Shaken baby syndrome: pathogenetic mechanism, clinical features and preventive aspects.

The shaken baby syndrome (SBS) is an extremely serious form of child abuse and a leading cause of death and disability in childhood. The syndrome usually occurs in infants younger than 1 year when a parent or a care-giver tries to stop the baby from crying by vigorous manual shaking. The repetitive oscillations with rotational acceleration of the head can result in injuries of both vascular and neuronal structures. The most frequent injuries associated with SBS include encephalopathy, retinal hemorrhages, and subdural hemorrhage. Fractures of the vertebrae, long bones, and ribs may also be associated with the syndrome. Victims of abuse have various presenting signs and symptoms ranging from irritability, decreased responsiveness and lethargy to convulsions, and death. Diagnosis is often difficult because usually parents or caregivers not tell the truth about what has happened to their child and because usually there is no external evidence of trauma. However, the syndrome might be suspected if the information provided are vague or changing and when the child presents with retinal hemorrhages, subdural hematoma, or fractures that cannot be explained by accidental trauma or other medical conditions. Of infants who are victims of SBS, approximately 15% to 38% die and 30% are at risk of long-term neurologic sequelae, including cognitive and behavioural disturbances, motor and visual deficits, learning deficits and epilepsy. Parents and caregivers must be warned about the dangers of shaking infants.

Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial.

BACKGROUND: The proposed introduction of the CAB (circulation, airway, breathing) sequence for cardiopulmonary resuscitation has raised some perplexity within the pediatric community. We designed a randomized trial intended to verify if and how much timing of intervention in pediatric cardiopulmonary resuscitation is affected by the use of the CAB vs. the ABC (airway, breathing, circulation) sequence. PATIENTS AND METHODS: 340 volunteers, paired into 170 two-person teams, performed 2-rescuer healthcare provider BLS with both a CAB and ABC sequence. Their performances were audio-video recorded and times of intervention in the two scenarios, cardiac and respiratory arrest, were monitored. RESULTS: The CAB sequence compared to ABC prompts quicker recognition of respiratory (CAB vs. ABC=17.48 ± 2.19 vs. 19.17 ± 2.38s; p<0.05) or cardiac arrest (CAB vs. ABC=17.48 ± 2.19 vs. 41.67 ± 4.95; p<0.05) and faster start of ventilatory maneuvers (CAB vs. ABC=19.13 ± 1.47s vs. 22.66 ± 3.07; p<0.05) or chest compressions (CAB vs. ABC=19.27 ± 2.64 vs. 43.40 ± 5.036; p<0.05). CONCLUSIONS: Compared to ABC the CAB sequence prompts shorter time of intervention both in diagnosing respiratory or cardiac arrest and in starting ventilation or chest compression. However, this does not necessarily entail prompter resumption of spontaneous circulation and significant reduction of neurological sequelae, an issue that requires further studies.

[Short-stay observation in the Pediatric Emergency Room: a 2003-1993 comparison]. / L'osservazione temporanea in Pronto Soccorso pediatrico. Confronto 2003-1993.

AIM: To evaluate the effectiveness of Short-Stay Observation (SSO) in the paediatric Emergency Room (ER) according to changes over time of guidelines. METHODS: This retrospective study analyses the probability of discharge immediately from ER or after SSO and of hospital admission in Trieste during 2003 as compared with 1993. Subjects aged under 18 with respiratory, urinary tract, neurological and gastrointestinal pathologies, selected symptoms and injuries were studied. RESULTS: In 2003 the 86.2% of 6 350 patients enrolled in the study were discharged immediately, compared with the 81.7% of 5475 subjects in 1993 (RR 1.05, IC 95% 1.04-1.07), the 10.0% were discharged after SSO, compared with the 5.9% in 1993 (RR 1.71, IC 95% 1.50-1.95). The 3.8% of the subjects were admitted in 2003, compared to the 12.4% in 1993 (RR 0.30, IC 95% 0.26-0.35). The role of SSO was particularly significant in case of pneumonia, URI, urinary tract infections, seizures, gastroenteritis, abdominal pain, infant fever, injuries. CONCLUSIONS: The decrease of hospital admissions, pointed out in 2003, are related to a better choice of candidates for SSO and to changes in guidelines concerning the approach to urinary tract infections and seizures, the treatment of respiratory distress and gastroenteritis dehydration, and the early identification of predictors of injuries complications. The study confirms the effectiveness of SSO in both avoiding inappropriate admissions and reducing those with limited needs of hospital assistance, assuring the quality of care. The reduced hospital stay decreases child and his family discomfort and favours the care continuity due to the involvement of family paediatrician.

Permanent sequelae in sports injuries: a population based study.

AIM: To identify permanent sequelae after sports injuries in children and adolescents. METHODS: In 1985, a prospective register was drawn up of all sports related injuries reported that year by the residents of Trieste, Italy aged 6-15 years. Moderate to severe injuries (scoring >/= 2 on the abbreviated injury scale (AIS)) were the object of a longitudinal clinical study. In 1988, 30.9% of the 220 subjects enrolled had sequelae. A further follow up was undertaken in 1997. RESULTS: The follow up in 1997 involved 54 subjects (26 girls; average age 24.5 years). Subjective and objective sequelae, by now considered to be permanent, were found in 61.1%, corresponding to 15% of the AIS >/= 2 injuries recorded in 1985. The prevalence of sequelae was similar in the two sexes, in relation to the child's age at time of injury, and in the different sports practised. It was higher in relation to the severity of the lesion (89% of AIS 3 injuries examined, 56% of AIS 2 injuries) and to the type of lesion and its location. With regard to AIS >/= 2 injuries, permanent sequelae were found in 50% of ankle fractures, 43% of elbow fractures, 33% of leg/foot fractures, 25% of knee sprains, and 23% of ankle sprains. CONCLUSIONS: The frequency of sequelae in sports injuries in children and adolescents is high. The risk appears to be connected to certain anatomical and functional age characteristics. Prevention strategies should include specific assessment of physical fitness and adequate follow up after the accident, particularly rehabilitation.

Childhood poisoning: a population study in Trieste, Italy, 1975-1994.

We describe the epidemiology of 1918 cases of childhood poisoning referred to the emergency room in Trieste, Italy, from 1975 to 1994. The incidence rate of emergency room referral and subsequent hospitalization was calculated on the basis of the distribution of children resident in Trieste by calendar year. The occurrence of childhood poisoning was described according to time trends, age and gender of the child, route of exposure, symptoms at presentation to the emergency room, role of the child or others, intention, and substance involved in the poisoning. The association between presence of symptoms and characteristics of referral, host factors and substances involved was evaluated by estimating the odds ratio in multivariate models. Possible determinants of the clinical decision to treat certain cases were evaluated using logistic regression. Despite an increasing incidence of referral (from 155 per 100,000 persons per year in 1975-79 to 352 per 100,000 in 1990-94), hospital admission rates showed a two-fold decrease. Younger children (age 0-4 years) were more likely to be asymptomatic and required treatment and hospitalization less often than older children (age > or = 10 years). Trends show a decrease in pharmaceutical poisonings due probably to the introduction of child-resistant containers and an increase in domestic poisons. We also observed a steady increase in carbon monoxide inhalation and alcohol poisonings, mostly among teenagers.

[Evaluation of temporary observation and short hospital stay in a pediatric emergency department]. / Valutazione dell'osservazione temporanea e del ricovero breve in un pronto soccorso pediatrico.

Temporary observation is a very short stay in Emergency Department, widely carried out in adult patients in our Country. No experience in childhood has been reported. In our emergency department children under 16 with acute diseases are admitted for 24-48 hours. From 1991 we carried out also temporary observation. Its effectiveness has been evaluated by studying our activity in 1992 (14.574 emergency room visits, with 664 admissions to our Department and 274 temporary observation) and 1993 (12820 emergency room visits, 573 admissions, 428 temporary observation). Compared to 1992, in 1993 there was a decrease of both emergency room visits (higher than expected from demographic lowering and in part due to payment for emergency room visits) and hospital admissions, and an increase of temporary observation. The stay in hospital was less than 6 hours in 94.2% of temporary observation patients. 18.2% of them were evaluated on clinical basis, 57% also by diagnostic examinations, 24.8% had some treatment. The 89% of the children were sent home following temporary observation, the others were admitted. Criteria for temporary observation were fairly similar to those for hospital admission, but not far as Central Nervous System and Renal Disease are concerned. Our study confirms the usefulness of temporary observation in childhood to reduce both the number of hospital admissions and the discomfort of the patient and his family. Nevertheless there is a need of criteria of appropriateness. Therefore we have elaborated guide lines for temporary observation and admission to our Department.

[Acute cannabis poisoning in a female child]. / Intossicazione acuta da cannabis in una bambina.

Cannabis poisoning is rarely reported in young children. We present the case of a child twenty months old admitted to the Emergency Room because of sopor, hypotonia and miosis. This is the first out of 1150 poisonings under the age of five registered at Trieste between 1975-1992. Cannabis poisoning has to be considered despite its rarity in a child with neurologic symptoms of unknown etiology and acute onset, especially when family behaviour is suspect for toxicomania.

The risk associated with poisonings in children.

The risk associated with poisonings in children was assessed on 6175 subjects admitted to the pediatric hospitals of 3 regions of Northern Italy between 1975 and 1990. The frequency of exposures and the severity of sequelae allowed high- and low-risk substances to be identified. Risks were studied separately in the 0-4, 5-9 and 10-13 y age group to determine age-related differences. A decrease in drug-related poisonings and an increase of those caused by household products, particularly in the first 2 y of life, were observed in 1983-90 as against 1975-82 in association with the introduction of safety caps and containers for drugs. Our study points out the need to strengthen active primary prevention through health education and parental and adolescent information, and to improve passive prevention through the extension of safety closures to household products.

[Approach to acute gastroenteritis in children: comparison over the years]. / Approccio alla gastroenterite acuta nel bambino: confronto negli anni.

Diagnostic and therapeutic approach to children admitted because of acute gastroenteritis has been retrospectively evaluated by auditing the hospital records in two periods respectively before (A: 103 patients) and after (B: 133 patients) the use of oral rehydration solution. Incomplete history taking was found out without differences between the two periods; in many cases the weight loss, one of the main criteria for hospitalization in acute diarrhoea, was not recorded at admission. In period B therapeutic behaviour was adequate to literature guidelines as regards both antibiotic prescription and use of oral rehydration solution. Nevertheless even if oral rehydration was carried out in more than 70% of patients, parenteral fluid administration was not significantly reduced in comparison with period A. Oral rehydration solution contributed to reduce the length of hospital stay in the more recent period. The study confirms the usefulness of medical audit to improve quality care.

[Evaluation of a pediatric emergency room: ten years later]. / Valutazione del ricorso al pronto soccorso pediatrico: 10 anni dopo.

Utilization of the pediatric Emergency Room has been evaluated during the year 1991, by a questionnaire study on 694 children. By comparison with a previous research in 1981 it was possible to identify a further decrease of urgent and appropriate visits with increase of those inappropriate. Visits were more frequently urgent of appropriate in case of acute health problems, inappropriate if related to recurrent problems. Without considering true emergencies, three main causes for ER consultation have been identified: family custom, inappropriate relationships with the practitioner, dependence on the hospital. In the first group of children most of the visits proved inappropriate. The study points out a further increase of inappropriate utilization of ER, due mainly to inappropriate relationships between the family and the practitioner. This has to be corrected to reduce costs and improve child care.

Epidemiology of children poisoning: comparison between telephone inquiries and emergency room visits.

We studied 674 telephone inquiries to the Poison Information Centre and 532 Emergency Room (ER) visits due to suspected poisonings in 1018 children below the age of 16 y and living at Trieste. The cases were prospectively recorded during 1985-1989. Age distribution, toxic substances and consequences were different in the 2 groups. Telephone inquiries concerned children below the age of 5 y more frequently, and most of the exposures were assessed as non-toxic. Among children admitted to the hospital ER, 22.2% were more than 10-y old, and of these 79.7% were confirmed poisonings. This study demonstrated the need to take account of both Poison Control Centre and ER data to get reliable information on the occurrence of poisonings in children.

Evaluation of skin laceration repair by tissue adhesive in the pediatric emergency room.

The effectiveness of skin laceration repair by tissue adhesive has been evaluated, by comparison also with thread suture and steristrip application, in 926 0-15-year-old patients referred to the Emergency Room of our Institute during 1988. Tissue adhesive has been carried out more frequently in younger children and in some wound localizations especially at the face. At follow-up good aesthetic and functional results were observed. The rare complications, being related to incorrect choice of site application, can be avoided by following appropriate directions for use. Considering the compliance of the patients and their family, this non invasive technique of repair seems to be particularly suitable in childhood.

[A multicenter study of child poisonings. Preliminary epidemiological results]. / Studio multicentrico degli avvelenamenti nel bambino (S.M.A.B.). Risultati epidemiologici preliminari.

The project of a multicentre study of poisoning in children planned by 4 Italian pediatric departments to get epidemiologic and clinic information is presented. The study is carried out retrospectively on admissions during 1975-90 and prospectively during 1991-92. Poisonings are classified as not-confirmed, asymptomatic because of early treatment or symptomatic. In the latter group three degrees of severity are assessed. Diagnostic-therapeutic protocols will be elaborated and quality of the hospital care evaluated according to peer review methodology. Preliminary data on changing pattern of poisoning over the time and on main toxic agents involved in younger children are also reported. The first topic has been studied taking into account 1831 patients aged 0-13 years, admitted during 1977-79 and 1987-89. A decrease of exposures to drugs and an increase of poisonings under the age of 3 years have been observed in more recent period. On the other hand household products resulted to be the main poisoning agents in 1044 children under the age of 5 years during 1984-86. Lack of infant supervision by parents and possible influence of compulsory child resistant containers only for drugs are stressed. The findings suggest the need of health education campaigns in general population as well of safety devices for some domestic harmful products.

Evaluation of changing patterns in children poisonings and prevention.

Poisoning prevention strategies have to be modified according to the risk variations with age and time. Epidemiologic surveillance usefulness was confirmed by studying the 0-15 y-old children in the Trieste area from 1976-1987. Significant differences were observed in children under 5 due to an increase in caustic substance and home detergents poisoning and a decrease in analgesic-antipyretics ingestion. This was probably due to the introduction by law in our country of child-resistant containers and to a better awareness by parents. At 10 y-of-age and older, alcohol is the cause of most intoxications and more recently benzodiazepine poisonings have significantly increased. At this age poisoning results from deliberate ingestion in most cases; therefore education should be the main preventive strategy.

[Traffic-related injuries in children at Trieste, 1984-1986]. / Lesioni da traffico nel bambino a Trieste 1984-86.

Traffic-related injuries to children are poorly known in our country, in spite of their role in mortality and morbidity. Being that they are rather different from those reported in the adults, their study is useful in identifying risks and elaborating prevention strategies. This paper reports epidemiologic and clinical data on 1050 children under 16, referred to our hospital because of road traffic accidents. The study has been prospectively carried out during 1984-86; injuries severity was assessed according to the Abbreviated Injury Scale. Incidence rates resulted to increase with the age, highest values being observed for 15 year old children, due to motorcycle use. Patterns and severity of the injuries were significantly different according to the age and the group of injured subjects. Younger children as pedestrians and 14-15 y.o. motorcyclists resulted to be more involved than car passengers and bicyclists. At a telephone inquiry after 6-12 months sequelae resulted in 20-40% out of 482 children, according to different AIS Score.

[The sports, the child and accidents. III. Long-term sequelae]. / Lo sport, il bambino e gli incidenti. Nota III.--Gli esiti a distanza.

Sports-related injuries in children and adolescents are an emergent health problem in our country, because of their incidence and severity. Nevertheless information is lacking on possible long term sequelae. This topic has been studied in 220 out of 1040 6-15 years old children, prospectively registered during 1985 in our hospital because of acute sports injuries. Selection for the follow-up was based on injuries severity, assessed according to the Abbreviated Injury Scale. Subjective and/or objective sequelae have been observed at a clinical control three years after the accident, in 68 out of the 220 controlled children (30.9%). The prevalence of the sequelae was similar in males and females, but quite different according to the age, being higher in children older than 14, the type of sports activity and the site of the injuries, with higher prevalence of those of the ankle and knee rather than of the wrist. Prevention of sports-related injuries and their possible sequelae is well established in Sports Medicine, but not yet fully applied to children. Pediatricians must sensitize the school and sports clubs to the problem.

[Costs and benefits of the use of tissue adhesives in wounds in children]. / Costi e benefici dell'impiego di collante tissutale nelle ferite del bambino.

Costs and benefits of the repair in Emergency Room of skin lacerations by tissue adhesive in children are reported. In 1987-88 2150 children under 16 were referred to our Institute because of lacerations. About one of three of them needed repair by subcutaneous suture; in the others, sutures or sterile stripes or adhesive tissue could be employed. Adhesive tissue use increased significantly during 1988 because of its advantages: no need of local anesthesia, syringes, sterile suture instruments and dressing materials; no further dressing; no suffering of children during the treatment; good aesthetic results. Now it is the first choice treatment of the lacerations in which subcutaneous suture is not necessary. Moreover this technique is cheap, and reduced significantly 1988 costs for laceration repair in our department.

Epidemiology of urinary tract infections and vesico-ureteral reflux in children.

The purpose of this study was to assess the incidence of symptomatic urinary tract infection (U.T.I.) and malformations, such as vesico-ureteral reflux (V.U.R.), in the Trieste area. Data were collected in the framework of a survey based on the application of a protocol on urinary infections between 1979 and 1983. The U.T.I. incidence was found to be 1.38% of the 0-14-year-old residents, with a higher frequency in females (2.36%) than in males (0.46%). As regards V.U.R., the incidence in the population studied turned out to be 0.25%, with a females/males ratio of 4:1. Striking differences in incidence data were observed according to the age of U.T.I. and V.U.R. diagnosis and to the infection level (cystitis or pyelonephritis). The incidence of renal scarring resulted to be extremely low, which can be ascribed to the early diagnosis in our cases.

[Evaluation of the usefulness of the motorcycle helmet in adolescents in Trieste]. / Valutazione dell'efficacia del casco da motociclista nell'adolescente triestino.

The effectiveness of the motorcycle helmet was assessed in 359 accidents involving adolescents under 16 in the Trieste area in 1985-88. Comparison of the 18 months preceding and following the introduction of the law revealed that helmet use significantly reduced the number and gravity (as objectively assessed using the Abbreviated Injury Scale) of cranial and facial injuries but made no significant difference to other areas. The 70-80% reduction in head injuries also significantly reduced the incidence of multiple injuries and hospital admissions. The effectiveness of the helmet demonstrated in this study primarily concerned with motorcycle accidents in urban areas suggests that it should now also be made obligatory for those currently exempt.