Pediatric Injury Trends in Rhode Island During the COVID-19 Pandemic.

BACKGROUND: Pediatric Emergency Department (PED) visits nationally decreased while the proportion of injury-related PED visits increased during the COVID-19 pandemic. Little is known about the trends in Rhode Island (RI). METHODS: This is a planned sub-analysis of RI data from a retrospective study of pediatric injury-related visits to 40 PEDs for children <18 years old from January 2019-December 2020. We calculated frequencies and compared patient demographics, injury types, severity, and mechanisms for 3/17/2019-12/31/2019 (pre-COVID-19) versus 3/15/2020-12/31/2020 (study period). RESULTS: Despite a 31.4% decrease in total injury-related PED visits from 2019 to 2020, the proportion of injury-related PED visits increased by 8.1% (p<0.001) in 2020. The mean age of patients decreased from 8.3 (SD 5.4) to 7.7 (SD 5.4) years old (p<0.0001), with a higher proportion of female (p=0.0018), privately insured (p=0.0274), and non-Hispanic White children (p<0.001) in 2020. There was a higher proportion of trauma activations, admissions, and injuries caused by intentional self-harm (all p<0.0001). CONCLUSIONS: In RI, the total number of injury-related PED visits decreased while the proportion of injury-related PED visits increased during the COVID-19 pandemic, similar to national trends. There were significant demographic, mechanism, and intent shifts among injured patients, highlighting epidemiologic changes during the pandemic and identifying high-risk groups that would benefit from targeted education and interventions.

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.

Counseling for opioids prescribed at discharge of hospitalized adolescent trauma patients.

BACKGROUND: Expert consensus recommends prescription opioid safety counseling be provided when prescribing an opioid. This may be especially important for youth with preexistent alcohol and other drug (AOD) use who are at higher risk of developing opioid use disorder. This study examined the frequency that adolescent trauma patients prescribed opioids at hospital discharge received counseling and if this differed by adolescents' AOD use. METHOD: This study was embedded within a larger prospective stepped-wedge type III hybrid implementation study of AOD screening across a national cohort of pediatric trauma centers. Data were collected during 2018-2021 from admitted adolescent trauma patients (12-17 yo) at seven centers. Patient data were extracted from the electronic health record (EHR) on any prescribed discharged opioids, documentation of counseling delivered on prescribed opioid, who delivered counseling, and patients' AOD screening results. Additionally, adolescents received an online survey within 30 days of hospital discharge that included asking about hospital discussions on safe use of prescription pain medication. RESULTS: Of the 247 adolescent trauma patients enrolled, 158 completed the 30-day survey. AOD screening results were documented in the EHR for 139 patients (88%), with 69 (44.1%) screening AOD-positive. Opioids at discharge were prescribed to 86 (54.4%) adolescent patients, with no significant difference between those screened AOD-positive and AOD-negative (42.4% vs. 46.3%, p = 0.89). Counseling was documented in the EHR for 30 (34.9%) of those prescribed an opioid and was not significantly different by sex, age, race, ethnicity or between adolescent patients with documentation of AOD use (29.3%) versus those who did not (33.3%, p = 0.71). According to the adolescent survey, among those prescribed an opioid, 61.2% reported someone had talked with them about safe use of newly prescribed pain medications with again no difference between AOD-positive and AOD-negative screening results (p = 0.34). CONCLUSIONS: Although adolescent trauma patients recalled discussions on safe use of prescribed pain medication more often than was documented in the EHR, these discussions were not universal and did not differ if adolescents had screened positive or negative for AOD use as documented in the EHR. TRIAL REGISTRY: clinicaltrials.gov NCT03297060.

A Case of Child Abuse Presenting With a Traumatic Chylothorax.

Chylothorax is a rare cause of pleural effusion in young children and may result from congenital lymphatic abnormalities, trauma, tumors, and systemic infections. Here we discuss a case of a previously healthy toddler who presented to the emergency department with fever and refusal to walk and subsequently developed respiratory distress with concern for impending respiratory failure. A large right sided pleural effusion was identified and ultimately determined to be consistent with chylothorax secondary to inflicted trauma.

Variability in firearm injury among major pediatric trauma centers across the USA.

Objectives: In 2020, firearm injuries surpassed automobile collisions as the leading cause of death in US children. Annual automobile fatalities have decreased during 40 years through a multipronged approach. To develop similarly targeted public health interventions to reduce firearm fatalities, there is a critical need to first characterize firearm injuries and their outcomes at a granular level. We sought to compare firearm injuries, outcomes, and types of shooters at trauma centers in four pediatric health systems across the USA. Methods: We retrospectively extracted data from each institution's trauma registry, paper and electronic health records. Study included all patients less than 19 years of age with a firearm injury between 2003 and 2018. Variables collected included demographics, intent, resources used, and emergency department and hospital disposition. Descriptive statistics were reported using medians and IQRs for continuous data and counts with percentages for categorical data. χ2 test or Fisher's exact test was conducted for categorical comparisons. Results: Our cohort (n=1008, median age 14 years) was predominantly black and male. During the study period, there was an overall increase in firearm injuries, driven primarily by increases in the South (S) site (ß=0.11 (SE 0.02), p=<0.001) in the setting of stable rates in the West and decreasing rates in the Northeast and Mid-Atlantic sites (ß=-0.15 (SE 0.04), p=0.002; ß=-0.19 (SE0.04), p=0.001). Child age, race, insurance type, resource use, injury type, and shooter type all varied by regional site. Conclusion: The incidence of firearm-related injuries seen at four sites during 15 years varied by site and region. The overall increase in firearm injuries was predominantly driven by the S site, where injuries were more often unintentional. This highlights the need for region-specific data to allow for the development of targeted interventions to impact the burden of injury.Level of Evidence: II, retrospective study.

Developing and Implementing Electronic Consent Procedures in Response to Covid-19 Restrictions.

The Covid-19 pandemic resulted in unprecedented restrictions on many public, private, and workplace activities throughout the United States and elsewhere. When restrictions were imposed, we were conducting a type III hybrid effectiveness-implementation trial in 10 pediatric trauma centers. In response to several pandemic-based restrictions, we had to develop procedures for engaging with potential research participants while limiting nonclinical, in-person interactions. This manuscript describes the procedures and challenges of obtaining electronic informed consent and assent in a multisite trauma center-based research study. We developed, tested, and trained staff to implement three options for obtaining informed consent. Twenty-five participants were enrolled in the effectiveness-implementation multisite trial during the first six months of utilization of the consent options, with eleven of these individuals enrolled using hybrid or electronic consent procedures. The challenges we identified involving electronic consent procedures included confusion over who would complete the electronic consent process and difficulties reconnecting with families. Lessons learned can strengthen electronic consent and assent procedures for future studies. More research is needed to further strengthen this process and increase its utilization.

Variability in opioid pain medication prescribing for adolescent trauma patients in a sample of US pediatric trauma centers.

Objectives: The primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge. Methods: This was a retrospective observational study using electronic health records of injured adolescents (12-17 years) admitted to one of 10 pediatric trauma centers. Results: Of the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%-72%). There was no association between patient factors and frequency of prescribing opioids. Center's trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative patients (53.5%). Conclusions: Across a sample of 10 pediatric trauma centers, just over half of adolescent trauma patients received an opioid prescription at discharge. Prescribing rates were similar for adolescent patients screening positive for AOD use and those screening negative. The only factor associated with a higher frequency of prescribing was trauma center volume. Consensus and dissemination of outpatient pain management best practices for adolescent trauma patients is warranted. Level of evidence: III-prognostic. Trial registration number: NCT03297060.

Neonate with Seizures After Consuming Star Anise Tea.

Chinese Star Anise (Illicium verum) is a common spice used in many cultures as an herbal treatment for infant colic.1,2 Often, it has been found to be contaminated with Japanese Star Anise (Illicium anisatum) or is used in high doses resulting in neurotoxicity and gastrointestinal disturbances.1,3,4 Here we present a case of a previously healthy 2-week-old male who was evaluated in the emergency department for abnormal movements, irritability, and emesis after ingestion of star anise tea for the treatment of colic.

Pediatric Rib Fractures Identified by Chest Radiograph: A Comparison Between Accidental and Nonaccidental Trauma.

OBJECTIVE: The objective of this study was to determine the prevalence of rib fractures (RFs) identified by chest x-ray (CXR) among children younger than 2 years who sustained accidental versus nonaccidental injuries. It is hypothesized that RFs are uncommon among all accidental pediatric trauma mechanisms (eg, falls, motor vehicle crashes) as compared with the prevalence of RFs in the setting of nonaccidental trauma (NAT). METHODS: A retrospective chart review of sequential CXRs of children younger than 2 years evaluated at a pediatric level 1 trauma center for accidental trauma and possible NAT was conducted from January 1, 2011, to October 31, 2016. Data collected included demographics, CXR indication and findings, history of cardiopulmonary resuscitation, trauma mechanism, associated injuries, final diagnoses, and outcomes. RESULTS: Two (<1%) of 226 CXRs obtained to evaluate accidental trauma demonstrated acute RFs. Ten (19.6%) of 51 CXRs obtained in the setting of concern for NAT revealed RFs (9/10 identified only healing RFs and 1/10 identified acute RFs). Among patients with a final diagnosis of NAT (ie, not neglect, accidental trauma, etc; n = 38), the overall prevalence increased to 26.3%. CONCLUSIONS: The presence of RFs in pediatric accidental trauma is uncommon even in the setting of high-force mechanisms, and when identified, these RFs are acute. Comparatively, the overall prevalence of RFs identified on CXR among cases with a final diagnosis of NAT was much higher and almost exclusively healing RFs. These data provide support that identification of RFs is highly concerning for NAT even if an accidental mechanism is provided. When RFs are identified, a full NAT work-up should be considered.

The Prevalence of Rib Fractures Incidentally Identified by Chest Radiograph among Infants and Toddlers.

OBJECTIVES: To determine the prevalence of incidental rib fractures identified by chest radiograph (CXR) obtained for indications unrelated to accidental trauma or nonaccidental trauma (NAT), and describe the histories associated with cases of incidental rib fractures and their proposed etiologies. It is hypothesized that incidental rib fractures are rare and alternative explanations for rib fractures occasionally used in a medico-legal context such as minor accidental trauma, undiagnosed medical conditions, and transient metabolic bone disturbances are unlikely to be the etiology of incidental rib fractures. STUDY DESIGN: A retrospective chart review of sequential CXRs of children ages 0 to <2 years was conducted from January 1, 2011 to October 31, 2016. CXRs were obtained in the emergency department, general pediatric or intensive care units, or outpatient pediatric clinics. Data collected included demographics, CXR indication and findings, history of cardiopulmonary resuscitation, laboratory and additional imaging results, and incidental rib fracture descriptions and proposed etiologies. RESULTS: A total of 7530 patients underwent 9720 CXRs associated with unique clinical encounters. Five CXRs had incidental rib fractures identified, making the prevalence of CXRs with incidental rib fractures in this cohort <0.1%. Of 5 identified incidental cases, mean age was 3.6 months, 3 were concerning for NAT, 1 was confirmed NAT, and 1 had radiographic findings consistent with osteopenia of prematurity. CONCLUSIONS: Identification of incidental rib fracture on CXR is rare. When detected in the absence of corresponding trauma history and/or objective laboratory or radiographic metabolic abnormalities, work-up for NAT should be pursued.

The Inverse Relationship between Digital Media Exposure and Childhood Flourishing.

OBJECTIVE: To describe the relationship between digital media exposure (DME) and parental perception of childhood flourishing, or overall positive well-being. It is hypothesized that there is an inverse association between parent-reported measures of childhood flourishing and increasing daily DME. STUDY DESIGN: Parental responses for children ages 6-17 years (N = 64 464) from the 2011-2012 National Survey of Children's Health were analyzed. Average weekday DME that was not school work related was categorized in 2-hour intervals: 0 to <2, 2 to < 4, 4 to < 6, and ≥6 hours. Bivariate analyses and logistic regression models were used to examine the relationship between DME and parent-reported frequency of 5 childhood flourishing markers: completing homework, caring about academics, finishing tasks, staying calm when challenged, and showing interest in learning. RESULTS: Only 31% reported <2 hours of weekday DME. For the remaining children, daily DME was 2 to <4 hours (36%), 4 to <6 hours (17%), or ≥6 hours (17%). In a model adjusted for age, sex, race, poverty level, primary language spoken at home, and highest maternal education level, there was a dose-dependent decrease in the odds of demonstrating all 5 markers of flourishing as weekday DME increased (test for trend for each outcome P < .001). In stratified analyses, this relationship held true regardless of the child's age group, sex, or poverty level. CONCLUSION: This study provides evidence that, among school-aged children, increasing weekday DME has an inverse dose-dependent relationship with multiple childhood flourishing markers.

Having a Regular Primary Care Provider Is Associated With Improved Markers of Well-Being Among Children With Attention-Deficit Hyperactivity Disorder.

We examined the association between having a regular primary care physician (PCP) and measures of flourishing and academic success in children with attention-deficit hyperactivity disorder (ADHD). We performed a cross-sectional study using data from the 2011-2012 National Survey of Children's Health. Children aged 6 to 17 years with a diagnosis of ADHD were included in the study (n = 8173). The exposure was whether the guardian identified a regular PCP for their child. The outcomes were parental-reported measures of child well-being and academic performance. Among the study population, 8.9% reported no regular PCP. These children were found to be significantly less likely to finish assigned tasks (adjusted odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.35-0.79), care about school (adjusted OR = 0.62, 95% CI = 0.38-0.92), and finish homework (adjusted OR = 0.58, 95% CI = 0.36-0.88). There were no differences in other examined outcomes. Enhancing longitudinal care for this population may optimize their academic performance.

Substance use patterns and in-hospital care of adolescents and young adults attending music concerts.

BACKGROUND: Few studies describe medical complaints and substance use patterns related to attending music concerts. As such, the objective of this study is to describe patient demographics, substance use and intoxication patterns, and medical interventions provided to adolescents and young adults assessed in an emergency department (ED) for complaints directly related to concert attendance. METHODS: A retrospective chart review of patients 13-30 years old who were transported to the ED directly from music concerts between January 2011 and December 2015 was conducted. Descriptive statistics and logistic regression were used to analyze patient demographic, intervention, and substance use data. RESULTS: There were 115 concerts identified, of which 48 (42%) were linked to 142 relevant ED visits; the total number of attendees at each concert is unknown. The mean age of the 142 described patients was 19.5 years (SD 3.3) with 72% < 21 and 33% < 18; 71% of patients were female and 96% of visits were substance-use related. Mean blood alcohol level was 242 mg/dL (range 104-412, SD 70). Glasgow Coma Scale (GCS) scores ranged from 3 to 15, with a mean of 14. Two patients required intubation and 61% of patients received interventions, including medications (47%), intravenous fluids (46%), specialty consultation (20%), restraints (14%), imaging (6%), and laceration repair (3%). Attendance at pop and electronic dance music concerts was associated with the widest ranges of GCS scores (8-15 and 6-14 respectively), mass casualty incident declarations, and among the highest mean blood alcohol levels (246 and 244 mg/dL, respectively). CONCLUSIONS: Substance use is the predominant reason for music concert related ED visits and patients may have serious levels of intoxication, receiving multiple medical interventions. These data demonstrate the need for additional large-scale studies to confirm trends and increase awareness of this important public health problem.

Management of acute pediatric pain in the emergency department.

PURPOSE OF REVIEW: This article provides a summary of recommendations for the multimodal and multidisciplinary approach to acute pediatric pain management and highlights recent research on this topic. RECENT FINDINGS: Recent literature has focused on updating recommendations for the use of various analgesics in the pediatric population. While codeine is no longer recommended due to increasing evidence of adverse effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified providers in the acute pediatric pain setting continues to grow. SUMMARY: The pediatric emergency medicine provider should be able to assess pain and develop individualized pain plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most recent literature and changes in recommendations for various pain medications is essential.

A systematic approach to the evaluation of acute unexplained crying in infants in the emergency department.

Crying is a common behavior of infancy that can be a signal of a broad spectrum of conditions ranging from the normal needs of hunger and sleep to significant medical or surgical pathology. In the medical setting, crying is often seen in concert with other signifiers of disease or distress, such as fever, vomiting, rash, or trauma. However, challenges in evaluation of infants may arise when crying is the only sign. A thorough, systematic, and appropriate history and physical examination are needed. Additionally, a broad range of medical possibilities coupled with caregiver concern need to be considered to ensure proper evaluation. In this issue, we will review crying as a chief complaint in the emergency department setting and provide a systematic and practical approach to the evaluation of crying infants.