A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic.

BACKGROUND: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. METHODS: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. RESULTS: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. CONCLUSIONS: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Diagnosis and Management of Aortic Dissection in a Pediatric Patient With Turner Syndrome: A Simulation.

Aortic dissection is exceedingly rare in the pediatric population. However, it is much more common among children and adolescents with certain underlying syndromes, including Turner syndrome. Furthermore, aortic dissection carries significant mortality without prompt diagnosis and management. Therefore, pediatric emergency providers should know how to recognize and treat pediatric aortic dissection in a patient with Turner syndrome. We designed this simulation for pediatric emergency medicine fellows. A simulated adolescent female patient with a known history of Turner syndrome presents with chest pain, tachycardia, and hypertension. Participants must order and interpret the appropriate diagnostics, diagnose aortic dissection, and manage aortic dissection adequately. This simulation was completed by six pediatric emergency medicine fellows and one pediatric resident. After completing the simulation, six participants (85.7%) provided anonymous feedback on a five-point Likert scale (one = strongly disagree, five = strongly agree). Feedback was positive, and participants agreed that the case content was relevant to their clinical practice and that the event will improve their clinical practice. This simulation encourages participants to recognize and manage pediatric aortic dissection in patients with Turner syndrome. Participants felt that the simulation was relevant and will improve their clinical practice.

Adverse childhood experiences, child behavioral health needs, and family characteristics associated with the presence of a firearm in the home: a survey of parents in Chicago.

BACKGROUND: Firearm violence is the leading cause of pediatric mortality in the USA. The presence of a firearm in the home poses an immense risk to children with increased rates of suicide and unintentional injury by firearm. Recent literature has not explored child ACEs and child behavioral health needs with the presence of a firearm in the home. The objective of this study was to explore an association between these factors, parent health, family experience with firearm violence, and demographics, and the presence of a firearm in the home. RESULTS: Overall, 382 of 1,436 (weighted to 22.0%) responding parents reported the presence of a firearm in the home. In an adjusted model, the odds ratio of firearm presence increased incrementally with a child's increasing exposure to ACEs. Compared to a child in the household exposed to no ACEs, a child in the household exposed to two or more ACEs was associated with a 5.16 times higher odds of firearm presence in the home (95% confidence interval (CI) 2.92-9.10). Similarly, a child in the household who had used behavioral health services was associated with a 2.10 times higher odds of firearm presence in the home (95% CI 1.35-3.26), compared to a child in the household who had not. Presence of firearm in the home was also associated with higher household income, younger parent age (under 35 years), and male parent gender. CONCLUSIONS: Chicago parents have higher odds of reporting the presence of a firearm in the home when living in a household with a child exposed to ACEs and with behavioral health needs. These findings could inform future public health interventions and targeted safe storage messaging to prevent pediatric firearm injury in the home.

Association of Pediatric Mortality With the Child Opportunity Index Among Children Presenting to the Emergency Department.

OBJECTIVE: Child health and development is influenced by neighborhood context. The Child Opportunity Index (COI) is a multidimensional measure of neighborhood conditions. We sought to evaluate the association of COI with mortality among children presenting to the emergency department (ED). METHODS: We performed a multicenter cross-sectional study of pediatric (<18 years) ED encounters from a statewide dataset from 2016 to 2020. We constructed a multivariable logistic regression model to evaluate the association between COI and in-hospital mortality after adjusting for sociodemographic characteristics and medical complexity. RESULTS: Among 4,653,070 included encounters, in-hospital mortality occurred in 1855 (0.04%). There was a higher proportion of encounters with mortality in the lower COI categories relative to the higher COI categories (0.053%, 0.038%, 0.031%, 0.034%, 0.034% ranging from Very Low to Very High, respectively). In adjusted models, child residence in Low (adjusted odds ratio 1.26; 95% confidence interval [CI], 1.04-1.53) and Very Low (adjusted odds ratio 1.58; 95% CI, 1.31-1.90) COI neighborhoods was associated with mortality relative to residence in Very High COI neighborhoods. This association was noted across all domains of COI (education, health and environment, and social and economic), using an expanded definition of mortality, using nationally normed COI, and excluding patients with complex chronic conditions. Other factors associated with increased odds of mortality included age, medical complexity, payor status, age, and race and ethnicity. CONCLUSIONS: Understanding the association of neighborhood context on child mortality can inform public health interventions to improve child mortality rates and reduce disparities.

Association of Youth Suicides and County-Level Mental Health Professional Shortage Areas in the US.

Importance: Suicide is the second leading cause of death among US adolescents. Workforce shortages of mental health professionals in the US are widespread, but the association between mental health workforce shortages and youth suicides is not well understood. Objective: To assess the association between youth suicide rates and mental health professional workforce shortages at the county level, adjusting for county demographic and socioeconomic characteristics. Design, Setting, and Participants: This retrospective cross-sectional study included all US counties and used data of all US youlth suicides from January 2015, through December 31, 2016. Data were analyzed from July 1, 2021, through December 20, 2021. Exposures: County health-professional shortage area designation for mental health, assigned by the US Health Resources and Services Administration based on mental health professionals relative to the population, level of need for mental health services, and service availability in contiguous areas. Designated shortage areas receive a score from 0 to 25, with higher scores indicating greater workforce shortages. Main Outcomes and Measures: Suicides by youth aged 5 to 19 years from 2015 to 2016 were identified from the US Centers for Disease Control and Prevention's Compressed Mortality File. A multivariable negative binomial regression model was used to analyze the association between youth suicide rates and mental health workforce shortage designation, adjusting for the presence of a children's mental health hospital and county-level markers of health insurance coverage, education, unemployment, income, poverty, urbanicity, racial and ethnic composition, and year. Similar models were performed for the subgroups of (1) firearm suicides and (2) counties assigned a numeric shortage score. Results: During the study period, there were 5034 youth suicides (72.8% male and 68.2% non-Hispanic White) with an annual suicide rate of 3.99 per 100 000 youths. Of 3133 US counties, 2117 (67.6%) were designated as mental health workforce shortage areas. After adjusting for county characteristics, mental health workforce shortage designation was associated with an increased youth suicide rate (adjusted incidence rate ratio [aIRR], 1.16; 95% CI, 1.07-1.26) and an increased youth firearm suicide rate (aIRR, 1.27; 95% CI, 1.13-1.42). For counties with an assigned numeric workforce shortage score, the adjusted youth suicide rate increased 4% for every 1-point increase in the score (aIRR, 1.04; 95% CI, 1.02-1.06). Conclusions and Relevance: In this cross-sectional study, US county mental health professional workforce shortages were associated with increased youth suicide rates. These findings may inform suicide prevention efforts.

Adequacy of maternal iron status protects against behavioral, neuroanatomical, and growth deficits in fetal alcohol spectrum disorders.

Fetal alcohol spectrum disorders (FASD) are the leading non-genetic cause of neurodevelopmental disability in children. Although alcohol is clearly teratogenic, environmental factors such as gravidity and socioeconomic status significantly modify individual FASD risk despite equivalent alcohol intake. An explanation for this variability could inform FASD prevention. Here we show that the most common nutritional deficiency of pregnancy, iron deficiency without anemia (ID), is a potent and synergistic modifier of FASD risk. Using an established rat model of third trimester-equivalent binge drinking, we show that ID significantly interacts with alcohol to impair postnatal somatic growth, associative learning, and white matter formation, as compared with either insult separately. For the associative learning and myelination deficits, the ID-alcohol interaction was synergistic and the deficits persisted even after the offsprings' iron status had normalized. Importantly, the observed deficits in the ID-alcohol animals comprise key diagnostic criteria of FASD. Other neurobehaviors were normal, showing the ID-alcohol interaction was selective and did not reflect a generalized malnutrition. Importantly ID worsened FASD outcome even though the mothers lacked overt anemia; thus diagnostics that emphasize hematological markers will not identify pregnancies at-risk. This is the first direct demonstration that, as suggested by clinical studies, maternal iron status has a unique influence upon FASD outcome. While alcohol is unquestionably teratogenic, this ID-alcohol interaction likely represents a significant portion of FASD diagnoses because ID is more common in alcohol-abusing pregnancies than generally appreciated. Iron status may also underlie the associations between FASD and parity or socioeconomic status. We propose that increased attention to normalizing maternal iron status will substantially improve FASD outcome, even if maternal alcohol abuse continues. These findings offer novel insights into how alcohol damages the developing brain.