where sufficient urine was available. The age- and sex-adjusted systolic and diastolic blood pressure percentiles were greater, and head circumference and weight percentiles were lower in BE-positive patients compared to those with negative drug screens. There were no associations between opiate exposure and any of these variables. We conclude that occult postnatal cocaine exposure is associated with measurable physical and physiologic differences.