Climate Change and Children's Health: Building a Healthy Future for Every Child.

The warming of our planet matters to every child. Driven by fossil fuel-generated greenhouse gas emissions, climate conditions stable since the founding of modern pediatrics in the mid-nineteenth century have shifted, and old certainties are falling away. Children's physical and mental health are threatened by climate change through its effects on temperature, precipitation, and extreme weather; ecological disruption; and community disruption. These impacts expose and amplify existing inequities and create unprecedented intergenerational injustice. Fossil fuel extraction and combustion cause harm today and reach centuries into the future, jeopardizing the health, safety, and prosperity of today's children and future generations. Appreciating the unique vulnerability of their patients, pediatricians have become leading health advocates for climate actions necessary to protect all living and future children. Policies that reduce reliance on fossil fuels and promote cleaner air, facilitate walking and bicycling, encourage more sustainable diets, increase access to nature, and develop more connected communities lead to immediate gains in child health and equity, and build a foundation for generations of children to thrive.

Climate Change and Children's Health: Building a Healthy Future for Every Child.

Observed changes in temperature, precipitation patterns, sea level, and extreme weather are destabilizing major determinants of human health. Children are at higher risk of climate-related health burdens than adults because of their unique behavior patterns; developing organ systems and physiology; greater exposure to air, food, and water contaminants per unit of body weight; and dependence on caregivers. Climate change harms children through numerous pathways, including air pollution, heat exposure, floods and hurricanes, food insecurity and nutrition, changing epidemiology of infections, and mental health harms. As the planet continues to warm, climate change's impacts will worsen, threatening to define the health and welfare of children at every stage of their lives. Children who already bear higher burden of disease because of living in low-wealth households and communities, lack of access to high quality education, and experiencing racism and other forms of unjust discrimination bear greater risk of suffering from climate change hazards. Climate change solutions, advanced through collaborative work of pediatricians, health systems, communities, corporations, and governments lead to immediate gains in child health and equity and build a foundation for generations of children to thrive. This technical report reviews the nature of climate change and its associated child health effects and supports the recommendations in the accompanying policy statement on climate change and children's health.

De-escalation Techniques for the Agitated Pediatric Patient.

ABSTRACT: The emergency department can be a particularly challenging environment for the care of pediatric patients presenting with acute agitation. Agitation is a behavioral emergency requiring prompt intervention. Timely recognition of agitation and proactive implementation of de-escalation strategies are critical for safe and effective management of agitation, as well as prevention of recurrent episodes. This article reviews the definition of agitation, explores the domains of verbal de-escalation, and considers multidisciplinary management strategies for children with acute agitation.

Complications of Long-Acting Reversible Contraceptive Modalities.

ABSTRACT: Long-acting reversible contraception has risen in popularity in recent decades and is becoming one of the more common modalities of contraception in the United States, with a growing adolescent population among its users. The 2 modalities of long-acting reversible contraception-intrauterine devices and subcutaneous hormonal implants/etonogestrel implants (referred to as Nexplanon in the US)-are beneficial for their excellent effectiveness, ease of use, and safety profile. This article reviews the pharmacology of these modalities, common complications and their presentations, and the initial evaluation and management in the pediatric emergency department setting. Where applicable, attention will be paid to problems unique to the adolescent population.

Ketofol for Procedural Sedation and Analgesia in the Pediatric Population.

ABSTRACT: The combination of ketamine and propofol, commonly referred to as ketofol, is sometimes used for procedural sedation and analgesia in the pediatric emergency department. This article reviews the pharmacology, dosing, and indications, as well as adverse effects and contraindications of ketamine, propofol, and ketofol.

The 2021 Core Content of Medical Toxicology.

The Medical Toxicology Subboard approved modifications to the Core Content of Medical Toxicology in March 2021. The document outlines the areas of knowledge considered essential for the practice of medical toxicology. The Core Content provides the organizational framework for the development of the Medical Toxicology Certification and Cognitive Expertise Examinations and serves as a template for the development of curricula for medical toxicology fellowship training programs.

Small Rare Earth Magnets Adhered to Pharyngeal Tissue in a Pediatric Emergency Department Patient.

BACKGROUND: Small rare earth magnets pose a known health risk to children and many cases of ingestion and aspiration with associated complications have been described. More unusual, but also seen in children, are retained foreign bodies in the oropharynx that require extraction. CASE REPORT: We present the case of a 3-year-old boy with persistent left-sided sore throat 1 h after ingestion of several 3-mm spherical rare earth magnets. No foreign bodies were visible in the oropharynx on examination; however, a chest radiograph revealed two adjacent magnets within the lower pharyngeal space, as well as four magnets linearly clumped within the small intestine. The patient was taken to the operating room, where visual inspection under general anesthesia revealed two magnets adhered to the pharyngoepiglottic folds (one on the laryngeal surface and one on the glottic surface). They were removed in full without issue, preventing aspiration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the recent increase in incidence of rare earth magnet ingestion, emergency providers ought to be aware of the risks and complications associated with magnetic foreign body ingestion in children and the workup and considerations involved in their removal. Providers should also advocate for improved safety controls of these products, which have been found to be effective in the past.

Chemical-Biological Terrorism and Its Impact on Children.

Children are potential victims of chemical or biological terrorism. In recent years, children have been victims of terrorist acts such as the chemical attacks (2017-2018) in Syria. Consequently, it is necessary to prepare for and respond to the needs of children after a chemical or biological attack. A broad range of public health initiatives have occurred since the terrorist attacks of September 11, 2001. However, in many cases, these initiatives have not ensured the protection of children. Since 2001, public health preparedness has broadened to an all-hazards approach, in which response plans for terrorism are blended with those for unintentional disasters or outbreaks (eg, natural events such as earthquakes or pandemic influenza or man-made catastrophes such as a hazardous-materials spill). In response to new principles and programs that have evolved over the last decade, this technical report supports the accompanying update of the American Academy of Pediatrics 2006 policy statement "Chemical-Biological Terrorism and its Impact on Children." The roles of the pediatrician and public health agencies continue to evolve, and only their coordinated readiness and response efforts will ensure that the medical and mental health needs of children will be met successfully. In this document, we will address chemical and biological incidents. Radiation disasters are addressed separately.

Chemical-Biological Terrorism and Its Impact on Children.

Chemical and biological events (including infectious disease outbreaks) may affect children disproportionately, and the threat of a chemical or biological attack remains in the United States and worldwide. Although federal programs and funding support a broad range of federal initiatives for public health preparedness and response, funding at the state and local levels has been flat or is decreasing, potentially leaving communities vulnerable. Consequently, pediatricians need to prepare and be ready to care for children in their communities before, during, and after a chemical or biological event, including during long-term recovery. Some medical countermeasures for particular chemical and biological agents have not been adequately studied or approved for children. The American Academy of Pediatrics provides resources and education on disaster preparedness and response, including information on the pediatrician's role in disasters, pediatric medical countermeasures, and mental health after an event as well as individual and family preparedness. This policy statement addresses the steps that clinicians and policy makers can take to protect children and mitigate the effects of a chemical or biological attack.

Acute Cannabis Toxicity.

The change in legal status of cannabis (the botanical species Cannabis sativa, commonly known as marijuana) in the United States has had significant impact on pediatric drug exposures. In states with decriminalization of recreational and medicinal use of cannabis, emergency department visits and poison control center calls for unintentional pediatric cannabis intoxication are on the rise in the last few decades. Exploratory or unintentional ingestions of cannabis-containing products (as opposed to those derived from synthetic cannabinoids, which may mimic the structure and/or function of cannabis, but are not the focus of this article) can lead to significant pediatric toxicity, including encephalopathy, coma, and respiratory depression. With the increasing magnitude of the public health implications of widespread cannabis use, clinicians who care for pediatric patients routinely must be adept in the recognition, evaluation, management, and counseling of unintentional cannabis exposure.

Synthetic drug intoxication in children: recognition and management in the emergency department.

When children and adolescents present to the emergency department with agitation or mental status changes, intoxication from synthetic drug use should be in the differential diagnosis. Identifying the responsible compound(s) may be difficult, so asking the patient broad questions and utilizing appropriate diagnostic studies, when indicated, will aid in making the diagnosis and help identify more-serious complications. This issue discusses the challenges presented by the changing chemical formulations of synthetic cannabinoids, cathinones, and phenethylamines; outlines common presentations of intoxication from these substances; and summarizes best practices for evaluating and managing patients who present with intoxication after consumption of these synthetic drugs of abuse.

"What do you know?"--knowledge among village doctors of lead poisoning in children in rural China.

BACKGROUND: This study evaluates the extent of village doctors' knowledge of lead poisoning in children in rural China and assesses the characteristics associated with possessing accurate knowledge. METHODS: A cross-sectional, questionnaire-based survey of 297 village doctors in Fenghuang County, Hunan Province, China was conducted. All village doctors were interviewed face-to-face using a "What do you know" test questionnaire focusing on prevention strategies and lead sources in rural children. RESULTS: A total of 287 (96.6%) village doctors completed the survey in full. Most village doctors had an appropriate degree of general knowledge of lead poisoning; however, they had relatively poor knowledge of lead sources and prevention measures. Village doctors with an undergraduate level education scored an average of 2.7 points higher than those who had a junior college level education (p = 0.033). Village doctors with an annual income ≤ 10,000 RMB yuan scored 1.03 points lower than those whose income was >10,001 RMB yuan. Ethnic Han village doctors scored 1.12 points higher, on average, than ethnic Tujia village doctors (p = 0.027). CONCLUSIONS: This study identified important gaps in knowledge concerning lead poisoning in children among a rural population of village doctors. There is a clear need for multifaceted interventions that target village doctors to improve their knowledge regarding lead poisoning in children. The "What do you know" questionnaire is a new tool to evaluate lead poisoning knowledge and education projects.

Baclofen Pumps: Uses and Complications.

Intrathecal baclofen therapy, given via an implanted pump in the abdominal wall either as a continuous infusion or bolus dosing, has been used for more than 25 years to treat the spasticity and dystonia associated with various brain and spinal cord conditions. Pediatric clinicians occasionally encounter baclofen pumps, and in the pediatric setting, significant morbidity can arise from their use. This article presents the background, mechanism of action, uses, and complications of intrathecal baclofen therapy and discusses various management strategies should complications occur.

Drug Misuse in Adolescents Presenting to the Emergency Department.

OBJECTIVES: Drug misuse is a disturbing, common practice among youth. One in 4 American adolescents reports consuming prescription medications without a clinical indication. We sought to explore current trends of drug misuse in adolescents. METHODS: Using the 37 participating sites of the ToxIC (Toxicology Investigators Consortium) Case Registry, a cross-country surveillance tool, we conducted an observational cohort study of all adolescents (aged 13-18 years) who presented to emergency departments with drug misuse and required a bedside medical toxicology consultation between January 2010 and June 2013. RESULTS: Of 3043 poisonings, 202 (7%) involved drug misuse (139 [69%] were males). Illicit drugs (primarily synthetic cannabinoids and "bath salts") were encountered in 101 (50%), followed by prescription medications (56 [28%]) and over-the-counter (OTC) drugs (51 [25%]). Dextromethorphan was the most commonly misused legal medication (24 [12%]). Polypharmacy exposure was documented in 74 (37%). One hundred sixty-three adolescents (81%) were symptomatic; of these, 81% had central nervous system impairments: psychosis (38%), agitation (30%), coma (26%), myoclonus (11%), and seizures (10%); and 66 (41%) displayed a specific toxidrome, most commonly sedative-hypnotic. Benzodiazepines were the most frequently administered medications (46%). Antidotes were administered to 28% of adolescents, primarily naloxone, physostigmine, N-acetyl-cysteine, and flumazenil. No deaths were recorded. CONCLUSIONS: Adolescents presenting with drug misuse may be exposed to a wide range and combinations of therapeutics or illicit substances and frequently display central nervous system abnormalities, compromising the ability to obtain a reliable history. Frontline clinicians should maintain a high index of suspicion, as routine toxicology screenings fail to detect most contemporary misused legal and designer drugs.

Drugs, guns and cars: how far we have come to improve safety in the United States; yet we still have far to go.

Significant breakthroughs in the field of injury prevention and childhood safety have occurred during the past half-century. For example, the Poison Prevention Packaging Act of 1970 and the institution of child passenger safety laws are responsible for a significant reduction in injuries among children and adolescents. This review will focus on the following three topics because of their significant contribution to pediatric injury morbidity, especially among adolescents, and their promise for further effective prevention research. Opioid overdoses by adolescents and young adults are increasing; however, the use of naloxone by bystanders represents a life-saving development in opioid overdose prevention that deserves further investigation. Youth firearm injury remains a major cause of death and disability in adolescents. Despite a lack of robust injury prevention research on the topic, the development of novel approaches to access and examine firearm injury data is leading to exploration of public health approaches to reduce these injuries. Finally, despite legislative and educational efforts surrounding child passenger safety and graduated driver license laws, motor vehicle crashes are still a leading cause of injury for both children and adolescents; however, research on these laws holds the opportunity for significant reduction in injuries. Focused efforts to reduce unintentional injuries from opiate overdoses, firearms and motor vehicle crashes may produce a breakthrough in the field of injury prevention similar to that of the Poison Prevention Packaging Act.

Magnetic Foreign Body Ingestions.

Magnets are inherently attractive to young children, but present a risk when ingested. If consumed alone, small, smooth magnetic foreign bodies are likely to pass without significant event; however, ingestion of multiple magnets may have catastrophic consequences, including bowel perforation, obstruction, peritonitis, and death. Increasing reports of morbidity and mortality in recent years from the US National Electronic Injury Surveillance System has led to numerous safety statements from the American Academy of Pediatrics and the Centers for Disease Control and Prevention, as well as several product recalls from the Consumer Product Safety Commission. This article presents the background and mechanism of injury of magnet ingestion, as well as recommended management and potential complications. We also review current legislation and opportunities for further patient advocacy regarding this polarizing problem.

Effects of alcohol-based hand hygiene solutions on breath alcohol detection in the emergency department.

This study aimed to investigate the effects of alcohol-based hand hygiene solution (ABHS) use by care providers on point-of-care alcohol breath analyzer interpretation under different clinically relevant conditions. Among each test condition (foam vehicle with immediate testing, gel vehicle with immediate testing, allowing hands to dry after the use of ABHS, and donning gloves after the use of ABHS), alcohol was detected in breath at 1 minute after use of ABHS. Because the use of ABHS by individuals administering breath alcohol detection may result in false-positive detection of alcohol, staff using these devices should consider traditional hand hygiene with soap and water.