Search

Background Diagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting. Objectives To assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems. Design/methods Retrospective single-centre cohort study of children ages 0-22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems. Results An e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen's K=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital's incident reporting system and five to the ED case review team (one reported to both). Conclusion An e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs. [ABSTRACT FROM AUTHOR]

Background Blunt head injury is a common pediatric injury and often evaluated in general emergency departments. It estimated that 50% of children will undergo a head computed tomography (CT), often unnecessarily exposing the child to ionizing radiation. Pediatric academic centers have shown quality improvement (QI) measures can reduce head CT rates within their emergency departments. We aimed to reduce head CT utilization at a rural community emergency department. Methods Children presenting with a complaint of blunt head injury and were evaluated with or without a head CT. Head CT rate was the primary outcome. We developed a series of interventions and presented these to the general emergency department over the duration of the study. The pre and intervention data was analysed with control charts. Results The preintervention and intervention groups consisted of 576 children: 237 patients with a median age of 8.0 years and 339 patients with a median age of 9.00 years (p=0.54), respectively. The preintervention HCT rate was 41.8% (95% CI 35.6% to 48.1%) and the postintervention rate was 27.7% (95% CI 23.3% to 32.7%), a decrease of 14.1% (95% CI 6.2% to 21.9%, p=0.0004). During the intervention period, there was a decrease in HCT rate of one per month (OR 0.96, 95% CI 0.92 to 1.00, p=0.07). The initial series of interventions demonstrated an incremental decrease in HCT rates corresponding with a special cause variation. Conclusion The series of interventions dispersed over the intervention period was an effective methodology and successfully reduced HCT utilisation among children with blunt head injury at a rural community emergency department. [ABSTRACT FROM AUTHOR]

Objective To assess quality of care for children presenting with acute abdominal pain using validated indicators. Design Audit of care quality for acute abdominal pain according to 21 care quality indicators developed and validated in four stages. Setting and participants Medical records of children aged 1-15 years receiving care in 2012-2013 were sampled from 57 general practitioners, 34 emergency departments (ED) and 28 hospitals across three Australian states; 6689 medical records were screened for visits for acute abdominal pain and audited by trained paediatric nurses. Outcome measures Adherence to 21 care quality indicators and three bundles of indicators: bundle AHistory; bundle B-Examination; bundle C- Imaging. Results Five hundred and fourteen children had 696 visits for acute abdominal pain and adherence was assessed for 9785 individual indicators. The overall adherence was 69.9% (95% CI 64.8% to 74.6%). Adherence to individual indicators ranged from 21.6% for assessment of dehydration to 91.4% for appropriate ordering of imaging. Adherence was low for bundle AHistory (29.4%) and bundle B- Examination (10.2%), and high for bundle C- Imaging (91.4%). Adherence to the 21 indicators overall was significantly lower in general practice (62.7%, 95% CI 57.0% to 68.1%) compared with ED (86.0%, 95% CI 83.4% to 88.4%; p<0.0001) and hospital inpatient settings (87.9%, 95% CI 83.1% to 91.8%; p<0.0001). Conclusions There was considerable variation in care quality for indicator bundles and care settings. Future work should explore how validated care quality indicator assessments can be embedded into clinical workflows to support continuous care quality improvement. [ABSTRACT FROM AUTHOR]

Background Survivors of critical illness in childhood commonly display subsequent psychiatric symptoms including emotional and behavioural difficulties, and manifestations of post-traumatic stress disorder (PTSD). Anomalies in inflammatory profiles are an established finding in these childhood psychiatric conditions. Objective This exploratory study aimed to investigate whether abnormal peripheral blood inflammatory markers measured during paediatric intensive care unit (PICU) admission were associated with psychiatric symptoms after discharge. Methods We performed a prospective observational cohort study on 71 children with septic illness, meningoencephalitis and other critical disorders admitted to two PICUs between 2007 and 2010. 3--6 months following discharge, subjects were assessed for global psychiatric risk (ie, presence of emotional and behavioural difficulties on the parental Strengths and Difficulties Questionnaire (SDQ)), and for PTSD risk using the child-rated Impact of Events Scale (IES-8). Inflammatory and related biological markers were transcribed from PICU admission notes (white cell count, lymphocytes, neutrophils, C reactive protein (CRP), platelets, fibrinogen and lactate). Findings Global psychiatric risk at follow-up was associated with abnormal lymphocyte count during admission (χ²=6.757, p=0.014, n=48). In children with sepsis, partial correlation analyses controlling for age and gender highlighted associations between (i) SDQ scores and low lymphocyte count (r=-0.712; p=0.009, n=14), and (ii) IES-8 score and high CRP levels (r=0.823; p=0.006, n=11). These associations remained after correction for multiple comparisons. conclusion These results support the hypothesis that acute inflammation may play a role in determining the development of psychopathology following PICU admission. Clinical implications If the findings are replicated, they may help to better highlight which children are at risk of post-PICU psychopathology and appropriately target follow-up. [ABSTRACT FROM AUTHOR]

Importance Suicide is a leading cause of death among youths. The relationship between mental health, psychosocial factors and youth suicidality needs further analysis. Objective To describe paediatric suicide in the USA and the impact of mental health and substance abuse using the National Child Death Review Case Reporting System (CDR-CRS). To identify psychosocial correlates contributing to suicide and whether these factors are more common among individuals with history of menta illness or substance abuse. Design Deidentified data (CDR-CRS) from 2004 to 2012 was obtained from 29 participating states. Demographic data and psychosocial correlates, including age, gender, cause of death, history of mental illness and/or substance abuse, school concerns, previous suicide attempts and family history of suicide, were collected. Results A total of 2850 suicides were identified. Mean age was 15.6±1.9 years; (range 7-21 years) 73.6% male and 65.1% Caucasian. The leading causes of death were asphyxia (50.2%) and weapon/firearm (36.5%). Among all subjects, 25.5% had history of mental illness and 19.0% had history of substance abuse. 60.0% had no report of mental illness or substance abuse. Subjects with both mental illness and substance abuse were more likely to have school concerns (OR=4.1 (p<0.001)), previous suicide attempts (OR=4.2 (p<0.001)) and a family history of suicide (OR=3.2 (p<0.001)) compared with subjects without those characteristics. Conclusions Most suicide records in the CDR-CRS had no indication of mental illness or substance abuse. The youth with mental-illness/substance-abuse issues were more likely to have other compounding psychosocial correlates that may be warning signs of suicide. [ABSTRACT FROM AUTHOR]

Background Drowning is the second leading cause of unintentional injury death among US children. Multiple studies describe decreased drowning risk among children possessing some swim skills. Current surveillance for this protective factor is self/proxy-reported swim skill rather than observed inwater performance; however, children's self-report or parents' proxy report of swim skill has not been validated. This is the first US study to evaluate whether children or parents can validly report a child's swim skill. It also explores which swim skill survey measure(s) correlate with children's inwater swim performance. Methods For this cross-sectional convenience-based sample, pilot study, child/parent dyads (N=482) were recruited at three outdoor public pools in Washington State. Agreement between measures of self-reports and parental-reports of children's swim skill was assessed via paired analyses, and validated by inwater swim test results. Results Participants were representative of pool's patrons (ie, non-Hispanic White, highly educated, high income). There was agreement in child/parent dyads' reports of the following child swim skill measures: 'ever taken swim lessons', perceived 'good swim skills' and 'comfort in water over head'. Correlation analyses suggest that reported 'good swim skills' was the best survey measure to assess a child's swim skill--best if the parent was the informant (r=0.25-0.47). History of swim lessons was not significantly correlated with passing the swim test. Conclusions Reported 'good swim skills' was most correlated with observed swim skill. Reporting 'yes' to 'ever taken swim lessons' did not correlate with swim skill. While non-generalisable, findings can help inform future studies. [ABSTRACT FROM AUTHOR]

Background Several studies have suggested potential links of phthalates to obesity in children and adults. Limited evidence, however, has been available for the relations between diethylhexyl phthalate (DEHP) and obesity-related markers or body mass change in early life. Methods 128 healthy pregnant women were recruited and, after delivery, their newborns' first urine and umbilical cord blood samples were collected. We measured urinary levels of two DEHP metabolites, mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) and mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP). We also measured the levels of leptin, total cholesterol and triglyceride (TG) in cord serum, and used them along with weight, length, head circumference and ponderal index (PI, 100 g/cm³) at birth, as obesity-related markers, and estimated the relations between DEHP metabolites and obesity-related markers using generalised linear models. For the evaluation of body mass increase by early life DEHP exposure, body mass index (BMI) z-score change during 3 months after birth by DEHP metabolites in the first urine samples of the newborns were evaluated using logistic regression. Results DEHP exposure was associated with decrease of PI and increase of TG (PI, p=-0.11, p=0.070 and TG, β=0.14, p=0.027), especially for boys (PI, β= -0.13, p=0.021; and TG, β=0.19, p=0.025). Moreover, DEHP exposure was positively associated with body mass increase during 3 months after birth (change of BMI z-scores, OR=4.35, p=0.025). Conclusions Our findings suggest that DEHP exposure may affect body mass change in early life through changes of obesity-related markers. [ABSTRACT FROM AUTHOR]

Background Differences in cognitive development have been observed across a variety of ethnic minority groups but relatively little is known about the persistence of these developmental inequalities over time or generations. Methods A repeat cross-sectional analysis assessed cognitive ability scores of children aged 3, 5 and 7 years from the longitudinal UK Millennium Cohort Study (white UK born n=7630; Indian n=248; Pakistani n=328; Bangladeshi n=87; black Caribbean n=172; and black African n=136). Linear regression estimated ethnic differences in age normed scores at each time point. Multivariable logistic regression estimated within-group generational differences in test scores at each age adjusting stepwise for sociodemographic factors, maternal health behaviours, indicators of the home learning environment and parenting styles. Results The majority of ethnic minority groups scored lower than the white UK born reference group at 3 years with these differences narrowing incrementally at ages 5 and 7 years. However, the black Caribbean group scored significantly lower than the white UK born reference group throughout early childhood. At 3 years, Pakistani, black Caribbean and black African children with UK born mothers had significantly higher test scores than those with foreign born mothers after baseline adjustment for maternal age and child gender. Controlling for social, behavioural and parenting factors attenuated this generational advantage. By 7 years there were no significant generational differences in baseline models. Conclusions Ethnic differences in cognitive development diminish throughout childhood for the majority of groups. Cumulative exposure to the UK environment may be associated with higher cognitive development scores. [ABSTRACT FROM AUTHOR]

Background Childhood falls are an important global public health problem, but there is lack of evidence about their prevention. Falls on one level result in considerable morbidity and they are costly to health services. Objective To estimate ORs for falls on one level in children aged 0-4 years for a range of safety behaviours, safety equipment use and home hazards. Design, setting and participants Multicentre case-control study at hospitals, minor injury units and general practices in and around four UK study centres. Participants included 582 children less than 5 years of age with a medically attended fall injury occurring at home and 2460 controls matched on age, sex, calendar time and study centre. Main outcome measure Fall on one level. Results Cases' most common injuries were bangs on the head (52%), cuts or grazes not needing stitches (29%) or cuts or grazes needing stitches (17%). Comparing cases to community controls in the adjusted analyses, significant findings were observed for only two exposures. Injured children were significantly less likely to live in a household without furniture corner covers (adjusted OR (AOR) 0.72, 95% CI 0.55 to 0.95), or without rugs and carpets firmly fixed to the floor (AOR 0.76, 95% CI 0.59 to 0.98). Conclusions We did not find any safety practices, use of safety equipment or home hazards associated with a reduced risk of fall on one level. Our findings do not provide evidence to support changes to current injury prevention practice. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to compare parents' expectations for their children crossing streets' with children s actual crossing behaviours and determine how accurately parents judge their own children's pedestrian behaviours to be. Method Using a fully immersive virtual reality system interfaced with a 3D movement measurement system, younger (7-9 years) and older (10-12 years) children's crossing behaviours were assessed. The parent viewed the same traffic conditions and indicated if their child would cross and how successful she/he expected the child would be when doing so. Results Comparing children's performance with what their parents expected they would do revealed that parents significantly overestimated the inter-vehicle gap threshold of their children, erroneously assuming that children would show safer pedestrian behaviours and select larger inter-vehicle gaps to cross into than they actually did; there were no effects of child age or sex. Child and parent scores were not correlated and a logistic regression indicated these were independent of one another. Conclusions Parents were not accurate in estimating the traffic conditions under which their children would try and cross the street. If parents are not adequately supervising when children cross streets, they may be placing their children at risk of pedestrian injury because they are assuming their children will select larger (safer) inter-vehicle gaps when crossing than children actually do. [ABSTRACT FROM AUTHOR]

Background Breastfeeding has been related to better cognitive development in children. However, due to methodological challenges, such as confounding, recall bias or insufficient power, the mechanism and nature of the relation remains subject to debate. Methods We included 3761 participants of a population-based cohort study from fetal life onwards and examined the association of breastfeeding duration with non-verbal intelligence in children of age 6 years. Maternal and paternal lifestyle, sociodemographic factors, child factors and maternal IQ were tested for their confounding effects on the association. Results We observed an initial association between breastfeeding duration and child IQ conferring an advantage of 0.32 (0.20 to 0.44) points for each additional month of breastfeeding. This association strongly attenuated to 0.09 (-0.03 to 0.21) points after adjustment for child factors, sociodemographic factors, parental lifestyle factors and maternal IQ. Similarly, the associations with breastfeeding duration as a categorical variable largely disappeared after confounding factors were added to the models. Conclusions The association between breastfeeding and child IQ can be largely explained by sociodemographic factors, parental lifestyle and maternal IQ. Our results cannot confirm beneficial effects of breastfeeding on child intelligence. [ABSTRACT FROM AUTHOR]

The article discusses a study which discusses the health risk associated with socioeconomic inequalities among Colombian children. Topics discussed include the association of low socioeconomic status (SES) with higher risk of cardiometabolic diseases in developed societies, the positive association of SES with obesity, and how SES is linked with abdominal adiposity.

Objective Assess the association between caregiver supervision and acute unintentional injury in young children; evaluate whether lower levels of supervision result in more severe injury. Methods A case cross-over study was conducted. Parents of children aged ≤4 years whose injuries required emergency department (ED sample) treatment or admission to the hospital (inpatient sample) were interviewed. Information on supervision (3 dimensions: proximity, attention, continuity) at the time of injury and 1 h before the injury (control time) was collected. An overall supervision score was created; a higher score indicates closer supervision. Hospital admission served as a proxy for injury severity. ORs and 95% CIs were calculated. Results Interviews were completed by 222 participants; 50 (23%) were in the inpatient sample. For each supervision dimension the inpatient sample had higher odds of injury, indicating effect modification requiring separate analyses for inpatient and ED samples. For both samples, proximity ‘beyond reach' was associated with the highest odds of injury; compared with 1 h before injury, children were more likely to be beyond reach of their caregiver at the time of injury (inpatient sample: OR 11.5, 95% CI 2.7 to 48.8; ED sample: OR 2.9, 95% CI 1.8 to 4.9). Children with lower supervision scores had the greatest odds of injury (inpatient sample: OR 8.0, 95% CI 2.4 to 26.6; ED sample: OR 3.3, 95% CI 1.9 to 5.6). Conclusions Lower levels of adult supervision are associated with higher odds of more severe injury in young children. Proximity is the most important supervision dimension for reducing injury risk. [ABSTRACT FROM AUTHOR]

Background SwimSafe, a basic swimming and safer rescue curriculum, has been taught to large numbers of Bangladeshi children since 2006. This study examines the frequency and characteristics of rescues reported by children who graduated from SwimSafe and compares them with age-matched and sex-matched children who did not participate in SwimSafe. Methods Interviews were conducted during the swimming season in Raiganj, Bangladesh. Data were collected from 3890 SwimSafe graduates aged 6-14. Two age-matched and sex-matched controls were selected; one who had learned to swim naturally, the other who had not learned to swim. Results 188 rescues were reported by the three groups. The 12-14-year age groups reported the highest monthly rate of rescues (SwimSafe 10.5/100 000 (95% CI 3.4 to 24.5), natural swimmers 8.5/100 000 (95% CI 2.2 to 21.2)) and annual rate of rescue reported (SwimSafe 25.4/100 000 (95% CI 13.2 to 43.9), natural swimmers 35.4/100 000 (20.8 to 56.2)). Reported rescue numbers among both swimming groups was similar. Mean victim age was 4.1 years and 92.5% were under 7 years. All victims were younger than their rescuer (mean 5.9 years less). Most rescues (73.7%) took place in ponds or ditches with most (86.6%) within 10 m of the bank. Most victims had entered the water to bathe (53.8%). A large majority of reported rescues (90.9%) were conducted with the rescuer in the water, half requiring the rescuer to swim. Conclusions Children report frequent drowning rescues of younger children in rural Bangladesh. Most reported are contact rescues with the rescuer in the water. Formal training for in-water rescue techniques may be needed to reduce the risk to the child rescuer. [ABSTRACT FROM AUTHOR]

Background Tobacco smoke pollution (TSP) has major negative effects on infant health. Our objectives were to determine the effectiveness of a brief primary care intervention directed at parents who smoke in reducing babies’ TSP exposure, and to establish variables related to greater exposure. Method A multicentre, open, cluster-randomised clinical trial in Catalonia. The 83 participating primary health paediatric teams of the Catalan Health Service recruited 1101 babies whose parents were smokers. The intervention group (IG) received a brief TSP intervention; the control group (CG) received the usual care. Outcomes were measured by parents’ reported strategies to avoid TSP exposure. Baseline clinical data and characteristics of each baby’s TSP exposure were collected, along with infant hair samples and parents’ tobacco use and related attitudes/behaviours. At 3-month and 6-month follow-up, behavioural changes to avoid TSP exposure were recorded; the association between reported parental behaviours and nicotine concentration in infant hair samples was tested in a random sample of 253 babies at baseline and 6 months. Results During follow-up, TSP-avoidance strategies improved more in the IG than in the CG: 35.4% and 26.9% ( p=0.006) at home, and 62.2% and 53.1% in cars (p=0.008). Logistic regression showed adjusted ORs for appropriate measures in the IG versus CG of 1.59 (95% CI 1.21 to 2.09) at home and 1.30 (95% CI 0.97 to 1.75) in cars. Hair samples showed that 78.7% of the babies tested were exposed. Reduced nicotine concentration was associated with improved implementation of effective strategies reported by parents at home (p=0.029) and in cars (p=0.014). Conclusions The intervention produced behavioural changes to avoid TSP exposure in babies. The proportion of babies with nicotine (>=1ng/mg) in hair samples at baseline is a concern. [ABSTRACT FROM AUTHOR]

Background. Much of the research on child injury risk has focused on trait-like factors (eg, hyperactivity, child gender) that influence injury risk rather than state-like factors (eg, environmental circumstances, child behaviour). Additional research is needed to better identify the proximal risk factors for children’s risk for unintentional injury. Objectives. The present study examined the antecedents to minor unintentional injury events and whether unusual circumstances and child behaviour predicted injury risk. Methods. The study used archival data that were collected via biweekly in-person interviews with 170 mothers of toddlers (15–36 months) for 6 months. A case crossover design was used to predict children’s risk for injury from proximal risk factors. Results. Children were at a higher risk for injury when circumstances were unusual and when they were engaging in an unusual behaviour. When a child was engaging in an unusual behaviour, higher levels of maternal supervision predicted lower injury risk. Children were more likely to be injured in a new environment, in an environment with animals or other people, in an environment with hazards or when engaging in a new activity or in a familiar activity performed in an unfamiliar way. Conclusions. The results indicate that toddlers may be at a greater risk for minor unintentional injury when environmental circumstances are outside of the norm or when a child is engaging in unusual behaviours. The findings also indicate that higher levels of caregiver supervision may be especially beneficial when children are engaging in new or unfamiliar activities. [ABSTRACT FROM AUTHOR]

The authors discuss the implications for practice and research of a study regarding the efficacy of topical lidocaine-epinephrine-tetracaine (LET) in reducing pain during laceration repair with tissue adhesive in children. They reveal the lesser pain experienced by children who received LET before wound closure than those who received the placebo. They also note the benefits of using LET in terms of pain reduction as well as better haemostasis during wound closure.