Frequency and nature of recorded childhood immunization-related errors in Greece.

BACKGROUND: While routine immunizations are very safe, their administration to healthy children requires minimization of immunization programmatic errors. In order to estimate the incidence and ascertain the nature of reported immunization errors in the Greek childhood population, we have undertaken a study using data from the National Poison Information Center in Greece, which also has the responsibility to address medication-induced errors. METHODS: All immunization errors concerning children and reported to the National Poison Information Center during the 2-yr period 1999-2000 were retrieved and the conditions of their occurrence were examined. The incidence of reported errors was calculated under the assumption that during each year 100,000 children are born in Greece, and during their childhood they receive a total of about 20 immunization doses of all childhood immunizations. RESULTS: There were 40 immunization errors reported, corresponding to a reported incidence of about 11 per million immunization doses. Of these errors, 20 concerned OPV, 13 DTP, 5 MMR, 1 Haemophilus influenza and 1 Hepatitis B immunizations. In 12 instances an erroneous route was used (out of which 11 concerned OPV), whereas overdose was documented in 13 instances (out of which 8 concerned OPV). The third most common error was administration of DTP instead of the recommended Td vaccine. No adverse patient outcomes were reported. CONCLUSIONS: In Greece, reported errors in immunization practice are relatively rare. Packaging modifications (about one in three errors in this study) of the OPV and DTP could further reduce their incidence.

[Perinatal mortality after previous cesarean section]. / Perinatale kindliche Todesfälle bei Kaiserschnitt in der mütterlichen Anamnese.

BACKGROUND: Perinatal neonatal mortality is increased where there is a maternal history of cesarean section (0.45 vs. 0.31 % in deliveries after previous vaginal delivery). In this study we have analyzed the causes of the perinatal deaths. PATIENTS AND METHODS: The increased risk was found by analyzing the database of the Swiss Working Group of Obstetric and Gynecological Institutions with its 29 046 deliveries with a history of previous cesarean section between 1983 and 1996. In this time period 130 perinatal neonatal deaths in deliveries after previous cesarean were recorded. RESULTS: The cause of death could be established in 124 cases. In the 42 term deliveries the causes of death were the following: malformations 20, uterine rupture 5, placental abruption 5, respiratory distress syndrome 5, and other causes 7. In the 82 preterm deliveries: prematurity caused by premature contractions/rupture of membranes 38, malformations 12, chorioamnionitis 12, placental abruption 9, severe growth retardation 4, complications of placenta praevia 2, uterine rupture 1, other causes 4. DISCUSSION: Preterm deliveries are more frequent (in births) after a previous c/s (7.75 vs. 5.55 % in multiparous mothers without previous cesarean) - not because of a higher frequency of preterm labor or premature rupture of membranes, but because of placental abruption, chorioamnionitis, placental insufficiency and severe growth retardation. Although some of the neonatal deaths are linked to the previous cesarean delivery, perinatal death after previous cesarean is a very rare event. A recommendation to routinely perform a repeat cesarean instead of a trial of labor seems not appropriate.

Serious injuries and deaths of adolescent girls resulting from interpersonal violence: characteristics and trends from the United States, 1989-1998.

BACKGROUND: Little published data are available concerning the death and disability of adolescent girls resulting from interpersonal violence (adolescents are defined as those aged 12-18 years in this study). OBJECTIVES: To determine whether there were sex differences in (a) the characteristics of those who were injured or died, (b) injury severity and outcomes, and (c) injury mechanism; and to describe time trends in these differences. DESIGN: Analysis of data concerning serious injuries due to assaults, recorded in the National Pediatric Trauma Registry (from January 1, 1989, through December 31, 1998), and homicides, recorded in the Web-Based Injury Statistics and Query Reporting System database (from January 1, 1990, through December 31, 1997). SETTING: Patient data from participating pediatric trauma centers (National Pediatric Trauma Registry) in 45 states and national death certificate data (Web-Based Injury Statistics and Query Reporting System). PATIENTS: Six hundred twelve adolescent girls who were seriously injured because of an assault were compared with 2656 adolescent boys who were seriously injured because of an assault. Three thousand four hundred eighty-seven adolescent girls who died due to a homicide were compared with 17 292 adolescent boys who died due to a homicide. RESULTS: Assaulted adolescent girls were more likely to have preexisting cognitive or psychosocial impairments than were adolescent boys (odds ratio, 1.68; 95% confidence interval, 1.12-2.51). Adolescent girls trended toward more injury-related impairments at discharge from the hospital (odds ratio, 1.16; 95% confidence interval, 0.92-1.47). Adolescent girls were more likely to have been stabbed, and less likely to have been shot. Also, adolescent girls were more likely to have been injured at a home or a residence. Compared with all National Pediatric Trauma Registry admissions, assaults declined at the same rate for adolescent girls and boys. The proportion resulting from penetrating trauma declined more slowly for adolescent girls. CONCLUSIONS: Interpersonal violence causes considerable morbidity and mortality for young women. Research and interventions should be developed to respond to adolescent girls who experience interpersonal violence.

Outcomes from television sets toppling onto toddlers.

OBJECTIVE: To assess outcomes of trauma caused by television sets falling onto children. METHODS: Retrospective review of medical charts of 183 children aged 7 years and younger hospitalized for injuries caused by falling television sets. Descriptive statistics were applied. DATA SOURCES: Phase 2 (1988-1995) and phase 3 (1995-1999) of the National Pediatric Trauma Registry. OUTCOME MEASURES: Demographics, injured body region, injury severity measured by the Injury Severity Score, length of hospital stay, admission to the intensive care unit, surgical intervention, in-hospital death rate, disability resulting from the injury, and disposition at discharge from the hospital. RESULTS: The sample population represented 0.5% of all National Pediatric Trauma Registry admissions in this age group. More than half (57.4%) of the children were boys, and more than three quarters (76.0%) were 1 to 4 years of age. In most cases (95.1%), the injury occurred at home. Most children (68.3%) sustained head injury, and 43.7% sustained injuries to multiple body regions. More than a quarter (28.4%) of the children had injuries of moderate to critical severity (Injury Severity Score, 10-75), about a third (31.1%) required admission to the intensive care unit, and 20.2% needed 1 or more surgical interventions. The average length of hospitalization was 3.3 days. Five children (2.7%) died, and 48 (26.2%) developed functional limitations, which required discharge to a rehabilitation facility in 5 cases. Most (94.0%) of the children returned to their home. The proportion of television set-related injuries increased more than 100% during the study period. CONCLUSIONS: The injuries reported are not trivial. Not only did they require hospitalization, but they also resulted in an in-hospital death rate comparable to the 2.5% rate observed in children of the same age group injured by unintentional blunt trauma, inclusive of motor vehicle traffic-related injuries. Since virtually all American children are at risk for such injury, we suggest that television set designs be modified to reduce the incidence and severity of the problem.

Outcomes of pediatric pedestrian injuries by locations of event.

Data from the National Pediatric Trauma Registry October 1995-October 2000, containing medical records of children under 20 years old hospitalized for pedestrian injuries, were examined. Demographics and outcome measures (nature and severity of injury, utilization of resources, deaths, and disability at discharge) were compared by location of occurrence. Pediatric pedestrian injuries resulted in severe outcomes whether the events occurred in driveways, public places, or in the road. Off the road injuries accounted for a significant proportion (13.2%) of all serious pedestrian injuries and disproportionately affected the youngest children. Prevention should consider the child's age and the location of injury occurrence.

Health care providers' experience reporting child abuse in the primary care setting. Pediatric Practice Research Group.

OBJECTIVES: To describe (1) primary care providers' experiences identifying and reporting suspected child abuse to child protective services (CPS) and (2) variables affecting providers' reporting behavior. DESIGN AND METHODS: Health care providers (76 physicians, 8 nurse practitioners, and 1 physician assistant) in a regional practice-based network completed written surveys that collected information about the demographic characteristics of each provider and practice; the provider's career experience with child abuse; and the provider's previous year's experience identifying and reporting suspected child abuse, including experience with CPS. RESULTS: All providers (N = 85) in 17 participating practices completed the survey. In the preceding 1 year, 48 respondents (56%) indicated that they had treated a child they suspected was abused, for an estimated total of 152 abused children. Seven (8%) of 85 providers did not report a total of 7 children with suspected abuse (5% of all suspected cases). A majority of providers (63%; n = 29) believed that children who were reported had not benefited from CPS intervention, and 21 (49%) indicated that their experience with CPS made them less willing to report future cases of suspected abuse. Providers who had some formal education in child abuse after residency were 10 times more likely to report all abuse than were providers who had none. CONCLUSIONS: Primary care providers report most, but not all, cases of suspected child abuse that they identify. Past negative experience with CPS and perceived lack of benefit to the child were common reasons given by providers for not reporting. Education increases the probability that providers will report suspected abuse.

Childhood head injuries: accidental or inflicted?

OBJECTIVES: To determine the relative incidence of accidental and abusive causes of head injuries in children younger than 6.5 years, to identify the types of craniocerebral damage resulting from reported mechanisms of injury, and to assess the likelihood of injuries being accidental or inflicted. METHODS: Retrospective review of medical records of 287 children with head injuries aged 1 week to 6.5 years admitted to a metropolitan children's hospital from January 1986 through December 1991. Those patients with diagnoses of skull fracture; concussion; subarachnoid hemorrhage (SAH); subgaleal, epidural, or subdural hematoma (SDH); parenchymal contusion or laceration; and closed head injury were included. Criteria were used for inclusion in categories of definite abuse or accident. RESULTS: Accidents accounted for 81% of cases and definite abuse for 19%. The mean age of the accident group was 2.5 years and for the definite abuse group, 0.7 years. Major differences were seen in the incidence of the following: SDH, 10% in the the accident group and 46% in the the definite abuse group; SAH, 8% in accident group and 31% in the definite abuse abuse; and retinal hemorrhages, 2% in the accident group and 33% in the definite abuse group. Associated cutaneous injuries consistent with inflicted injury were seen in 16% of the accident group and 50% of the definite abuse group. Twenty-three percent of those in the accident group were injured in motor vehicle crashes (MVCs), 58% by falls, 2% in play activities, and the rest had insufficient medical record information. In 56% of those in the definite abuse group, there was no history to account for the injuries and no history of MVC. In 17%, a fall was said to have been the mechanism of injury. In 24%, inflicted injury was admitted. Mortality rates were 13% in the definite abuse group and 2% in the accident group. Median hospital stay was 9.5 days for the definite abuse group and 3 days for the accident group. In falls less than 4 feet in the accident group, 8% had SDH, 2% had SAH, and none had retinal hemorrhages; among those in the definite abuse group reportedly falling less than 4 feet, 38% had SDH, 38% had SAH, and 25% had retinal hemorrhages. CONCLUSIONS: A substantial percentage of head injuries requiring hospitalization in children younger than 6.5 years are attributable to inflicted injury. Subdural hematoma, subarachnoid hemorrhage, retinal hemorrhages, and associated cutaneous, skeletal, and visceral injuries are significantly more common in inflicted head injury than in accidental injury.

Child abuse and unintentional injuries: a 10-year retrospective.

OBJECTIVE: To identify differences between hospitalized children injured by child abuse and those with unintentional injuries. DESIGN: Comparative analysis of patients injured by child abuse (n = 1997) with patients injured unintentionally (n = 16 831), newborn to 4 years of age. MAIN OUTCOME MEASURES: Patient characteristics, nature and severity of injury, treatment, length of stay, survival, functional limitations, and disposition at discharge from the hospital. DATA SOURCE: Retrospective review of medical records submitted to the National Pediatric Trauma Registry between January 1, 1988, and December 31, 1997. RESULTS: During the 10-year study period, child abuse accounted for 10.6% of all blunt trauma to patients younger than 5 years. Children injured by child abuse were significantly younger (mean, 12.8 vs 25.5 months) and were more likely to have preinjury medical history (53% vs 14.1%) and retinal hemorrhages (27.8% vs 0.06%) than children with unintentional injuries. Abused children were mainly injured by battering (53%) and by shaking (10.3%); unintentionally injured children were hurt mainly by falls (58.4%) and by motor vehicle-related events (37.1%). Abused children were more likely than unintentionally injured children to sustain intracranial injury (42.2% vs 14.1%) and thoracic (12.5% vs 4.5%) and abdominal (11.4% vs 6.8%) injuries; to sustain very severe injuries (22.6% vs 6.3%); to be admitted to the intensive care unit (42.5% vs 26.9%); and to receive Child Protective Services (82.3% vs 8%) and Social Services (72.9% vs 27.6%) intervention. The mean length of stay for children who were abused was significantly longer (9.3 vs 3.8 days) and the survival to discharge from the hospital was significantly worse (87.3% vs 97.4%) than for those unintentionally injured. Among the survivors, children who were abused developed extensive functional limitations more frequently than those unintentionally injured (8.7% vs 2.7%). More than half (56.6%) of the children who were abused were discharged to custodial/foster/Child Protective Services care; most (96.1%) of the children unintentionally injured returned to their homes. CONCLUSIONS: Child abuse continues to be a serious cause of mortality and morbidity to infants and toddlers. On average, among children hospitalized for blunt trauma, those injured by abuse sustain more severe injuries, use more medical services, and have worse survival and functional outcome than children with unintentional injuries.

Comparing pediatric intentional injury surveillance data with data from publicly available sources: consequences for a public health response to violence.

OBJECTIVE: A hospital based intentional injury surveillance system for youth (aged 3-18) was compared with other publicly available sources of information on youth violence. The comparison addressed whether locally conducted surveillance provides data that are sufficiently more complete, detailed, and timely that clinicians and public health practitioners interested in youth violence prevention would find surveillance worth conducting. SETTING: The Boston Emergency Department Surveillance (BEDS) project was conducted at Boston Medical Center and the Children's Hospital, Boston. METHOD: MEDLINE and other databases were searched for data sources that report separate data for youth and data on intentional injury. Sources that met these criteria (one national and three local) were then compared with BEDS data. Comparisons were made in the following categories: age, gender, victim-offender relationship, injury circumstance, geographic location, weapon rates, and violent injury rates. RESULTS: Of 14 sources dealing with violence, only four met inclusion criteria. Each source provided useful breakdowns for age and gender; however, only the BEDS data were able to demonstrate that 32.6% of intentional injuries occurred among youth aged 12 and under. Comparison data sources provided less detail regarding the victim-offender relationship, injury circumstance, and weapon use. Comparison of violent injury rates showed the difficulties for practitioners estimating intentional injury from sources based on arrest data, crime victim data, or weapon related injury. CONCLUSIONS: Comparison suggests that surveillance is more complete, detailed, and timely than publicly available sources of data. Clinicians and public health practitioners should consider developing similar systems.

Ten years after: examination of adolescent screening questions that predict future violence-related injury.

PURPOSE: To determine which screening questions used in routine adolescent health care maintenance visits correlate with subsequent violence-related injury. METHODS: A prospective cohort study was undertaken of adolescents initially seen at the East Boston Neighborhood Health Center (EBNHC) in 1986. Risk factor data were collected based on the adolescent health intake form in the medical records. The primary outcome measure, time until first violence-related injury was determined through identification on chart review of the treatment of any such injuries at the urgent care center at EBNHC in the subsequent 10 years. Kaplan-Meier survival statistics and Cox proportional hazards models were used to account for loss of patients to follow-up. RESULTS: Median follow-up for this sample was >5 five years. Male gender, cigarette smoking, alcohol use, other drug use, poor relationships with parents, not being in school or failing school, and history of fighting in the past year, predicted violence-related injury within the follow-up period. The number of fights in the past year appeared to have a dose-response effect on risk of subsequent violence-related injury. A simple screening instrument consisting of items concerning school status, drug use, and fighting history was used to stratify youth into low, moderate, and high risk of violence-related injury during the follow-up period. CONCLUSIONS: These results suggest that a simple three-item screening instrument may be used to stratify the risk of future injury at the time of adolescent health maintenance visits. Further research is indicated to validate this finding in other populations. Interventions designed to assist adolescents who are not in school or who have drug use problems should also incorporate violence prevention strategies.

Child centered literacy orientation: a form of social capital?

OBJECTIVE: To describe the home literacy environment and to identify financial, human, and social capital variables associated with the presence or lack of Child Centered Literacy Orientation (CCLO) in families with young children who regularly attend pediatric primary care clinics. DESIGN: Cross-sectional case-control analysis of structured parent interviews conducted in two hospital-based and four community-based pediatric clinics in New England. SUBJECTS: Parents of 199 healthy 1- to 5-year-old children whose mean age was 30 +/- 15 (SD) months were interviewed. Parents were primarily mothers (94%) with a mean age of 28 +/- 7 (SD) years 60% of whom were single. Educational levels of study parents varied: 43% had not graduated from high school, 29% had a high school equivalency, and 28% had at least a year of college or vocational training. This was a multiethnic parent group. Sixty-five percent were bilingual or non-English speaking. Fifty-eight percent were born outside of the continental United States. Parents were primarily of low-income status with 85% receiving Women, Infant, and Children (WIC) food supplements, Aid to Families With Dependent Children, and/or Medicaid. RESULTS: Half of the parents interviewed reported that they rarely read books. Sixty percent of children had fewer than 10 books at home and two-thirds of these households contained fewer than 50 books total. When asked open-ended questions, 28% of parents said that sharing books with their child was one of their three favorite activities together, 14% said that looking at books was one of their child's three favorite things to do, and 19% reported sharing books at bedtime at least six times each week. Thirty-nine percent of families had at least one of these three literacy-related responses present and so were said to have a CCLO. A backwards stepwise multiple logistic regression on CCLO was performed with family financial, human, and social capital variables. Parents married or living together (odds ratio [OR] 2.56, 95% confidence interval [CI] = 1.21-5.42), higher adult-to-child ratios in the home (OR 1.92, 95% CI = 1.20-3.05), households speaking only English (OR 2.67, 95% CI = 1.24-5.76), parents reading books themselves at least a few times a week (OR 2.86, 95% CI = 1.38-5.91), and homes with more than 10 children's books (OR 3.3, 95% CI = 1.6-6.83), were all independently and significantly associated with the presence of CCLO. Older child age and higher parent education remain in the model but were not significant at the P <.05 level. Ethnicity and income status were dropped for lack of additional significance from this model, which described 24% of the variance in CCLO. CONCLUSION: Although two-parent families and higher adult-to-child ratios in the home appear to be social capital variables with protective effects, low-income, single-parent, and minority or immigrant families are at significant risk for lacking both children's books and a CCLO. We suggest that CCLO may itself be another form of social capital reflecting parental goals and expectations for their children. We speculate that interventions which provide children's books and information about reading with children to impoverished families with young children may facilitate more parent-child book sharing. Pediatricians and other primary care providers serving underserved populations may have a unique opportunity to encourage activities focusing on young children and promoting literacy.

Short-term effectiveness of anticipatory guidance to reduce early childhood risks for subsequent violence.

OBJECTIVE: To determine whether newly developed anticipatory guidance materials designed to teach the use of time-outs and the importance of reductions in childhood television viewing would be recalled by parents and if their use would result in changes in self-reported parental behavior. SUBJECTS AND SETTING: A total of 559 parents of children aged 14 months to 6 years recruited at the time of routine child health maintenance visits at 2 managed care pediatric departments in eastern Massachusetts. METHODS: In-person parent interviews were conducted in the waiting room prior to office visits, with follow-up telephone calls 2 to 3 weeks after the visit. Two groups of families were enrolled: a control group who received usual anticipatory guidance and an intervention group who received written materials. Intervention group providers were trained to include study topics during the office visit and to introduce the written materials. RESULTS: Provider training and the provision of written materials increased the parents' specific recall of anticipatory guidance of at least 2 to 3 weeks following the office visit. This effect was specific to the areas of intervention and did not carry over to other commonly used topics of anticipatory guidance. Among parents who had never used a time-out prior to the office visit, there was a significant increase in the use of time-outs. Parents who received anticipatory guidance regarding the link between exposure to television violence and subsequent violence in children were somewhat more likely to report reductions in weekend television viewing than were parents in the control group, although this change was not statistically significant. CONCLUSIONS: Certain parenting behaviors have been associated with subsequent violence. Brief, inexpensive anticipatory guidance in relevant areas, provided in the context of routine health supervision visits, appears to result in favorable short-term changes in parenting practices.

Family violence: an overview.

This article reviews the definitions and epidemiology of the several forms of interpersonal violence in family and intimate relationships. Interpersonal violence includes both fatal and nonfatal violence where physical force, or other means, is used by one person with the intent of causing harm, injury, or death: family violence includes child maltreatment, adult intimate-partner violence, and elder mistreatment; abuse refers to a pattern of behaviors organized around the international use of power by one person to control another; and child maltreatment involves the abrogation of adult responsibilities for the care and protection of children, and includes child abuse, child sexual abuse, and child neglect. Violence is a major public health problem in the United States. Half of assault and homicide victims are related to or acquainted with their assailants, as are two-thirds of rape victims. Children and adolescents are at particular risk of violence. The study of interpersonal violence is a complex and evolving held, and is increasingly a part of training and medical practice in academic settings.

Interpersonal violence and the education of physicians.

Physicians in every field of practice can expect to be called upon to care for patients whose lives have been affected by interpersonal violence. Although the medical profession has begun to acknowledge the appropriate role of physicians in screening, diagnosis, and treatment of interpersonal violence, these areas have not been fully addressed in the curricula of most medical schools. Competencies in the understanding of violence and its treatment are proposed for medical students, residents, and practicing physicians. By the time of graduation, all medical students should be able to demonstrate appropriate attitudes, core knowledge, and basic skills in assessment and intervention of patients at risk from or experiencing violence. During postgraduate training, residents should amass specialized knowledge and skill concerning the spectrum of injuries and illnesses they may encounter in clinical practice. Faculty development efforts should address the advancement of faculty who are well trained in a scholarly approach to teaching and research in this field. This paper describes methods by which educational efforts in interpersonal violence can be introduced into medical education. Proposed goals and objectives for curriculum development in schools of medicine, along with an implementation plan, are offered.

Violence: A preventable cause of head injury in children.

Violence is one of the most important and preventable causes of head injury in children. This review discusses the epidemiology of youth violence from previously published reports and from new information obtained from the National Pediatric Trauma Registry. Violence prevention is considered in two categories: primary prevention aimed at the general population, and secondary prevention strategies focused on injured children and adolescents. Rehabilitation professionals have substantial roles to play in both primary and secondary prevention of youth violence.

Intentional injury surveillance in a primary care pediatric setting.

OBJECTIVE: To describe intentional injuries identified by primary care providers caring for children and adolescents, as reported through a prospective surveillance system. SETTING: Pediatric departments at four sites affiliated with a large health maintenance organization in eastern Massachusetts. DESIGN: Primary care providers completed brief injury encounter reports for patients aged 3 to 18 years treated for an intentional injury during a 20-month study period. For comparison purposes, a convenience sample of medical record was reviewed. RESULTS: Two hundred eleven injury encounter reports were received, representing a reported rate of 4.1 intentional injuries per 1000 panel members per year. These injuries ranged from contusions and lacerations to sexual assault and homicide. The median age of children at the time of injury was 14 years (interquartile range, 12 to 16 years), older than the population median age of 10 years (interquartile range, 6 to 14 years) (P<.001, Wilcoxon Signed Rank Test). Boys had a relative risk 1.5 times that of girls (P<.05, binomial test). Almost half of the injuries to adolescent girls resulted from encounters with other girls; 10% were the result of dating violence. In most cases, the patient and his or her assailant were friends or acquaintances (56%). This prospective surveillance detected, at most, 67% of intentional injuries seen, while medical record review detected 59% of the total identified injuries. CONCLUSIONS: Primary care pediatricians can identify and treat children and adolescents for intentional injuries. As these patients may form an appropriate group for interventions directed at reducing the risk of future intentional injuries, more effective public health surveillance must be developed.

Television viewing and violence in children: the pediatrician as agent for change.

Three decades of research suggest a causal link between exposure of children to violent images on television and subsequent violent behavior. The epidemic of violence in American society mandates a critical reappraisal of the televised images that children see. To slow the cycle of violence, pediatricians can: (1) Help shape parental attitudes toward children's viewing habits; (2) lobby for school systems to adopt curricula that include critical viewing skills; and (3) work with Congress, Federal regulators, television producers, and broadcasters to reduce the exposure of children to televised violence.