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Study objective This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice. Methods This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit. Results In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ. Conclusion Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.

BACKGROUND: Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data. METHODS: We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to RESULTS: In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8). CONCLUSIONS: Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.

Background Febrile infants commonly present to emergency departments for evaluation. Objective We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network. Methods We enrolled a convenience sample of non-critically ill–appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0–28 days of age) and older (29–60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance. Results Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0–28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29–60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%. Conclusions The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29–60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.

Vaso-occlusive pain events (VOE) are the leading cause of emergency department (ED) visits in sickle cell anemia (SCA). This study assessed the variability in use of intravenous fluids (IVFs), and the association of normal saline bolus (NSB), on pain and other clinical outcomes in children with SCA, presenting to pediatric emergency departments (PED) with VOE. Four-hundred charts of children age 3-21 years with SCA/VOE receiving parenteral opioids at 20 high-volume PEDs were evaluated in a retrospective study. Data on type and amount of IVFs used were collected. Patients were divided into two groups: those who received NSB and those who did not. The association of NSB use on change in pain scores and admission rates was evaluated. Among 400 children studied, 261 (65%) received a NSB. Mean age was 13.8 ± 4.9 years; 46% were male; 92% had hemoglobin-SS. The IVFs (bolus and/or maintenance) were used in 84% of patients. Eight different types of IVFs were utilized and IVF volume administered varied widely. Mean triage pain scores were similar between groups, but improvement in pain scores from presentation-to-ED-disposition was smaller in the NSB group (2.2 vs 3.0, P = .03), while admission rates were higher (71% vs 59%, P = .01). Use of NSB remained associated with poorer final pain scores and worse change in pain scores in our multivariable model. In conclusion, wide variations in practice utilizing IVFs are common. NSB is given to >50% of children with SCA/VOE, but is associated with poorer pain control; a controlled prospective trial is needed to determine causality.

The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse.A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs.Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer.A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

Objective: To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. Study design: We reviewed medical records of children 13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. Results: A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children 26%. Conclusions: The HUS severity score was able to discriminate between high- and low-risk children

Background Shiga toxin–producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. Methods We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged Results Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69–.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42–4.54]), higher hematocrit (1.83 [1.21–2.77] per 5% increase) and serum creatinine (10.82 [1.49–78.69] per 1 mg/dL increase), platelet count Conclusions The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.

Importance In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

BACKGROUND: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question screen is a valid adolescent alcohol screening tool. No studies have examined if this tool predicts future alcohol problems. We conducted a study at 16 pediatric emergency departments to determine the tool’s predictive validity for alcohol misuse and alcohol use disorders (AUDs). METHODS: Participants (N = 4834) completed a baseline assessment battery. A subsample of participants completed the battery at 1, 2, and 3 years follow up. RESULTS: Of the 2209 participants assigned to follow-up, 1611 (73%) completed a 1-year follow-up, 1591 (72%) completed a 2-year follow-up, and 1377 (62%) completed a 3-year follow-up. The differences in AUDs between baseline NIAAA screen nondrinkers and lower-risk drinkers were statistically significant at 1 year (P = .0002), 2 years (P CONCLUSIONS: The NIAAA 2-question screen can accurately characterize adolescent risk for future AUDs. Future studies are needed to determine optimaluse of the screen.

BackgroundAcute gastroenteritis develops in millions of children in the United States every year, and treatment with probiotics is common. However, data to support the use of probiotics in this population are limited.MethodsWe conducted a prospective, randomized, double-blind trial involving children 3 months to 4 years of age with acute gastroenteritis who presented to one of 10 U.S. pediatric emergency departments. Participants received a 5-day course of Lactobacillus rhamnosus GG at a dose of 1×1010 colony-forming units twice daily or matching placebo. Follow-up surveys were conducted daily for 5 days and again 14 days after enrollment and 1 month after enrollment. The primary outcome was moderate-to-severe gastroenteritis, which was defined as an illness episode with a total score on the modified Vesikari scale of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease), within 14 days after enrollment. Secondary outcomes included the duration and frequency of diarrhea and vomiting, the duration of day-care absenteeism, and the rate of household transmission (defined as the development of symptoms of gastroenteritis in previously asymptomatic household contacts).ResultsAmong the 971 participants, 943 (97.1%) completed the trial. The median age was 1.4 years (interquartile range, 0.9 to 2.3), and 513 participants (52.9%) were male. The modified Vesikari scale score for the 14-day period after enrollment was 9 or higher in 55 of 468 participants (11.8%) in the L. rhamnosus GG group and in 60 of 475 participants (12.6%) in the placebo group (relative risk, 0.96; 95% confidence interval, 0.68 to 1.35; P=0.83). There were no significant differences between the L. rhamnosus GG group and the placebo group in the duration of diarrhea (median, 49.7 hours in the L. rhamnosus GG group and 50.9 hours in the placebo group; P=0.26), duration of vomiting (median, 0 hours in both groups; P=0.17), or day-care absenteeism (median, 2 days in both groups; P=0.67) or in the rate of household transmission (10.6% and 14.1% in the two groups, respectively; P=0.16).ConclusionsAmong preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT01773967 .).

Background Fractures are common in children, and it can be difficult to distinguish unintentional injuries from child abuse. Objective We describe circumstances of injury, prevalence of suspicion for physical abuse, and use of imaging to identify additional occult fractures in young children with femur fractures. Methods We reviewed the medical records for children younger than 48 months old with femur fractures treated at a pediatric referral hospital (2011–2013). We abstracted age, ambulation, injury circumstances, bruising, head trauma, additional fractures, and determination of injury suspicious for abuse. Results In 22 of 127 (17%) children with femur fractures, there was strong suspicion for physical abuse. Infants ≤ 12 months old accounted for 19 of 22 (86%) of those with suspicious injuries. In 2 of 22 (9%) with suspected abuse, the child could walk independently. In 8 of 22 (36%) with suspicious injuries, an injury event was reported as directly witnessed versus 50 of 105 (48%) of the unintentional injuries. Six of 22 (27%) with suspicious injuries had bruises versus 11 of 105 (10%) with unintentional injuries (χ2, p Conclusions Most children with femur fractures suspicious for abuse were ≤ 12 months old and not walking independently. Skeletal surveys identified additional fractures in 7% of children, and were useful in the forensic evaluation of non-ambulatory children ≤ 12 months old.

OBJECTIVE: Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient’s race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient-level factors. METHODS: This was a retrospective, observational cohort study. Pediatric patients (

Magnesium, a vasodilator, anti-inflammatory, and pain reliever, could alter the pathophysiology of sickle cell pain crises. We hypothesized that intravenous magnesium would shorten length of stay, decrease opioid use, and improve health-related quality of life (HRQL) for pediatric patients hospitalized with sickle cell pain crises. The Magnesium for Children in Crisis (MAGiC) study was a randomized, double-blind, placebo-controlled trial of intravenous magnesium vs normal saline placebo conducted at 8 sites within the Pediatric Emergency Care Applied Research Network (PECARN). Children 4 to 21 years old with hemoglobin SS or Sβ(0) thalassemia requiring hospitalization for pain were eligible. Children received 40 mg/kg of magnesium or placebo every 8 hours for up to 6 doses plus standard therapy. The primary outcome was length of stay in hours from the time of first study drug infusion, compared using a Van Elteren test. Secondary outcomes included opioid use and HRQL. Of 208 children enrolled, 204 received the study drug (101 magnesium, 103 placebo). Between-group demographics and prerandomization treatment were similar. The median interquartile range (IQR) length of stay was 56.0 (27.0-109.0) hours for magnesium vs 47.0 (24.0-99.0) hours for placebo (P = .24). Magnesium patients received 1.46 mg/kg morphine equivalents vs 1.28 mg/kg for placebo (P = .12). Changes in HRQL before discharge and 1 week after discharge were similar (P > .05 for all comparisons). The addition of intravenous magnesium did not shorten length of stay, reduce opioid use, or improve quality of life in children hospitalized for sickle cell pain crisis. This trial was registered at www.clinicaltrials.gov as #NCT01197417.

BACKGROUND AND OBJECTIVE:Children and adolescents with minor blunt head trauma and isolated skull fractures are often admitted to the hospital. The objective of this study was to describe the injury circumstances and frequency of clinically important neurologic complications among children with minor blunt head trauma and isolated linear skull fractures.METHODS:This study was a planned secondary analysis of a large prospective cohort study in children RESULTS:In the parent study, we enrolled 43 904 children (11 035 [25%] CONCLUSIONS:Children with minor blunt head trauma and isolated linear skull fractures are at very low risk of evolving other traumatic findings noted in subsequent imaging studies or requiring neurosurgical intervention. Hospital admission for neurologically normal children with isolated linear skull fractures after minor blunt head trauma for monitoring is typically unnecessary.

Introduction Acute gastroenteritis (AGE) is a common and burdensome condition that affects millions of children worldwide each year. Currently available strategies are limited to symptomatic management, treatment and prevention of dehydration and infection control; no disease-modifying interventions exist. Probiotics, defined as live microorganisms beneficial to the host, have shown promise in improving AGE outcomes, but existing studies have sufficient limitations such that the use of probiotics cannot currently be recommended with confidence. Here we present the methods of a large, rigorous, randomised, double-blind placebo-controlled study to assess the effectiveness and side effect profile of Lactobacillus rhamnosus GG (LGG) (ATCC 53103) in children with AGE. Methods and analysis The study is being conducted in 10 US paediatric emergency departments (EDs) within the federally funded Pediatric Emergency Care Applied Research Network, in accordance with current SPIRIT and CONSORT statement recommendations. We will randomise 970 children presenting to participating EDs with AGE to either 5 days of treatment with LGG (1010colony-forming unit twice a day) or placebo between July 2014 to December 2017. The main outcome is the occurrence of moderate-to-severe disease over time, as defined by the Modified Vesikari Scale. We also record adverse events and side effects related to the intervention. We will conduct intention-to-treat analyses and use an enrichment design to restore the statistical power in case the presence of a subpopulation with a substantially low treatment effect is identified. Ethics and dissemination Institutional review board approval has been obtained at all sites, and data and material use agreements have been established between the participating sites. The results of the trial will be published in peer-reviewed journals. A deidentified public data set will be made available after the completion of all study procedures. Trial registration number NCT01773967.

OBJECTIVE: To determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) two-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network (PECARN) pediatric emergency departments. This article describes the study methodology, sample characteristics and baseline outcomes of the NIAAA two-question screen. METHODS: Participants included 12–17 year olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA two-question screen and other measures of alcohol, drug use and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was re-administered the NIAAA two-question screen one week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA two-question screen. RESULTS: There were 4,834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across gender and age. Forty-six percent of participants identified as White and 26% identified as Black. Approximately one-quarter identified as Hispanic. Using the NIAAA two-question screen algorithm, approximately 8% were classified as low risk, 12% as moderate risk and 4% as highest risk. Alcohol use was less likely to be reported by Black participants, non-Hispanic participants and those less than 16 years old. DISCUSSION: This study successfully recruited a large, demographically diverse sample, in order to establish rates of the NIAAA screen risk categories across age, gender, ethnicity and race within pediatric emergency departments.

Background Detecting change in health status over time and ascertaining meaningful changes are critical elements when using health-related quality of life (HRQL) instruments to measure patient-centered outcomes. The PedsQL™ Sickle Cell Disease module, a disease specific HRQL instrument, has previously been shown to be valid and reliable. Our objectives were to determine the longitudinal validity of the PedsQL™ Sickle Cell Disease module and the change in HRQL that is meaningful to patients. Methods An ancillary study was conducted utilizing a multi-center prospective trial design. Children ages 4–21 years with sickle cell disease admitted to the hospital for an acute painful vaso-oclusive crisis were eligible. Children completed HRQL assessments at three time points (in the Emergency Department, one week post-discharge, and at return to baseline (One to three months post-discharge). The primary outcome was change in HRQL score. Both distribution (effect size, standard error of measurement (SEM)) and anchor (global change assessment) based methods were used to determine the longitudinal validity and meaningful change in HRQL. Changes in HRQL meaningful to patients were identified by anchoring the change scores to the patient’s perception of global improvement in pain. Results Moderate effect sizes (0.20–0.80) were determined for all domains except the Communication I and Cognitive Fatigue domains. The value of 1 SEM varied from 3.8–14.6 across all domains. Over 50% of patients improved by at least 1 SEM in Total HRQL score. A HRQL change score of 7–10 in the pain domains represented minimal perceived improvement in HRQL and a HRQL change score of 18 or greater represented moderate to large improvement. Conclusions The PedsQL™ Sickle Cell Disease Module is responsive to changes in HRQL in patients experiencing acute painful vaso-occlusive crises. The study data establish longitudinal validity and meaningful change parameters for the PedsQL™ Sickle Cell Disease Module. Trial Registration ClinicalTrials.gov (study identifier: NCT01197417). Date of registration: 08/30/2010 Electronic supplementary material The online version of this article (doi:10.1186/s12955-017-0700-2) contains supplementary material, which is available to authorized users.

OBJECTIVES: To assess the performance of the Yale Observation Scale (YOS) score and unstructured clinician suspicion to identify febrile infants ≤60 days of age with and without serious bacterial infections (SBIs). METHODS: We performed a planned secondary analysis of a prospective cohort of non–critically ill, febrile, full-term infants ≤60 days of age presenting to 1 of 26 participating emergency departments in the Pediatric Emergency Care Applied Research Network. We defined SBIs as urinary tract infections, bacteremia, or bacterial meningitis, with the latter 2 considered invasive bacterial infections. Emergency department clinicians applied the YOS (range: 6–30; normal score: ≤10) and estimated the risk of SBI using unstructured clinician suspicion (50%). RESULTS: Of the 4591 eligible infants, 444 (9.7%) had SBIs and 97 (2.1%) had invasive bacterial infections. Of the 4058 infants with YOS scores of ≤10, 388 (9.6%) had SBIs (sensitivity: 51/439 [11.6%]; 95% confidence interval [CI]: 8.8%–15.0%; negative predictive value: 3670/4058 [90.4%]; 95% CI: 89.5%–91.3%) and 72 (1.8%) had invasive bacterial infections (sensitivity 23/95 [24.2%], 95% CI: 16.0%–34.1%; negative predictive value: 3983/4055 [98.2%], 95% CI: 97.8%–98.6%). Of the infants with clinician suspicion of CONCLUSIONS: In this large prospective cohort of febrile infants ≤60 days of age, neither the YOS score nor unstructured clinician suspicion reliably identified those with invasive bacterial infections. More accurate clinical and laboratory predictors are needed to risk stratify febrile infants.

OBJECTIVES Lollapalooza (LP) is an annual 3-day outdoor music festival in Chicago. Underage drinking and drug use are believed to be common, but the burden on emergency departments (EDs) has not been documented. We assessed the burden on health care resources associated with this music festival. METHODS We performed a retrospective chart review of adolescent (aged 11-20 years) ED visits during LP weekend and 4 summer comparison weekends at Lurie Children's Hospital in Chicago, Ill, in 2014 (n = 356). We then analyzed adolescent alcohol- and drug-related hospital visits to all Chicago hospitals for each weekend in 2014 0 using Illinois hospital discharge data. RESULTS Adolescents accounted for a greater proportion of our ED visits during LP weekend than comparison weekends (25% vs 19%, P < 0.02). Lollapalooza weekend patients were more likely female (P = 0.025), older (P = 0.0067), more often unsupervised (P < 0.0001), and less likely to live in the city (P < 0.001) than adolescents seen during comparison weekends. Thirty-one underage adolescents who attended LP were treated in our ED; 84% were intoxicated (blood alcohol content, 88-328 mg/dL). Citywide there was an 11-fold increase in adolescent alcohol-related hospital visits during LP weekend compared with an average weekend. Drug intoxication was much less common. CONCLUSIONS Adolescents seen in our ED the weekend of LP were older, more often female, frequently unsupervised, and less likely to be city residents than those seen during comparison weekends. Those who attended LP had high rates of alcohol intoxication. This surge of intoxicated adolescent patients affected numerous EDs in the city.

OBJECTIVES Pediatric cervical injuries are uncommon. This study was to describe injury circumstances, clinical findings, and management among children diagnosed with atlantoaxial rotatory subluxation (AARS) to aid in its recognition and management. METHODS Subanalysis of a large case-control study from January 2000 to December 2004 in 17 hospitals in the Pediatric Emergency Care Applied Research Network was performed. Cases were children younger than 16 years with AARS after blunt trauma (n = 55); controls were (a) children with other cervical spine injuries (other CSI, n = 485) and (b) those with normal imaging of the cervical spine (non-CSI, n = 1060). RESULTS Children with AARS were younger (mean [SD] age, 7.7 [3.8] vs 10.7 [4.6]; Wilcoxon P < 0.01). Falls accounted for 36% of injuries; there were no diving mechanisms (vs other CSI, falls 19%, Fisher exact P < 0.01, and diving 7%, P = 0.04). Children with AARS sought medical care more than 24 hours after the injury event (21% vs 1% for non-CSI controls, P < 0.01). Clinical findings associated with AARS included neck pain (67%) and torticollis (57%) versus other CSI, pain (47%) and torticollis (5%, P < 0.01) for each, and versus non-CSI controls, pain (33%) and torticollis (6%, P < 0.01) for each. Management of AARS included no intervention (n = 6, 11%), soft or rigid collar only (n = 24, 44%), traction (n = 14, 25%), halo (n = 9, 16%), internal fixation (n = 2, 4%), and varied across institutions (P = 0.02). CONCLUSIONS Children with AARS often have a delayed presentation with neck pain and torticollis; falls are a common injury mechanism. Treatment varied across institutions. Further work is needed to identify optimal management.

BACKGROUND AND OBJECTIVE: Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children. METHODS: We conducted a 5-year retrospective review of children RESULTS: A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children CONCLUSIONS: We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.

OBJECTIVES: To determine the test-retest reliability, concurrent, convergent, and discriminant validity of a recently devised screen (“Newton screen”) for alcohol and cannabis use/misuse, and its predictive validity at follow up. STUDY DESIGN: Adolescents, 12-17 years old (N=4,898), treated in one of 16 participating pediatric emergency departments (PEDs) across the United States were enrolled in a study as part of a larger study within the Pediatric Emergency Care Applied Research Network (PECARN). Concurrent and predictive validity (at 1, 2, and 3-year follow-up) were assessed in a random subsample with a structured Diagnostic and Statistical Manual of Mental Disorders (DSM)-based interview. Convergent validity was assessed with the Alcohol Use Disorders Identification (AUDIT), a widely used alcohol screening measure. RESULTS: The sensitivity of the Newton screen for alcohol use disorder (AUD) at baseline was 78.3% with a specificity of 93.0%. The cannabis use question had a baseline sensitivity of 93.1% and specificity of 93.5% for cannabis use disorder (CUD). Predictive validity analyses at 1, 2, and 3 years revealed high specificity but low sensitivity for alcohol and high specificity and moderate sensitivity for cannabis. CONCLUSION: The Newton screening instrument may be an appropriate brief screening tool for use in the busy clinical environment. Specificity was high for both alcohol and cannabis, but sensitivity was higher for cannabis than alcohol. Like other brief screens, more detailed follow-up questions may be necessary to definitively assess substance misuse risk and need for referral to treatment.

Objective To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections. Study design Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants. Results Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis. Conclusions Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.

The burden of acute gastroenteritis (AGE) in US children is substantial. Research into outpatient treatment strategies has been hampered by the lack of easily used and validated gastroenteritis severity scales relevant to the populations studied. We sought to evaluate, in a US cohort, the reliability, construct validity, and generalizability of a gastroenteritis severity scale previously derived in a Canadian population, the modified Vesikari score (MVS).We conducted a prospective, cohort, clinical observational study of children 3 to 48 months of age with acute gastroenteritis presenting to 5 US emergency departments. A baseline MVS score was determined in the emergency department, and telephone follow-up 14 days after presentation was used to assign the follow-up MVS. We determined reliability using inter-item correlations; construct validity via principal component factor analysis; cross-sectional construct validity via correlations with the presence of dehydration, hospitalization, and day care and parental work absenteeism; and generalizability via score distribution among sites.Two hundred eighteen of 274 patients (80%) were successfully contacted for follow-up. Cronbach α was 0.63, indicating expectedly low internal reliability because of the multidimensional properties of the MVS. Factor analysis supported the appropriateness of retaining all variables in the score. Disease severity correlated with dehydration (P0.001), hospitalization (P0.001), and subsequent day care (P = 0.01) and work (P0.001) absenteeism. The MVS was normally distributed, and scores did not differ among sites.The MVS effectively measures global severity of disease and performs similarly in varying populations within the US health care system. Its characteristics support its use in multisite outpatient clinical trials.

The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma.This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes.We enrolled 42,041 patients, of whom 10,499 (25.0%) were2 years old. Among patients2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI.The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.

Study objective Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. Methods We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity. Results We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. Conclusion We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

Ondansetron is increasingly used to prevent emesis in children with acute gastroenteritis; however, the optimal dose is unknown. To determine if higher doses of oral ondansetron are associated with greater efficacy or side effects. We analyzed data from a prospective clinical trial performed between January 2004 and April 2005. Data were collected on 105 children with dehydration due to gastroenteritis who received an ondansetron oral disintegrating formulation. The following outcomes of efficacy were analyzed: number of vomiting episodes, volume of oral rehydration fluids consumed, percent weight gain, and the proportions of children who had ongoing vomiting, received intravenous rehydration, and were hospitalized. In addition, the number of episodes of diarrhea was evaluated to measure whether there were dose-dependent side effects. Participants were aged 0.5–8.2 years and the dose ranged between 0.13 and 0.26mg/kg. There was no significant association between the dose of ondansetron and the outcomes of number of vomiting episodes, volume of fluids consumed, increase in bodyweight, or number of diarrhea episodes/hour. The mean dose of ondansetron (mg/kg) administered was not different amongst those who did and did not have ongoing vomiting, undergo hospitalization, and receive intravenous rehydration. Within the dose range of 0.13–0.26 mg/kg, higher doses of ondansetron were not superior to lower doses, nor were they associated with increased side effects. Thus, ondansetron in this dose range was shown to result in a similar reduction in emesis in children with acute gastroenteritis.

BACKGROUND: Specific information about the supervision of young children with injuries related to falls is limited. In this study, we describe the supervision and physical environment of falls resulting in medical care in the emergency department. METHODS: We enrolled a convenience sample of 108 children younger than 7 years with fall injuries. RESULTS: The average age was 3 years, and 56% were male. Seventy-six (70%) were a fall from a height including 16 that involved stairs. Among caretakers in a nongroup setting (n = 95), most (61%) were supervising more than one child. The attention to the child was holding or playing with the child (13%), observing (45%), usually constantly, or listening for the child (19%); 9% reported no supervision at the time of the fall. Thirty-two percent stated they were touching or within reach of the child. Of falls indoors (n = 56), the supervisor was in the same room as the child for more than half of cases. There was no association between the number of children supervised and fall type (height vs. same level). When compared with those with same level falls, children with falls from a height were more often supervised with listening or no supervision (vs. observation, holding, or playing with the child) χ², p = 0.004. CONCLUSIONS: Many children were supervised at the time of their fall. Most caretakers had visual contact, and up to a third were touching or within reach of the child. The strategies used in these apparently low-risk situations were insufficient to prevent the falls we report. Language: en

BACKGROUND: Young children are at risk for injuries in the home. This study was to compare a safe house model to The Injury Prevention Program (TIPP) sheet for providing injury prevention information. METHODS: Parents of children who were younger than 6 years were randomized to injury prevention education using a safe home model or an age appropriate TIPP sheet. There was a pretest before the intervention. The recall of injury prevention information was assessed by a telephone posttest 4 weeks to 6 weeks after the intervention. To obtain a sample broadly representative of community demographics, we recruited families in the dermatology clinic of a teaching hospital. RESULTS: We collected complete information for 371 families of which 181 were in the safe home model group and 190 were in the TIPP group. There were no differences between groups in percent minority race, education, or insurance; the parents in the safe home group were slightly older (34.4 ± 6.5 vs. 32.9 ± 5.8). More than 80% in each group had education beyond high school. There was no difference between groups in pretest scores, 8.0 ± 1.3 for the safe home model group and 8.1 ± 1.1 for the TIPP group. There was no difference between groups in posttest scores, 9.0 ± 0.8 for the safe home model group and 9.1 ± 0.9 for the TIPP group. CONCLUSIONS: The safe home model and the TIPP sheets were both effective in improving safety knowledge. The use of a safe home model complements current strategies to improve injury prevention knowledge. Language: en

OBJECTIVE: There is significant variation in the literature regarding the characteristics that are associated with pediatric ovarian torsion and its management. National data regarding the demographics and management of pediatric ovarian torsion are lacking. Our objective was to describe the epidemiology of pediatric ovarian torsion and the rate of oophorectomy by using nationally representative data. Demographic factors and hospital characteristics that are associated with rates of oophorectomy were also explored. METHODS: This was a cohort analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) 2000, 2003, and 2006. All females aged 1 to 20 years who were hospitalized with ovarian torsion in states participating in KID 2000, KID 2003, and KID 2006 representing 900, 1224, and 1232 ovarian torsion-related hospitalizations, respectively, were included. Primary outcome measures included the incidence of ovarian torsion and rate of associated oophorectomy. Multivariable regression was used to control for patient and hospital characteristics. RESULTS: Among females aged 1 to 20 years, there were 1232 cases of ovarian torsion in KID 2006, an estimated incidence of 4.9 per 100000. A total of 713 (58%) were treated with oophorectomy. The rate of ovarian torsion–associated oophorectomy remained unchanged from 2000 to 2006. The adjusted odds of having an oophorectomy decreased by 0.95 for every increasing year of age. Residing in a lower quartile of household income by zip code increased the adjusted odds of oophorectomy. A diagnosis of benign neoplasm increased the adjusted odds of oophorectomy by 2.16. Fewer than 0.5% of ovarian torsion hospitalizations were associated with malignant neoplasm. CONCLUSIONS: Nationally representative hospital data indicate that ovarian torsion is uncommon but occurs in all ages and is typically associated with normal ovaries or benign lesions. Improved awareness of the epidemiology may help to guide management. Ongoing analysis to identify factors that are associated with successful conservative management is warranted.

OBJECTIVES. Oral rehydration therapy is underused by physicians treating children with acute infectious enteritis. To guide management, we hypothesized that clinical variables available at the initial assessment could be identified that will predict the need for intravenous fluid administration. PATIENTS AND METHODS. Clinical data were prospectively collected on a cohort of 214 children, aged 6 months to 10 years, treated in an emergency department for dehydration secondary to acute enteritis. All of the children performed supervised oral rehydration therapy for a minimum of 60 minutes according to protocol. Outcomes assessed were intravenous rehydration, return visits after discharge, and successful oral rehydration therapy. The latter variable was defined as the consumption of ≥12.5 mL/kg per hour of oral rehydration solution. Variables individually associated with outcomes of interest were evaluated by using multiple logistic regression analysis. RESULTS. Forty-eight(22%) of 214 children received intravenous rehydration. In multivariate analysis, the 2 clinical predictors of intravenous rehydration were large urinary ketones and altered mental status. Significant predictors of repeat emergency department visits within 3 days included ≥10 episodes of vomiting over the 24 hours before presentation and a higher heart rate at discharge from the emergency department. CONCLUSIONS. Among children with enteritis and mild-to-moderate dehydration, the presence of large urine ketones or an altered mental status is associated with intravenous rehydration after a 60-minute oral rehydration therapy period. Caution should be exercised before discharging children with either tachycardia or a history of significant vomiting before presentation, because they are more likely to require future emergency department care.

BACKGROUND Vomiting limits the success of oral rehydration in children with gastroenteritis. We conducted a double-blind trial to determine whether a single oral dose of ondansetron, an antiemetic, would improve outcomes in children with gastroenteritis. METHODS We enrolled 215 children 6 months through 10 years of age who were treated in a pediatric emergency department for gastroenteritis and dehydration. After being randomly assigned to treatment with orally disintegrating ondansetron tablets or placebo, the children received oral-rehydration therapy according to a standardized protocol. The primary outcome was the proportion who vomited while receiving oral rehydration. The secondary outcomes were the number of episodes of vomiting and the proportions who were treated with intravenous rehydration or hospitalized. RESULTS As compared with children who received placebo, children who received ondansetron were less likely to vomit (14 percent vs. 35 percent; relative risk, 0.40; 95 percent confidence interval, 0.26 to 0.61), vomited less often (mean number of episodes per child, 0.18 vs. 0.65; P

Objective. To describe the incidence, external cause, and types of injuries among infants treated in US emergency departments (EDs) and to compare the external cause of nonfatal to fatal injuries.Design. ED survey from the National Center for Health Statistics (NCHS) National Hospital Ambulatory Medical Care Survey for 1992–1999 and NCHS mortality data.Patients. National probability sample of patients treated in EDs; data for children Outcome Measures. Incidence and external cause of nonfatal injury among infants. Rates were calculated using NCHS data for live births.Results. The 8-year annualized, weighted estimate of infant injuries was 426 957, a rate of 108.2 per 1000 infant years (95% confidence interval [CI]: 94.8–121.5). There were no significant differences in rates by sex, race, or ethnicity. An estimated 6% were admitted to the hospital (admission rate: 6.1 per 1000). Most injuries occurred in the home. Head trauma accounted for injuries in 12% of children (injury rate: 13.4 per 1000 per year [95% CI: 9.3–17.3]; 21% of children with head trauma had a skull fracture or an intracranial injury. An estimated 30.2 per 1000 (95% CI: 23.8–36.6) had face trauma and 23.9 per 1000 (95% CI: 18.2–29.6) had extremity injuries; open wounds or superficial injuries accounted for many of these injuries. An estimated 4% had extremity fractures (annual rate: 4.6/1000). Falls were the most frequent cause of injury (an estimated 35.1 per 1000 infant years). The rate of motor vehicle traffic injuries was 8.8 per 1000. Foreign bodies accounted for an estimated 5.2 injuries and poisonings for an estimated 3.8 injuries per 1000 infant years. A comparison with infant mortality data showed the ratio of nonfatal to fatal falls to be 8789:1. The ratio of nonfatal to fatal motor vehicle traffic injuries was 197:1. There were an estimated 1271 nonfatal poisonings for each poisoning fatality.Conclusions. Nonfatal injuries far outnumber fatalities. Injuries from falls are very common, but they are rarely fatal. Surveillance of nonfatal injuries is essential to accurately describe and understand the burden of injury among infants. Prevention strategies must be developed to address extremely frequent, less serious injuries in infancy.

Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children.We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14.Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients' characteristics were as follows: median age, 1.7 years (interquartile range, 1.1-2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%-21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%-12%): laryngospasm 1 (0.2%; 95% CI, 0%-1.1%), failed sedation 31 (6%; 95% CI, 4%-8%), vomiting 6 (1%; 95% CI, 0.4%-2%), hypotension 13 (4%; 95% CI, 2%-7%), and hypoxia 1 (0.2%; 95% CI, 0%-2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate.Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.

Firearm violence is a serious threat to the health of our children: an American child dies of gunshot wounds every 1 1/2 hours, and every 2 days 30 children--the equivalent of a school classroom--lose their lives to guns. Injured children and adolescents are cared for in emergency departments and trauma centers, and in some urban areas the increasing incidence of firearm injuries threatens to overwhelm the trauma care delivery system. Because of the prevalence and enormous cost of firearm violence it has been identified as an epidemic and a public health emergency. In this article we discuss the burden of firearm injury and its effect on children and young adult, and we outline a public health approach to firearm injury prevention.

Objective : To describe the estimated frequency and types of injuries associated with in-line skates in U.S. children and to compare in-line skating injuries to rollerskating injuries. Design : National case series. Setting : Emergency departments of hospitals participating in the United States Consumer Product Safety Commission (USCPSC) National Electronic Injury Surveillance System. Patients : Persons with injuries associated with the use of in-line skates or rollerskates reported to the USCPSC in 1992 and 1993. Results : There were an estimated 66,465 injuries associated with in-line skates ; the incidence of injury was highest in children 11 and 12 years old. An estimated 40,730 in-line skate injuries involved children

Study objective We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. Methods This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). Results Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. Conclusion Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.

Background: The purpose of this study was to describe the incidence of serious bacterial infections in febrile outpatient pediatric kidney transplant recipients and to assess the utility of using white blood cell indices to identify patients at low risk for bacteremia. Methods: A retrospective study was conducted on all kidney transplant recipients followed at a single children's hospital. All outpatient visits from January 1, 1995 to June 6, 2007 in which fever was evaluated were reviewed. Patients with history of a primary immunodeficiency, receiving concurrent chemotherapy, or a stem cell or small bowel transplant were excluded. Demographic, historical, physical examination, laboratory, and radiographic data were then recorded. Results: In all, 101 patients had 251 individual episodes of fever evaluation. In 209 visits, a blood culture was drawn with results available. There were 21 (10.0%) true positive blood cultures and 3 (1.4%) false positives. Two-thirds of the true positive blood cultures occurred in patients with indwelling hardware. There was a positive urine culture in 52/192 (27.1%) visits. Pneumonia was diagnosed in 14/74 (18.9%) visits. In nonill-appearing children without indwelling central lines or focal bacterial infections, the incidence of bacteremia was zero. No practical decision rule based on white blood cell indices could be derived. Conclusions: The majority of bacteremic cases in febrile outpatient pediatric kidney transplant patients occurred in patients with indwelling hardware. We did not detect any occult cases of bacteremia in this study cohort. A larger prospective multicenter study is required to confirm the low incidence of bacteremia in this patient subset.

Objectives: The purpose of this study was to describe the incidence of serious bacterial infections (SBIs) in febrile outpatient pediatric heart transplant recipients and to assess the utility of using white blood cell (WBC) indices to identify patients at low risk for bacteremia. Methods: A retrospective study was conducted on all heart transplant recipients followed at a single children’s hospital. All outpatient visits from January 1, 1995, to June 1, 2007, in which fever was evaluated were reviewed. Patients with history of a primary immunodeficiency, receiving concurrent chemotherapy, or having had a stem cell or small bowel transplant were excluded. Demographic, historical, physical examination, laboratory, and radiographic data were then recorded. Results: Sixty-nine patients had 238 individual episodes of fever evaluation; of these, 217 (91.2%) had blood cultures drawn with results available in their initial evaluation. There were six (2.8%) true-positive blood cultures and eight (3.7%) false-positive cultures. Chest radiography was done in 185 evaluations (77.8%), and 44 episodes of pneumonia (23.8%) were diagnosed. Of 112 urine cultures done, one (0.9%) was positive. Neither of two lumbar punctures performed were positive. In non–ill-appearing children without indwelling central lines or focal bacterial infections (pneumonia, cellulitis), the incidence of bacteremia was 1.2%. In children with a focal bacterial infection, the rate of bacteremia was 6.3%. WBC indices were not significantly different between bacteremic and nonbacteremic patients. A band-to-neutrophil ratio (BNR) of ≥0.25 and a published guideline for identifying low-risk infants using WBC indices identified all bacteremic patients, each with a sensitivity of 100% (95% confidence interval [CI] = 48% to 100% and 54% to 100%, respectively). Conclusions: The incidence of bacteremia was low in febrile, outpatient pediatric heart transplant patients, especially in those who were not ill-appearing and did not have a focus of serious infection. Two different low-risk criteria performed well in identifying the bacteremic patients, although given the low number of true-positive cultures, the CIs for the sensitivities of these tests were extremely wide, and neither test could be reliably used at present. A prospective multicenter study is required to confirm the low incidence of bacteremia and low-risk criteria in this population.

Objectives: A noninvasive method to assess ventilation may aid in management of children with acute asthma. The purpose of this study was to evaluate the association between end-tidal carbon dioxide (EtCO2) values and disease severity among children with acute asthma. Methods: This was a prospective, blinded, observational study of children 3–17 years old treated for acute asthma in a pediatric emergency department (ED). EtCO2 measurements were taken before the initiation of therapy and after each nebulization treatment (maximum of three). Peak expiratory flow rate (PEFR), Pediatric Asthma Severity Score (PASS), oxygen saturation, and disposition were recorded. Treating physicians, unaware of the EtCO2 results, made all treatment decisions, including disposition. Results: One hundred children were enrolled. The mean initial EtCO2 value was 35 mm Hg (95% confidence interval = 34.3 to 36.1 mm Hg). The mean disposition EtCO2 value was 33.3 mm Hg (95% confidence interval = 32.6 to 34.4 mm Hg). PEFR measures were completed on 43 patients and PASS recorded on 100 patients. There was an overall trend toward lower EtCO2 values during treatment (p < 0.01). Sixteen patients were admitted. Initial EtCO2 values were lower among children admitted to the hospital (35.6 mm Hg vs. 32.9 mm Hg; Mann-Whitney U test; p < 0.02). EtCO2 values at disposition did not differ between groups based on PEFR, PASS, or hospital admission. Conclusions: Noninvasive bedside measurement of EtCO2 values among children with acute asthma is feasible. EtCO2 values did not distinguish children with mild disease from those with more severe disease. Further data are needed to clarify the association between EtCO2 values and other indicators of disease severity, particularly in children with more severe disease. ACADEMIC EMERGENCY MEDICINE 2007; 14:1135–1140 a 2007 by the Society for Academic Emergency Medicine

Background: Window falls are a frequent cause of injury (15/100 000) among Chicago preschool children. In Boston and New York, public health efforts have successfully decreased window fall injuries. Local data are needed to develop appropriate interventions for Chicago. Objective: To describe the housing characteristics and types of injuries among children who fell from windows treated in a Chicago pediatric trauma center. Methods: Children treated in a pediatric trauma center for injuries related to window falls between 1995 and 2002 were identified retrospectively. We reviewed family demographics, the circumstances of the fall, and types of injuries. Site visits were performed to determine the height and type of building and type of window where the fall took place. Results: The authors reviewed 90 cases; 55 were male. The median age was 2 years. Ninety eight percent of falls were reported to be from the third floor or lower. Site visits (n = 77) showed that 96% of the buildings were four storeys or lower. The median length of hospital stay was two days (range 0–24 days). The most common injuries were head trauma and extremity fractures. Three patients died, and an additional three patients were discharged to rehabilitation centers. Conclusions: Some window falls result in serious injury. In Chicago, most falls were from modest heights (2nd/3rd floor windows) in buildings of four or fewer storeys, rather than from “high rises”. Strategies to prevent window falls should be directed to the owners and occupants of this type of housing.

The aims of this study were to determine the annual prevalence of intimate-partner violence (IPV) in an urban pediatric emergency department (ED) among mothers seeking care for their children, to examine the associations between IPV and family socioeconomic characteristics, triage time, and child's diagnosis, and to describe perceptions and preferences for IPV screening.A confidential 15-item survey was completed by 451 women caretakers who were unaccompanied by a male partner in an urban pediatric ED associated with a children's hospital. Women were enrolled during 4-hour time blocks selected to represent ED use patterns during June and July 2002. Survey questions addressed experiences of IPV (physical or sexual violence and perception of safety) in the preceding year and preferences for IPV screening. We also collected information about the women's socioeconomic characteristics and the child's triage time and diagnosis.Fifty women reported IPV, an annual prevalence of 11%. Compared with white women, the relative risk of IPV among black women was 1.1 (95% confidence interval [CI], 1.0-1.2) and among Hispanic women was 1.1 (95% CI, 1.0-1.2). Compared with women who completed college, the relative risk of women who had not completed high school was 5.8 (95% CI, 2.0-26.4). We observed no association with poverty. Women who reported IPV more often sought care for their child in the evening (4-12 pm, chi2, P0.01); there was no association with the child's diagnosis. Most (75%) stated that IPV screening in the pediatric ED was appropriate.The annual prevalence of IPV in a pediatric ED is 11%. As socioeconomic and visit characteristics are imprecise in identifying women at risk, screening should include all women. Screening for IPV in the pediatric ED is acceptable to women.

To describe trends in scooter-related injuries among US youth and compare scooter injuries to those related to in-line skates and skateboards.Retrospective review of data for children 1-19 years old from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission for 1997-2002.There were an estimated 190,878 scooter-related injuries (95% confidence interval: 145,984-235,773) among children treated in US emergency departments; 90% were in those 15 years old or younger. There was a marked increase in scooter-related injuries in 2000, injuries peaked in 2001, and declined. In 2002, the number of scooter-related injuries was similar to in-line skates and lower than skateboard-related injuries. Scooter- and in-line skate-associated injuries primarily involved children 5-12 years old: rates of scooter-related injuries were higher than rates of in-line skate-associated injuries among those 1-9 years old. Skateboard-related injuries more often involved teens. Forearm fractures accounted for 56% of fractures related to scooters (vs 74% in-line skates and 49% skateboards, chi-square, P.01). Five percent of children injured using scooters had a closed head injury or skull fracture, similar to in-line skates and skateboards.The annual number of injuries related to scooters, which peaked in 2001, is now similar to the number of injuries related to in-line skates. Injuries related to scooters primarily involve children 5-12 years old, and forearm fractures are common. These data suggest helmets should be used, and protective equipment should be developed to reduce forearm fractures.

OBJECTIVE: To describe the use of an emergency department (ED)-based injury surveillance model to determine the incidence and mechanisms of nonfatal injuries among children living in Cabrini Green, a poor urban community. METHODS: Using ED records and census data, population-based injury rates were determined for a retrospective cohort of children, 0 to 14 years old, (N = 3908) with nonfatal injuries resulting in ED treatment between January 1994 and December 1998. RESULTS: There were 1950 nonfatal injuries during the 5-year study period (annual injury incidence of 998/10,000). Age-specific rates (per 10,000 per year) were 899 among 0- to 4-year olds, 616 among 5- to 9-year olds, and 435 among 10- to 14-year olds. Sixty-three percent were male. The most common injury mechanisms were falls (339/10,000 per year), being struck by/against an object (201/10,000 per year), and being cut/pierced by an object (87/10,000 per year). Falls from a building window (2/10,000 per year) were infrequent. The incidence of housefire-related burns was 1.5/10,000 per year. Intentional injuries included alleged child abuse, 43/10,000 per year, and assaults, 30/10,000 per year. The assault rate among 10- to 14-year-old males was 100/10,000 per year. One hundred thirty-four children were admitted to the hospital (average annual rate of 69/10,000). The most frequent admission diagnoses were falls (22/10,000) among 0- to 9-year olds and assaults (13/10,000) among 10- to 14-year olds. CONCLUSION: An ED-based injury surveillance system can provide an efficient and useful way to determine injury incidence in a defined urban community. The data suggest that rates of violence-related injuries were high, while rates of window falls and housefires were low. These data have allowed targeted injury prevention efforts in Cabrini Green, and future surveillance will allow the evaluation of injury prevention activities. Language: en

To describe the incidence, circumstances, and types of high chair-related injuries among US children.Retrospective review of data for children 3 years old and younger from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission for 1994-98.There were an estimated 40 650 high chair-related injuries (95% confidence interval [CI], 32 657-48 643) to children 3 years old and younger treated in hospital emergency departments in the US during the 5-year study period. An estimated 5231 injuries (13%) were related to use of an attachable high chair (including booster seats), and an estimated 4067 (10%) were related to the use of a youth chair. The annual rate of injury among childrenor =3 years old was 5.3 per 10 000. The mean age was 10 months (median, 1 year); 56% were boys. Ninety-four percent of injuries resulted from a fall from the chair. Most injuries involved the head (44%) or face (39%). Injury diagnoses included contusions or abrasions (36%), lacerations (25%), closed head injury (21%), and fractures (8%). Two percent of injured children, an estimated 941 (95% CI, 399-1487), were admitted to the hospital during the study period, an annual admission rate of 0.1 per 10 000. There were no significant differences between attachable high chairs, youth chairs, and high chairs in anatomic sites of injury, injury diagnosis, or frequency of hospital admission.Injuries related to high chairs are common, particularly among children in the first year of life. They often result from falls from the chair. The data suggest that restraint use would prevent most of these injuries.

Objective—To describe rates and trends in the incidence of non-fatal and fatal firearm assault among children (16 years old or younger) over an 11 year period in Chicago, Illinois and to identify the socioeconomic characteristics of community areas where assaults are common. Methods—The Chicago Police Department (CPD) records from 1986 through 1996 were reviewed for children assaulted with a firearm. United States census data for 1990 for Chicago were used to calculate incidence rates; census data were also used for community area (defined by census tract) socioeconomic descriptions. Results—The CPD recorded 11 163 pediatric firearm assaults during the study period: 10 571 non-fatal and 592 (5%) fatal. From 1986 through 1996 non-fatal assaults more than doubled, with the highest rates in 1994; fatal assaults tripled, with rates peaking in 1993–94. Significant increases in non-fatal firearm assaults occurred among black and Hispanic males and females. In 1994, compared with white males, the relative risk of non-fatal assault was 7.0 (95% confidence interval (CI) 5.3 to 9.1) for black males and 3.3 (95% CI 2.5 to 4.4) for Hispanic males; the relative risk was 1.5 (95% CI 1.1 to 2.1) for black females. A handgun was the firearm used in most assaults (88% of non-fatal and 84% of fatal). Within community areas, the correlation between non-fatal and fatal assault incidence was strong (r=0.80, p

We report a case of a 10-week-old girl, with tetralogy of Fallot and a Blalock-Taussig shunt, who presented with hypercyanotic episodes. She was found to have serous fluid leakage around her shunt, causing compression of her trachea. Hypercyanotic episodes resulting from shunt leakage have not previously been reported. An awareness of this possible complication of a Blalock-Taussig shunt will allow the emergency physician to consider it in the differential diagnosis of hypercyanotic episodes.

Objective To describe the symptoms, diagnostic studies, and rate of ovarian salvage among children and adolescents with ovarian torsion. Methods We reviewed the medical records of all children with acute ovarian torsion treated at a university-affiliated pediatric hospital from 1987 to 2002; prenatal cases were excluded. For each child we recorded the time from onset of symptoms to initial examination and the time from initial examination to operation. We reviewed diagnostic tests used, operative reports, and pathology reports. Results We identified 22 cases; the mean age was 10.2 years (range, 3-15 years). In 6 cases (27%), the ovary was salvaged. Prolonged duration of symptoms prior to initial examination was not significantly associated with ovarian necrosis. Mean time of symptoms prior to care was 76 hours for both salvaged and nonsalvaged ovaries (range, 7-159 hours). The mean time from initial examination to operation, 11 hours for salvaged ovaries (range, 1-23 hours) and 21 hours for nonsalvaged ovaries (range, 2-71 hours), was not significantly different between groups. Twenty-one patients underwent imaging; 19 of 20 ultrasounds and 4 of 5 computed tomographic scans suggested the diagnosis. Less than half (10 of 22) of the torsed ovaries contained cysts, teratomas, or other masses. Conclusions These data suggest pediatric ovarian torsion is a more salvageable condition than previously reported. Prolonged time of symptoms prior to initial examination does not preclude ovarian salvage. Ovarian tumor accounts for less than half of cases. Urgent imaging and surgical management may lead to improved outcomes.

Objective To describe the incidence and circumstances of nonfatal firearm-related injuries among children and adolescents treated in US emergency departments. Design Data were obtained from the Firearm Injury Surveillance Study, 1993-1997; data were collected through medical record review at hospitals participating in the National Electronic Injury Surveillance System. Setting The hospitals participating in National Electronic Injury Surveillance System are a stratified probability sample of all US hospitals. Main Outcome Measures Numbers and population rates for nonfatal firearm-related injuries among children and adolescents younger than 20 years old. Results An estimated 115 131 (95% confidence interval, 76 769-153 493) children and adolescents were treated for a nonfatal gunshot wound during the study period. The estimated annual rates of injury (per 100 000) were 2.0 (children 0-4 years old), 2.2 (children 5-9 years old), 15.4 (children 10-14 years old), and 106.5 (adolescents 15-19 years old). The ratios of nonfatal to fatal firearm-related injuries were 4.0 (children 0-4 years old), 4.4 (children 5-9 years old), 5.0 (children 10-14 years old), and 4.4 (adolescents 15-19 years old). An additional estimated 103 814 children (95% confidence interval, 69 223-138 405) were shot with a nonpowder firearm (BB or pellet gun). Boys 5 to 9 and 10 to 14 years old had the highest rates of injury related to nonpowder firearms, an estimated 36.2 and 99.8 per 100 000, respectively. Fifty-six percent of those 15 to 19 years old were assault victims. An estimated 48% of children and adolescents with powder firearm–related gunshot wounds and an estimated 4% with nonpowder firearm injuries were admitted to the hospital. Conclusions Nonfatal injuries related to powder firearms and nonpowder firearms (BB or pellet guns) are an important source of injury among US children and adolescents. Ongoing surveillance of nonfatal firearm-related injury among children and adolescents is needed.

To describe the incidence, circumstances, and severity of bicycle-related injuries among children treated in US emergency departments (EDs) and to compare injuries in children aged 1 to 4 years (young children) with those in children and adolescents aged 5-9 and 10-14 years (intermediate-age and older children, respectively).Emergency department survey from the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for January 1, 1992, through December 31, 1997.National probability sample of patients who sought care in EDs; data for children 1 to 14 years old were used.Incidence and description of bicycle-related injuries among children grouped by age treated in US EDs.The 6-year weighted estimate of bicycle-associated injuries was 2,176,173. Young children had 270,098 ED visits; their average annual incidence was 45,016, a rate of 28.8 per 10,000 (95% confidence interval [CI], 19.1-38.5). Children in the intermediate-age and older groups had an incidence of 82.0 (95% CI, 66.6-97.4); and 86.4 (95% CI, 70.4-102.4) per 10,000, respectively. The highest rates of bicycle-related injuries were observed among boys in the intermediate-age (108.3 per 10,000 per year) and older groups (123.8 per 10,000 per year). Few injured children were involved in collisions with motor vehicles (1% of young and 4% of intermediate-age groups). The annual incidence of head trauma was 4.0 per 10,000 (95% CI, 0.4-7.5) for young children, 9.3 per 10,000 (95% CI, 4.3-14.2) for intermediate-age children, and 8.1 per 10,000 (95% CI, 3.5-12.8) for older children. Children aged 5 to 9 years had the highest rates of face trauma (estimated 29.8 per 10,000). The incidence of extremity fractures (range, 6.9-17.6 per 10,000) was similar for all groups.Although boys in the intermediate-age and older groups have the highest incidence of bicycle-related injuries, young children are also commonly injured. The anatomic sites of injury among young cyclists (head and face trauma and extremity fractures) are similar to those observed in both other groups. Bicycle helmets are indicated for the youngest children as well.