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Firearms contribute substantially to leading causes of death among US children ages 10-19 (suicide and homicide). Safe storage of guns is important but poorly adopted. This study sought to understand knowledge, attitudes, beliefs, and firearm storage practices among parents living in households with firearms. Focus groups (FG) were conducted with gun-owning parents/guardians in three US states with high firearm ownership. Participants also completed an anonymous survey which included demographic characteristics, previous gun education, purpose of gun ownership, and storage practices. Eight FG were conducted with 57 parents. 74% of participants stored at least one firearm unlocked, with many loaded. Overall risk perception for firearm injury was low. Many participants believed modeling responsible use within the family would demystify the presence of a firearm and decrease accidental shootings. There was strong perception that safe storage interferes with personal protection needs, especially for handguns. Trigger locks were considered a nuisance and rarely used. Parents were confident in their youth's ability to handle guns safely and did not believe that safe storage would deter suicide. Preferred messengers for safe storage education were military or law enforcement rather than physicians. Participants advocated for safe storage education paired with hands-on use education. Gun-owning parents supported safety education and endorsed education from nonmedical sources. Education about suicide prevention may improve adoption of safe storage by parents. These results will inform the development of a firearm safe storage campaign with improved acceptability for communities with high firearms use and ownership.

Mediation analysis was used to investigate the role of white matter integrity in the relationship between injury severity and verbal memory performance in participants with chronic pediatric traumatic brain injury (TBI). DTI tractography was used to measure fractional anisotropy (FA) within the corpus callosum, fornix, cingulum bundles, perforant pathways, and uncinate fasciculi. Injury severity was indexed using Glasgow Coma Scale (GCS) scores obtained at the time of the injury. Verbal memory was measured by performance on the long-delay free recall (LDFR) trial of the California Verbal Learning Test–Children’s version. Participants were between the ages of 10–18 and included 21 children with TBI (injured before age 9) and 19 typically-developing children (TDC). Children with TBI showed lower FA across all pathways and poorer LDFR performance relative to TDC. Within the TBI group, mediation analysis revealed neither a significant total effect of GCS on LDFR nor significant direct effects of GCS on LDFR across pathways; however, the indirect effects of GCS on LDFR through FA of the corpus callosum, left perforant pathway, and left uncinate fasciculus were significant and opposite in sign to their respective direct effects. These results suggests that the predictive validity of GCS for LDFR is initially suppressed by the substantial variance accounted for by FA, which is uncorrelated with GCS, and the predictive validity of GCS increases only when FA is considered, and the opposing path is controlled. These findings illustrate the complex associations between acute injury severity, white matter pathways, and verbal memory several years following pediatric TBI.

OBJECTIVES The objectives of this study were to estimate the prevalence of cell phone and computer use among urban families bringing their children to an emergency department and to determine which technologies parents prefer to use to receive health information. METHODS We visited 2 pediatric emergency departments in Baltimore, Md, and Little Rock, Ark. A convenience sample of parents of children 8 years old or younger completed a self-administered survey in the waiting area. RESULTS Two hundred thirty-eight surveys were completed. Respondents were primarily female (83%), less than 35 years old (74%), and had at least a high school diploma or General Educational Development (94%). Forty-three percent were employed full time. A majority (95%) of respondents reported owning a cell phone, with most (88%) owning a smartphone and 96% reported having some internet access. Of cell phone owners, 91% reported daily text messaging activity. Over half (63%) of respondents reported having computer internet access at home; 31% reported having internet access at work. Patterns of behavior and preferences emerged for both cell phone and computer use. Respondents were more likely to check their email (75% vs 50%, P < 0.0001) and access the internet (78% vs 67%, P = 0.002) with a smartphone rather than their computer. CONCLUSIONS Both cell phones and computers are prevalent and used among urban families seen in pediatric emergency departments, offering new ways to deliver health information to these often underserved populations. Providers aiming to deliver health information should consider smartphone applications, text message-based programs, and email to communicate with their patients.

Purpose: Research demonstrates that children receive twice as much medical radiation from Computed Tomography (CT) scans performed at non-pediatric facilities as equivalent CTs performed at pediatric trauma centers (PTCs). In 2014, AFMC outreach staff educated Emergency Department (ED) staff on appropriate CT imaging utilization to reduce unnecessary medical radiation exposure. We set out to determine the educational campaign’s impact on injured children received radiation dose. Methods: All injured children who underwent CT imaging and were transferred to a Level I PTC during 2010 to 2013 (pre-campaign) and 2015 (post-campaign) were reviewed. Patient demographics, mode of transportation, ED length of stay, scanned body region, injury severity score, and trauma center level were analyzed. Median effective radiation dose (ERD) controlled for each variable, pre-campaign and post-campaign, was compared using Wilcoxon rank sum test. Results: Three hundred eighty-five children under 17 years were transferred from 45 and 48 hospitals, pre- and post-campaign. Most (43%) transferring hospitals were urban or critical access hospitals (30%). Pre- and post-campaign patient demographics were similar. We analyzed 482 and 398 CT scans pre- and post-campaign. Overall, median ERD significantly decreased from 3.80 to 2.80. Abdominal CT scan ERD declined significantly from 7.2 to 4.13 (P-value 0.03). Head CT scan ERD declined from 3.27 to 2.45 (P-value < 0.0001). Conclusion: A statewide, CT scan educational campaign contributed to ERD decline (lower dose scans and fewer repeat scans) among transferred injured children seen at PTCs. State-level interventions are feasible and can be effective in changing radiology provider practices.

Introduction:Sudden unexpected infant death is the leading cause of infant mortality with black: white infant mortality remaining at 2:1 for the last decade. Smartphone technology provides a convenient and accessible tool for injury prevention anticipatory guidance among at-risk communities.Materials and Methods:A convenience sample of pregnant teen mothers who own a smartphone. During a 1-month postnatal home visit, a safe sleep environment survey was administered, infant sleep practices were observed, and mothers trained to take and submit standard infants’ sleep environment photographs. Photographs were independently assessed for inter-rater reliability (IRR) across five sleep safety domains (primary outcome): sleep location, surface, position, presence of soft items, and hazards near the sleep area. Expert and novice coders IRR was measured using Cohen’s kappa coefficient (K). Sleep safety correlation between photographs and observation, and parent report and observation was determined.Results:Sixteen (57.1%) mothers completed the home visit. Most parents reported infants sleeping supine (78.5) in parents’ bedroom (85.9%). Photographs demonstrated sleep position, soft items without the baby present, and hanging toys had perfect agreement across all three coder pairs. Safe sleep experts’ IRR demonstrated perfect agreement for sleep location, position, and soft items. While 83.8% of parents were observed putting their infants down to sleep on their back, 78.5% of parents reported doing the same and 82.4% of the photographs demonstrated supine infant sleep position.Conclusion:Using photographs, coders can reliably categorize some key infant sleep safety aspects, and photograph sleep safety is comparable to parent report and direct observation.

Purpose Safety in Seconds (SIS) is a smartphone app that has demonstrated effectiveness at changing injury prevention behaviors. The aim of this analysis was to understand how parents engaged with each component of the app and determine if there was an association between app usage and behaviors. Methods Parents of children aged 4–7 visiting the pediatric emergency room in the two participating sites (regardless of the reason for the visit) were recruited. Study participants downloaded the SIS app onto their smartphone and were randomized receive car seat or fire safety information. Both groups completed a 10-minute assessment about their safety knowledge and behaviors and received tailored feedback relevant to their study group. The app contained a portal with educational links and sent monthly push notification reminders for parents to interact with the app. Parents completed follow-up assessments at 3- months and 6-months. Results Among the 602 parents completing all follow up points, 37% visited each page of the report, 19% emailed the report to themselves or someone else, and 33% visited the Parent Portal. Among 555 parents reporting at least one unsafe behavior at baseline, 130 (23.5%) changed their safety behaviors and reported no unsafe behaviors at the 6-month follow up. Those changing their behavior had more mean clicks (24 vs. 18; p Conclusion Smartphone applications hold potential for changing behaviors that are known to improve child passenger safety.

OBJECTIVES: All-terrain vehicle (ATV) crashes have been responsible for significant injuries among children, despite public education efforts. Our study examined pediatric ATV injury patterns in US emergency departments (EDs) compared with injuries after motor vehicle crash (MVC) and sports activities. METHODS: We studied 2006 to 2011 data from the Nationwide Emergency Department Sample. Children younger than 18 years and involved in ATV crashes, MVC, or sports activities were included. The primary outcome analyzed was a constructed binary measure identifying severe trauma, defined as injury severity score greater than 15. Logistic regression models were fit to determine the association between mechanism of injury and severe trauma. RESULTS: A total of 6,004,953 ED visits were identified. Of these, ATV crashes accounted for 3.4%, MVC accounted for 44.7%, and sports activities accounted for 51.9%. Emergency department visits after ATV crashes were more likely to result in admission (8%) and incur higher median charges ($1263) compared with visits after sports activities (1%, $1013). Visits after sports activities were 90% less likely to result in severe trauma when compared with ATV crash visits. Emergency department visits after ATV crashes result in severe injuries similar to those sustained in MVC (odds ratio, 1.03; P = 0.626). CONCLUSIONS: Pediatric ED visits after ATV crashes result in significant injuries and charges. Public health interventions such as education, legislation, and engineering are needed to reduce injuries among children and the subsequent ED visits for care. The impact of proven interventions may be greatest for children living in rural areas and among older children, 10 to 17 years old. Language: en

The growing interest in incorporating prevention into emergency health care make it timely to examine the use of computer technology to efficiently deliver effective education in this setting.This RCT compared results from an intervention group (n=367) that received child passenger safety information, to an attention-matched control (n=375). A baseline survey and two follow-up surveys at 3 and 6 months were conducted.Data were collected from June 2014 to September 2016 from a sample of parents with children aged 4-7 years recruited from a pediatric emergency department in an East Coast urban area and one in a Midwest semi-rural area.A theory-based, stage-tailored educational program, Safety in Seconds v2.0Four car seat behaviors: (1) having the correct restraint for the child's age and weight; (2) having the child ride in the backseat all the time; (3) buckling up the child all the time; and (4) having the child's restraint inspected by a child passenger safety technician.At 3 months, adjusting for baseline behaviors and attrition, the odds of reporting the correct behavior by the intervention group relative to the control group was 2.07 (p0.01) for using the correct car seat; 2.37 (p0.05) times for having the child ride in the back seat; 1.04 (nonsignificant) for riding buckled up all the time; and 1.99 (p0.01) times for having the car seat inspected. At 6 months, there were statistically significant effects for reporting use of the correct car seat (OR=1.84, p0.01) and having the car seat inspected (OR=1.73, p0.01).Mobile apps hold promise for reaching large populations with individually tailored child passenger safety education.Clinical Trial Registration # NCT02345941.

Background Sudden Unexpected Infant Death (SUID) results in 3400 sleep-related deaths yearly in the United States, yet caregivers’ compliance with safe sleep recommendations remains less than optimal. Paternal caregiver’s attitudes toward infant safe sleep messages are largely unaddressed, despite established differences between female and male caregiver perceptions. This study aimed to explore the determinants of safe sleep practices among male caregivers. Methods Focus groups were conducted in Arkansas with male caregivers of infants ages 2–12 months to discuss infant sleep routines, parental roles, sources for safe sleep information, and messaging suggestions for safe sleep promotion. The Health Belief Model of behavior change framed a moderator guide. Transcript-based analysis was used, and data were managed using HyperRESEARCH (version 2.8.3). The transcribed data were coded to identify significant themes. Results Ten focus groups were conducted with 46 participants. Inconsistent adherence to safe sleep practices was reported. Participants were more likely to describe safe location (57% of participants) and supine position behaviors (42%) than an uncluttered bed environment (26%). Caregivers acknowledged the importance of recommended safe sleep behavior, but admitted to unsafe practices, such as co-sleeping and unsafe daytime sleep. Lack of perceived risk, comfort, and/or resources, and disagreement among family members about safety practices were identified as barriers. Participants voiced concerns that current advertising portrays males as incompetent caregivers. Suggestions included portraying positive images of fathers and male caregivers acting to promote safety and the incorporation of statistics about the hazards of unsafe sleep to better engage fathers. Potential distribution venues included sporting events, home improvement and/or automotive stores, and social media from trusted sites (e.g. hospitals or medical professionals). Conclusions Male caregivers demonstrate some knowledge base about infant sleep safety, but are not fully practicing all aspects of safe sleep. Targeted messaging towards male caregivers that includes factual information and statistics along with representing males in a positive light is desired.

Purpose Sudden Infant Death Syndrome (SIDS) and suffocation account for more than half of all Sudden Unexpected Infant Deaths (SUID). The American Academy of Pediatrics (AAP) recommendations describe the safest environments to protect infants. This study compared parent responses on the Newborn Sleep Safety Survey and observational assessments ( N = 72) of infant sleep environments in families thought to be at high-risk for non-compliance with AAP recommendations. Design and Methods A naturalistic study of participants enrolled in two home visitation support programs was used. Observed risks ranged from 36.6% (never use pacifier) to 4.3% (never use firm mattress). Results Results comparing report to observation demonstrated acceptable concordance. Five items had fair concordance (Kappa > .4), four showed moderate concordance (Kappa > .6), and one excellent concordance (Kappa > .8). Although direct observation of safety behaviors is the gold standard in the injury prevention field, direct observation is logistically difficult, time consuming, and costly. Conclusions Research and interventions aimed at a reduction of Sudden Infant Death Syndrome (SIDS) and suffocation require accurate assessment of the infant sleep environment. This study provides acceptable evidence for the use of the Newborn Sleep Safety Survey as an alternative to direct observation to assess parent adherence to recommendations. Limitations are discussed. Practical Implications This study provided evidence of the usefulness of the Newborn Sleep Safety Survey , a parent survey of infant sleep environments. This tool will provide medical and research professionals a reliable, inexpensive tool to evaluation of the quality of sleep environments using a standard definition.

Purpose The long-term cancer risks for children exposed to radiologic images can be two to three times higher than for adults because children are more sensitive to radiation and have a longer lifetime in which to accumulate exposure from CT scans. Injured children often undergo repeat CT imaging if they are transferred from non-pediatric hospitals to a Level I pediatric trauma center (PTC). This study determined the impact of a statewide web-based image repository (WBIR) on repeat imaging among transferred injured children. Methods All injured children who underwent CT imaging and were transferred to the PTC in 2010 (pre-WBIR) and 2013 (post-WBIR) were included. Patient-level factors studied included demographics, body region of scan, Injury Severity Score, and Emergency Department (ED) disposition. Change from pre to post on rate of repeat imaging was assessed. Results Two hundred fifty-four and 233 children, with a median age of 7.3 years, were transferred to the Children's Hospital in 2010 and 2013, respectively. Repeat imaging levels at the PTC were lower post-WBIR than pre-WBIR (20% versus 33%, odds ratio [OR] 0.54, P = .005). Images of the head decreased most significantly (60% versus 33%, OR 0.33). Images performed at Level II and III trauma centers were repeated less often after WBIR. Conclusions The WBIR significantly reduced repeat imaging among injured children transferred to a PTC, especially children transferred from Level II and Level III trauma centers, children with lower-acuity injuries, and children with initial scans of the head. Radiation savings are expected to be beneficial to children.

The long-term effects of TBI on verbal fluency and related structures, as well as the relation between cognition and structural integrity, were evaluated. It was hypothesized that the group with TBI would evidence poorer performance on cognitive measures and a decrease in structural integrity.Between a paediatric group with TBI and a group of typically-developing children, the long-term effects of traumatic brain injury were investigated in relation to both structural integrity and cognition. Common metrics for diffusion tensor imaging (DTI) were used as indicators of white matter integrity.Using DTI, this study examined ventral striatum (VS) integrity in 21 patients aged 10-18 years sustaining moderate-to-severe traumatic brain injury (TBI) 5-15 years earlier and 16 demographically comparable subjects. All participants completed Delis-Kaplan Executive Functioning System (D-KEFS) sub-tests.The group with TBI exhibited lower fractional anisotropy (FA) and executive functioning performance and higher apparent diffusion coefficient (ADC). DTI metrics correlated with D-KEFS performance (right VS FA with Inhibition errors, right VS ADC with Letter Fluency, left VS FA and ADC with Category Switching).TBI affects VS integrity, even in a chronic phase, and may contribute to executive functioning deficits.

Background Sudden infant death syndrome (SIDS) and suffocation are leading causes of infant mortality. Supine sleep position and use of appropriate sleep surfaces reduce SIDS risk but are not universally practiced. Mothers’ decisions about sleep position and environment may be influenced by guidance provided by infants’ grandmothers and other caregivers. Methods A survey was conducted of a convenience sample of grandmothers aged 30–70 years who provide care at least weekly for an infant grandchild

Background Motor vehicle crashes are the leading cause of death for teens 14–19 years of age, with younger teen drivers at higher risk than older teens. Graduated driver licensing has been proven to reduce teen driver-related motor vehicle crashes and fatalities. Arkansas allows parents to request age waivers, which allow a teen to obtain a license for independent driving before the sixteenth birthday. The objectives of this study were to: (1) determine the prevalence of age waivers issued in Arkansas and (2) determine motor vehicle crash risks associated with 14 and 15 year old drivers. Methods This is a brief report on an informative query exploring risk factors related to age waivers. Publicly available databases were utilized for across state comparisons. The Web-based Injury Statistics Query and Reporting Systems (WISQARS) was utilized to calculate motor vehicle crash crude death rates. National Highway Traffic Safety Administration data were utilized to identify seat belt use rates. The Fatal Analysis Reporting System (FARS) was utilized to identify crash fatality risks for 14 and 15 year old drivers in Arkansas (N = 24). Age waiver data were obtained from the Arkansas Driver Control Administration. De-identified data on fatal crashes and rates of age waiver issuance in Arkansas for 14 and 15 year olds from 2004 through 2016 were calculated. Results We reviewed crash data for 14 and 15 year old drivers in Arkansas between 2004 and 2014 to determine fatality risks. Thirty-one out of seventy-five counties in Arkansas were above the state age waiver issuance rate of 30.4 per 1000 14 to 15 year old teens. Among the four states that had similar age waivers for 14 to 15 year olds, Arkansas had the highest motor vehicle death rate of 10.2 per 100,000 young teens and the lowest seat belt use rate at 73%. Conclusions Arkansas had the highest reported teen crash fatality rates among 4 states with age waivers. The volume of age waivers issued in Arkansas is concerning. Further research is needed to understand parental motivation when asking for age waivers and their level of awareness of the risks involved.

Current American Academy of Pediatrics recommendations regarding transition from child safety/booster seat to adult safety belt use indicate that children should be at least 4 feet 9 inches, 8 years old, or 80 pounds. Proper fit in the vehicle seat, assessed with a five-point fit test, should also be met. Although most children reach 4 feet 9 inches around age 8 years, each child and vehicle presents a unique combination; thus a child may not fit appropriately in all vehicle types using only the 4 feet 9 inches requirement.We enrolled children, aged 7 years to 12 years, into our study. Height, weight, and demographic data were obtained. A Child Passenger Safety Technician then performed the five-point fit test in each of a uniform lineup of five vehicles. Data were collected on fit in the standard vehicle seat and also in a booster seat. We set 90% as the threshold proportion of children who meet all criteria for proper fit to validate current recommendations of a height of 4 feet 9 inches.Data were collected on 388 children. The percentage of 90% proper fit was met in the compact car and small sport-utility vehicle (SUV). However, only 80 (77%) of 104 students (p0.0001) that were 4 feet 9 inches or higher fit properly in the large SUV, only 87 (83%) of 105 students (p = 0.02) fit properly in the pickup truck, and only 91 (89%) of 102 students (p = 0.74) fit properly in the minivan.Substantial proportions of children meeting current height guidelines for an adult seat belt do not meet safety requirements for fit, especially in larger, commonly used vehicles (large SUVs and trucks). This emphasizes the need for evaluation of fit by a trained personnel and/or development of standard back seat dimensions in all vehicles for maximum safety.Epidemiologic study, level III; Therapeutic study, level V.

Purpose Although child safety seats are known to reduce the risk of death from motor vehicle crashes, use among children 4–7 years old remains low and misuse is widespread. The aim of this prospective randomised trial was to test the efficacy of a smartphone app, Safety In Seconds 2.0, which delivered theory-based tailored education about child safety seats to parents in Little Rock, Arkansas and Baltimore, Maryland Methods Parents of children aged 4–7 visiting the paediatric emergency room in the two participating sites (regardless of the reason for the visit) were recruited. Study participants downloaded the Safety In Seconds app onto their smartphone and were randomised to the intervention (car seat) or control (fire safety) group. Both groups completed a 10 min assessment about their safety knowledge and behaviours and received tailored feedback relevant to their study group. The app contained a portal with educational links and sent monthly push notification reminders for parents to interact with the app. Parents completed follow-up assessments at 3 months and 6 months. Results A total of n=1129 parents were enrolled, and 742 (66%) completed the 6 month follow-up survey. At follow-up relative to the CG, IG parents were more likely to report using the correct child safety seat for their child’s age and size (OR=1.8; p Conclusions/Significance Smartphone applications hold potential for changing behaviours that are known to improve child passenger safety.

Use of cranial CT scans in children has been increasing, in part due to increased awareness of sports-related concussions. CT is the largest contributor to medical radiation exposure, a risk factor for cancer. Long-term cancer risks of CT scans can be two to three times higher for children than for adults because children are more radiosensitive and have a longer lifetime in which to accumulate exposure from multiple scans.To compare the radiation exposure injured children receive when imaged at nonpediatric hospitals (NPHs) versus pediatric hospitals.Injured children younger than 18 years who received a CT scan at a referring hospital during calendar years (CYs) 2010 and 2013 were included. Patient-level factors included demographics, mode of transportation, and Injury Severity Score, and hospital-level factors included region of state, radiology services, and hospital type and size. Our primary outcome of interest was the effective radiation dose.Four hundred eighty-seven children were transferred to the pediatric trauma center during CYs 2010 and 2013, with a median age of 7.2 years (interquartile range 5-13). The median effective radiation dose received at NPHs was twice that received at the pediatric trauma center (3.8 versus 1.6 mSv, P.001). Results were confirmed in independent and paired analyses, after controlling for mode of transportation, emergency department disposition, level of injury severity, and at the NPH trauma center level, hospital type, size, region, and radiology services location.NPHs have the potential to substantially reduce the medical radiation received by injured children. Pediatric CT protocols should be considered.

OBJECTIVES: Motor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population. METHODS: A multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions. RESULTS: Four hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02). CONCLUSIONS: In this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified. Language: en

Controlling for injury and patient characteristics, one would expect comparable in-hospital outcomes for injured patients with and without epilepsy. The historical stigma associated with epilepsy is well-documented, yet potential disparities in injury care for people with epilepsy/seizures have not been examined. We compared in-hospital outcomes of injured patients with epilepsy/seizures with patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy have worse outcomes. Methods: Existing data were analyzed from the Nationwide Inpatient Sample-the largest, longitudinal, all-payer inpatient care database in the United States. Injured patients of all ages were included. Multivariable logistic regression was used to control for patient and hospital characteristics. Main outcome measure: in-hospital mortality. Results: When controlling for patient and injury characteristics, our results show that people with epilepsy/seizures were more likely to die in-hospital than people without epilepsy odds ratio (OR) 1.17, p Language: en

OBJECTIVE. Children with moderate to severe traumatic brain injury (TBI) show early neurobehavioral deficits that can persist several years after injury. Despite the negative impact that TBI can have on a child's physical, cognitive, and psychosocial well-being, only 1 study to date has documented the receipt of health care services after acute care and the needs of children after TBI. The purpose of this study was to document the health care use and needs of children after a TBI and to identify factors that are associated with unmet or unrecognized health care needs during the first year after injury. METHODS. The health care use and needs of children who sustained a TBI were obtained via telephone interview with a primary caregiver at 2 and 12 months after injury. Of the 330 who enrolled in the study, 302 (92%) completed the 3-month and 288 (87%) completed the 12-month follow-up interviews. The health care needs of each child were categorized as no need, met need, unmet need, or unrecognized need on the basis of the child's use of post-acute services, the caregiver's report of unmet need, and the caregiver's report of the child's functioning as measured by the Pediatric Quality of Life Inventory (PedsQL). Regardless of the use of services or level of function, children of caregivers who reported an unmet need for a health care service were defined as having unmet need. Children who were categorized as having no needs were defined as those who did not receive services; whose caregiver did not report unmet need for a service; and the whose physical, socioemotional, and cognitive functioning was reported to be normal by the caregiver. Children with met needs were those who used services in a particular domain and whose caregivers did not report need for additional services. Finally, children with unrecognized needs were those whose caregiver reported cognitive, physical, or socioemotional dysfunction; who were not receiving services to address the dysfunction; and whose caregiver did not report unmet need for services. Polytomous logistic regression was used to model unmet and unrecognized need at 3 and 12 months after injury as a function of child, family, and injury characteristics. RESULTS. At 3 months after injury, 62% of the study sample reported receiving at least 1 outpatient health care service. Most frequently, children visited a doctor (56%) or a physical therapist (27%); however, 37% of caregivers reported that their child did not see a physician at all during the first year after injury. At 3 and 12 months after injury, 26% and 31% of children, respectively, had unmet/unrecognized health care needs. The most frequent type of unmet or unrecognized need was for cognitive services. The top 3 reasons for unmet need at 3 and 12 months were (1) not recommended by doctor (34% and 31%); (2) not recommended/provided by school (16% and 17%); and (3) cost too much (16% and 16%). Factors that were associated with unmet or unrecognized need changed over time. At 3 months after injury, the caregivers of children with a preexisting psychosocial condition were 3 times more likely to report unmet need compared with children who did not have one. Also, female caregivers were significantly more likely to report unmet need compared with male caregivers. Finally, the caregivers of children with Medicaid were almost 2 times more likely to report unmet need compared with children who were covered by commercial insurance. The only factor that was associated with unrecognized need at 3 months after injury was abnormal family functioning. At 12 months after injury, although TBI severity was not significant, children who sustained a major associated injury were 2 times more likely to report unmet need compared with children who did not. Consistent with the 3-month results, the caregivers of children with Medicaid were significantly more likely to report unmet needs at 1 year after injury. In addition to poor family functioning's being associated with unrecognized need, nonwhite children were significantly more likely to have unrecognized needs at 1 year compared with white children. CONCLUSIONS. A substantial proportion of children with TBI had unmet or unrecognized health care needs during the first year after injury. It is recommended that pediatricians be involved in the post-acute care follow-up of children with TBI to ensure that the injured child's needs are being addressed in a timely and appropriate manner. One of the recommendations that trauma center providers should make on hospital discharge is that the parent/primary caregiver schedule a visit with the child's pediatrician regardless of the post-acute services that the child may be receiving. Because unmet and unrecognized need was highest for cognitive services, it is important to screen for cognitive dysfunction in the primary care setting. Finally, because the health care needs of children with TBI change over time, it is important for pediatricians to monitor their recovery to ensure that children with TBI receive the services that they need to restore their health after injury.

Trisomy 18 and trisomy 13 are associated with serious and/or fatal birth defects, with death frequently occurring in the first month of life. Previous studies are limited by small samples and are dated. This study characterized the comorbid birth defects associated with trisomy 18 and trisomy 13 among US liveborn infants using the Healthcare Cost and Utilization Project's Kids' Inpatient Database and Nationwide Inpatient Sample, two large, current and nationally representative databases. The occurrence of 39 commonly reported comorbid birth defects among infants with trisomies 18 and 13 was compared to the occurrence of malformations among newborns without trisomies. The prevalences of trisomy 18 and 13 were 1.29/10,000 and 0.85/10,000 live births, respectively. Among infants with trisomy 18, 61% were female, 45.4% with heart defects. Among those with trisomy 13, 53% were female, 38.4% had heart defects, 24.5% had orofacial anomalies, and 11.2% had central nervous system abnormalities. More than half of the newborns with both conditions died prior to discharge. This updated information can be used to inform clinical decision-making and may help providers better prepare families for infants with trisomies.

McCarthy ML, MacKenzie EJ, Durbin DR, Aitken ME, Jaffe KM, Paidas CN, Slomine BS, Dorsch AM, Berk RA, Christensen JR, Ding R, and the CHAT Study Group. The Pediatric Quality of Life Inventory: an evaluation of its reliability and validity for children with traumatic brain injury. Objectives To assess the reliability and validity of the Pediatric Quality of Life Inventory, version 4.0 (PedsQL), and to compare it with that of the Behavior Rating Inventory of Executive Function (BRIEF) among children with traumatic brain injury (TBI). Design Prospective cohort study that documented the health-related quality of life of 391 children at 3 and 12 months postinjury. Setting Four level I pediatric trauma centers. Participants Children (age range, 5–15y) hospitalized with a TBI or an extremity fracture. Interventions Not applicable. Main Outcome Measures Parent-reported PedsQL and BRIEF scale scores. Results Both the PedsQL and BRIEF scales showed good internal consistency (PedsQL α range, .74–.93; BRIEF α range, .82–.98) and test-retest reliability (PedsQL r range, .75–.90; BRIEF r range, .82–.92), respectively. Factor analysis revealed that most PedsQL items loaded most highly on their conceptually derived scale. The PedsQL cognitive function scale detected the largest differences among groups of children with varying severities of TBI as well as parents' assessment of change in cognition postinjury. Conclusions Although the reliability of the 2 instruments is comparable, the PedsQL discriminates better among children with TBI. The PedsQL is a promising instrument for measuring the health of children after TBI.

Objective. All-terrain vehicle (ATV) injuries among children represent a significant and growing problem. Although state-level analyses have characterized some aspects of pediatric ATV-related injuries, little information on the national impact on hospitalization is available. This study was designed to characterize more fully the patterns of injury, hospital length of stay, and hospital charges associated with ATV-related injuries, with a nationally representative sample.Methods. Analyses were based on the 1997 and 2000 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The KID is the only national, all-payer database of hospital discharges for children. KID data were weighted to represent all discharges from general hospitals in the United States. Discharges with external cause-of-injury codes consistent with off-road ATV-related injuries were selected, and the affected population was described. Nationally representative rates of ATV-related injuries were calculated, and changes between 1997 and 2000 were documented.Results. An estimated 5292 children were hospitalized because of ATV-related injuries during the 2-year period, and hospitalizations increased 79.1% between 1997 and 2000. Rates of ATV-related hospitalization were highest among adolescent white male subjects, consistent with previous studies. Most patients had hospital lengths of stay of 8 days. Injury severity varied considerably, with more than one third of patients sustaining moderate to severe injuries. Approximately 1% of hospitalizations resulted in in-hospital deaths. Total hospital charges for this injury mechanism were $74367677 for the 2-year study period. Most of these charges were paid by private insurers.Conclusions. This study provides evidence supporting recent substantial increases in childhood ATV-related injuries. The hospitalization impact of ATV-related injuries among children is considerable. Our data support the need for ongoing creative attempts to identify effective strategies to decrease ATV injuries among children.

Aitken ME, Mele N, Barrett KW. Recovery of injured children: parent perspectives on family needs. Arch Phys Med Rehabil 2004;85:567–73. Objective To study the broader impact of emotional and financial burdens of injury in children on their families, along with solutions to these problems. Design Focus groups were conducted to reveal the needs of parents and children after injury. Audiotaped semistructured interviews were conducted by a team of qualitative researchers. Setting Tertiary care children's hospital. Participants Mothers of children who had sustained traumatic injury. Interventions Not applicable. Main outcome measures Summary of reported themes of experience and suggested interventions. Data were analyzed by using content analysis software. Results Overall satisfaction with care was high. Parents expressed concerns with communication, access to care, and the transition both within the phases of medical care and from medical care into the community. Consistent financial and social stressors were voiced, along with the need for peer support during all phases of care. Conclusions Parents provided valuable insight into their needs after their child's injury. Attention to constructive communication, clarification of the system of care, continued family-centered care, and development of peer support programs may meet the needs of caregivers and therefore facilitate improvement in pediatric injury recovery.

Objective. Injury is the major cause of death in children ages 1 to 19 in the United States and is a leading cause of morbidity. Few studies have described the impact of injuries on the health status of affected children over time or used newer, child-specific measures in this population. The objective of this study was to describe the health status of children in the 6 months after admission for injury using child-specific health status measures. Methods. Injured children who were ages 3 to 18 years and admitted to an academic children’s hospital were evaluated at discharge and at 1 and 6 months after discharge with a battery of outcome measures. The Child Health Questionnaire (CHQ) measured health status. The scores on the Functional Independence Measure (FIM) or pediatric version of the FIM tracked physical function. Results. A total of 195 children were enrolled. Boys outnumbered girls (67% vs 33%). Injury mechanisms and severity scores were typical of pediatric injury populations reported in other studies. Most (90%) children had at least 1 area of functional limitation by FIM at discharge, and 57% had some impairment at 1 month. By 6 months, 28% reported some limitation. At discharge, CHQ summary scores for the injury group were markedly depressed compared with normative populations. Differences in both physical health and psychosocial health summary scores between the injured and normal children persisted through 6 months of follow-up. Scores on 11 of 12 subscales were significantly below the normal population at discharge. This was particularly evident for bodily pain (injury group mean 49.1 vs normative mean 81.7) and parental impact-emotional (43.9 vs 80.3), and physical functioning (50.9 vs 96.1). Significant differences persisted in all subscales at 1 month and in 6 subscales at 6 months. Conclusions. The CHQ provided useful information about the impact of injuries on children and their families over time. Significantly reduced scores in several domains of the CHQ highlight problem areas for injury patients, several of which persist through 6 months of follow-up. Low scores in areas of bodily pain and parental emotional burden suggest that improved management of these problems is required. Additional study of risk factors for persistent problems after injury may suggest ways to improve functional outcomes of injured children and reduce the impact on their families.

This study was undertaken to examine variation in therapies and outcome for pediatric head trauma patients by patient characteristics and by pediatric intensive care unit. Specifically, the study was designed to examine severity of illness on admission to the pediatric intensive care unit, the therapies used during the pediatric intensive care unit stay, and patient outcomes.Consecutive admissions from three pediatric intensive care units were recorded prospectively (n = 5,749). For this study, all patients with an admitting diagnosis of head trauma were included (n = 477). Data collection occurred during an 18-month period beginning in June 1996. All of the pediatric intensive care units were located in children's hospitals, had residency and fellowship training programs, and were headed by a pediatric intensivist.Admission severity was measured as the worst recorded physiological derangement during the periodor=6 hrs before pediatric intensive care unit admission. Therapies and resource use were based on the Therapeutic Intervention Scoring System with adaptations for pediatrics. The use of intracranial pressure monitoring was recorded on admission to the unit (within 1 hr) and at any time during the pediatric intensive care unit stay. Outcomes were measured at the time of pediatric intensive care unit discharge by the Pediatric Overall Performance Category scale. Risk factors for mortality were examined by using bivariate analyses with significant predictors as candidate variables in a logistic regression to predict expected mortality. Intracranial pressure monitoring and other therapies were added to the mortality prediction model to test for protective effects. Finally, race and insurance status were added to the model to test for differences in the quality of care.The overall mortality rate for the entire sample was 7.8%. Mortality rates for childrenor=1 yr old were significantly higher than for children1 yr old (16.1% vs. 6.1%; p = .002). Comparisons by insurance status indicated that observed mortality rates were highest for self-paying patients. However, patient characteristics were not associated with use of therapies or standardized mortality rates after adjustment for patient severity. There was significant variation in the use of paralytic agents, seizure medications, induced hypothermia, and intracranial pressure monitoring on admission across the three pediatric intensive care units. In multivariate models, only the use of seizure medications was associated significantly with reduced mortality risk (odds ratio = 0.17; 95% confidence interval = 0.04-0.70; p = .014).Therapies and outcomes vary across pediatric intensive care units that care for children with head injuries. Increased use of seizure medications may be warranted based on data from this observational study. Large randomized controlled trials of seizure prophylaxis in children with head injury have not been conducted and are needed to confirm the findings presented here.

Background Child safety seats are known to reduce the risk of death from motor vehicle crashes by between 50%–80%. CSS use among younger children is common, use for older children is low, and CSS misuse is widespread. We developed a smart phone app to promote correct CSS use among children younger than 8 years old and tested it with parents of children who presented in one urban and one rural paediatric emergency department in 2 US states. Methods Research staff helped enrolled parents download the Safety in Seconds app to their smart phone. Parents completed a series of assessment items about their CSS knowledge and beliefs. Intervention group parents reported in more detail about their CSS beliefs and practices with all age-eligible children while control parents answered a similar number of items about another safety topic. Both groups received an electronic report from the app in real time that offered recommendations for improving their health behaviour of interest. All parents received periodic text messages and completed follow up reports through the app at 3 and 6 months. Study enrollment is expected to end in January 2016 and follow ups by July 2016. Results To date, 761 parents completed baseline surveys (32% rural; 68% urban). Study parents, on average, are black (65.6%), employed (65.8%), with more than a high school education (60.0%), with no differences between study groups. Index child is 5.2 years old. At 6 month follow up, more intervention group parents had gotten their child’s safety seat inspected by a car seat technician (34% vs 24%) and properly identified that children should ride in the back seat of the car until at least age 13 (35% vs 27%). Additional CSS knowledge, beliefs and practices will be explored when the final data set is ready. Conclusions Child passenger safety remains an important public health problem. Programs are needed to correct widespread misuse and to promote CSS use among older children.

BACKGROUND: Family-centered rounds (FCR) are defined as interdisciplinary bedside teaching rounds with active family participation. The objective of this study was to examine the association of FCR with family experiences and health services use. METHODS: Prospective study comparing families with a child admitted to general pediatric inpatient services with and without FCR. The presence of FCR elements was assessed before study enrollment. Study data were obtained by an in-person interview, a follow-up phone interview RESULTS: A total of 140 of 203 eligible families were enrolled; 97 completed follow-up surveys (49 on FCR team). Compared with non-FCR, FCR families were more likely to report consistent medical information (P < .001), the option of discussing care plan (P < .001), doctors listening carefully (P < .01), and doctors showing respect (P < .001). No differences were found in number of medications (mean 2.4 vs 2.9, P = .26) or discharge time (mean 3:06 pm versus 2:43 pm, P = .39). No difference was found for hospital charges after adjusting for length of stay outliers. CONCLUSIONS: FCR are associated with higher parent satisfaction, consistent medical information, and care plan discussion, with no additional burden to health service use. Additional studies should assess FCR under different settings of care.

BACKGROUND:In the United States, drowning is the second leading cause of unintentional injury death in children aged 1 to 19 years, accounting for nearly 1100 deaths per year. Although a decline in overall fatal drowning deaths among children has been noted, national trends and disparities in pediatric drowning hospitalizations have not been reported.METHODS:To describe trends in pediatric drowning in the United States and provide national benchmarks for state and regional comparisons, we analyzed existing data (1993–2008) from the Nationwide Inpatient Sample, the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0 to 19 years were included. Annual rates of drowning-related hospitalizations were determined, stratified by age, gender, and outcome.RESULTS:From 1993 to 2008, the estimated annual incidence rate of pediatric hospitalizations associated with drowning declined 49% from 4.7 to 2.4 per 100 000 (P < .001). The rates declined for all age groups and for both males and females. The hospitalization rate for males remained consistently greater than for females at each point in time. Rates of fatal drowning hospitalization declined from 0.5 (95% confidence interval, 0.4–0.7) deaths per 100 000 in 1993–1994 to 0.3 (95% confidence interval, 0.2–0.4) in 2007–2008 (P < .01). No difference was observed in the mean hospital length of stay over time.CONCLUSIONS:Pediatric hospitalization rates for drowning have decreased over the past 16 years. Our study provides national estimates of pediatric drowning hospitalization that can be used as benchmarks to target and assess prevention strategies.

Emergency department (ED) crowding is an increasingly common problem in the United States. Crowding can lead to ED closure and diversion, poor patient satisfaction, and patient safety issues. The purpose of this study was to examine measures of ED census and measures of crowding to determine if a correlation exists in a pediatric ED setting.Arkansas Children's Hospital is a major pediatric referral center. Measures of ED acuity (including total census, admission rate, total number of admissions, and proportion of triage category nonurgent patients) and measures of throughput (left-without-being-seen [LWBS] rate and ED length of stay [LOS]) data for 11 years (1996-2006) were plotted, and correlation coefficients were calculated.Annual ED census varied between 35,415 and 40,711 during the 11-year study period. The total number of admissions increased from 4179 in 1996 to 6539 in 2006. When total census was plotted against LWBS rate and ED LOS, a poor correlation was found (R² = 0.007 for total census vs LWBS rate). However, a strong correlation was found when the relationship between the total number of admissions and LWBS rate was examined (R² = 0.89). Similarly, a strong relationship between the admission rate and LWBS rate was seen (R² = 0.75). In addition, a strong correlation was seen between admissions (total and percentage) versus ED LOS.There is a strong correlation between the number of patients admitted and measures of overcrowding in this pediatric ED, but there is a poor correlation between the total census and overcrowding measures. Targeting process improvement on hospital-wide patient flow may help reduce ED crowding.

In the United States, burns are the third leading cause of unintentional injury death in children aged 1-14 years, accounting for more than 600 deaths per year in children aged 0-19 years.To describe trends in paediatric burn hospitalisations in the United States and provide national benchmarks for state and regional comparisons.Analysis of existing data (1993-2006) from the Nationwide Inpatient Sample-the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0-19 years were included.Estimated national annual rates of burn-related hospitalisations, stratified by age, gender, and in-hospital mortality.From 1993 to 2006, the estimated annual incidence rate of paediatric hospitalisations associated with burns declined 40% from 27.3 (1993-94) to 16.1 per 100,000 (p0.001). The rates declined for all age groups and for both boys and girls. Boys were consistently more likely to be hospitalised than girls (20.3 vs 11.7 hospitalisations per 100,000 during 2004-06, p0.001). For children less than 5 years of age, burn hospitalisations decreased 46% from 65.2 per 100,000 in 1993-94 to 35.1 per 100,000 in 2004-06 (p0.001). Fatal hospitalisation rates also declined from 0.3 deaths per 100,000 in 1993-94 to 0.1 in 2004-06 (p0.001).Paediatric hospitalisation rates for burns have decreased over the past 14 years. The study also provides national estimates of paediatric burn hospitalisations that can be used as benchmarks to further injury prevention effectiveness through targeting of effective strategies.

Wide variation has been reported in the proportion of injury deaths occurring during the prehospital phase. Potential disparities in where injured people with epilepsy and seizure disorders die have not been examined. We compared location of death between injured patients with epilepsy and seizure disorders and similar patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy/seizures are more likely to die outside of a hospital or health care setting.U.S. vital statistics (mortality) data from the multiple cause of death files of the National Center for Health Statistics were analyzed. Patients less than 65 years of age at death who had injury as the underlying cause of death were included. Multinomial logistic regression was used to assess location of death, controlling for patient and injury characteristics.Controlling for potential confounders, people with epilepsy/seizures were more likely to die at home from unintentional injuries (relative risk ratio [RRR]=1.51, P0.001) and less likely to die in public places (RRR=0.27, P0.001). People with epilepsy/seizures were less likely to die at home or in public places from suicide, but significantly more likely to die at home from homicide (RRR=2.29, P0.001). By mechanism of injury, people with epilepsy/seizures were more likely to die at home from drowning (RRR=2.35, P0.001).Disparities in where injured people with epilepsy/seizures die deserve further attention. Identifying the underlying causes of these disparities will allow for the development of targeted prevention interventions.

Objective.We determined the rate and costs of recent U.S. all-terrain vehicle (ATV) and bicycle deaths.Methods.Fatalities were identified from the National Center for Health Statistics Multiple Cause-of-Death public-access file. ATV and bicycle deaths were defined by International Classification of Diseases, 10th Revision codes V86.0–V86.9 and V10–V19, respectively. Lifetime costs were estimated using standard methods such as those used by the National Highway Traffic Safety Administration.Results.From 2000 through 2005, 5,204 people died from ATV crashes and 4,924 from bicycle mishaps. A mean of 694 adults and 174 children died annually from ATV injuries, while 666 adults and 155 children died from bicycle injuries. Death rates increased among adult ATV and bike riders and child ATV riders. Males had higher fatality rates for both ATVs and bicycles. Among children, total costs increased 15% for ATV deaths and decreased 23% for bicycle deaths. In adults, ATV costs increased 45% and bike costs increased 39%.Conclusions.Bicycle- and ATV-related deaths and associated costs are high and, for the most part, increasing. Promotion of proven prevention strategies, including helmet use, is indicated. However, enforcement of helmet laws is problematic, which may contribute to observed trends.

Although helmet use has been shown to be effective in reducing traumatic brain injuries (TBIs) due to motorcycle and bicycle crashes, it is unknown whether helmet use is associated with different injury patterns and severity for users of all-terrain vehicles (ATVs).To compare likelihood of injury and death between helmeted and unhelmeted riders of ATVs.The National Trauma Data Bank for years 2002-2006 was used to examine the records of 11 589 patients hospitalized for injuries resulting from ATV use. The likelihood of receiving a TBI diagnosis or a significant injury to other body regions and differences in injury severity and in-hospital mortality between helmeted and unhelmeted ATV riders were compared.After multivariable adjustment, compared with helmeted riders, unhelmeted riders were significantly more likely to sustain any TBI (OR 1.62, 95% CI 1.49 to 1.76, p0.001) and major/severe TBI (OR 3.19, 95% CI 2.39 to 4.25, p0.001). Unhelmeted riders were significantly more likely to die while in hospital than were helmeted riders (OR 2.58, 95% CI 1.79 to 3.71, p0.001). Significant injuries to the neck and face regions were also significantly more likely in unhelmeted riders (OR 3.53, 95% CI 1.28 to 9.71, p = 0.015, and OR 1.94, 95% CI 1.32 to 2.84, p = 0.001, respectively).ATV riders who do not wear helmets are more likely to receive significant injuries to the head, face, and neck. Prevention strategies and enforceable policy interventions to increase helmet use among ATV riders appear warranted.

OBJECTIVE. Traumatic brain injury has a substantial impact on caregivers. This study describes the burden experienced by caregivers of children with traumatic brain injury and examines the relationship between child functioning and family burden during the first year after injury.PATIENTS AND METHODS. Children aged 5 to 15 years hospitalized for traumatic brain injury at 4 participating trauma centers were eligible. Caregivers completed baseline and 3- and 12-month telephone interviews measuring the child's health-related quality of life using the Pediatric Quality of Life Inventory. The emotional impact scale of the Child Health Questionnaire was used to identify caregivers with substantial distress, including general worry or interference with family routine. Caregiver perceptions of whether health care needs were met or unmet and days missed from work were also measured.RESULTS. A total of 330 subjects enrolled; follow-up was conducted with 312 at 3 months and 288 at 12 months. Most subjects were white (68%) and male (69%). Abnormal Pediatric Quality of Life Inventory subscores were related to substantial caregiver burden (either general worry or interference in routine). These abnormalities were reported by >75% of patients at 3 months and persisted to 1 year in some patients. Parental perception of unmet health care needs was strongly related to family burden outcomes, with up to 69% of this subset of parents reporting substantial worry, and nearly one quarter reporting interference with daily routine/concentration 1 year after injury. Child dysfunction predicted parental burden at 3 and 12 months. Burden was greater when health care need was unmet. Abnormalities on the Pediatric Quality of Life Inventory predicted the amount of work missed by parents, especially in the presence of unmet needs.CONCLUSIONS. Caregivers are more likely to report family burden problems when child functioning is poorer and health care needs are unmet. Improved identification and provision of services is a potentially modifiable factor that may decrease family burden after pediatric traumatic brain injury.

OBJECTIVES. The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons. METHODS. Analysis of existing data (1991–2005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratified according to age, gender, severity of traumatic brain injury, and outcome, were determined. RESULTS. From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100 000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100 000 in 1991–1993 to 2.8 deaths per 100 000 in 2003–2005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged. CONCLUSIONS. Although pediatric hospitalization rates for mild traumatic brain injuries have decreased over the past 15 years, rates for moderate and severe traumatic brain injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.

Substantial variation exists with respect to the management of traumatic brain injuries (TBI) in children. Centers that practice aggressive treatment of TBI may improve survival, but it is not clear that the outcomes can be justified using cost-effectiveness criteria. This study illustrates the use of cost-effectiveness analysis to assess interventions for improving outcomes in children by assessing the cost per quality-adjusted life year (QALY) gained from technological change in the treatment of TBI. Cost and survival data associated with technological change in the treatment of pediatric TBI was based on nationally representative hospital administrative data for all children

Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking.This study seeks to describe the preference-weighted health outcomes of children following a traumatic brain injury at 3- and 6-months following pediatric intensive care unit (ICU) discharge.Children aged 5-17 who required ICU admission and endotracheal intubation or mechanical ventilation.The Quality of Well-being (QWB) score was used to describe preference-weighted outcomes. Clinical measures from the intensive care unit stay were used to estimate risk of mortality. Risk of mortality, Glasgow coma scores, patient length of stay in the intensive care unit, and parent-reported items from the Child Health Questionnaire (CHQ) were used to test construct validity.Subject data were obtained from nine pediatric intensive care units with consent procedures approved by representative institutional review boards. Medical records containing clinical information from the ICU stay were abstracted by the study coordinating center. Caregivers of children were contacted by telephone for follow-up interviews at 3- and 6-months following ICU discharge. All interviews were conducted by telephone with the primary caregiver of the injured child. Preference score statistics are presented overall and in relation to characteristics of the patient and their ICU admission.A response rate of 59% was achieved for the 3-month interviews (N = 56) and 67% for the 6-month interviews (N = 65) for caregivers of children aged 5 years and above that consented to participate. Overall, QWB scores averaged 0.508 (95% CI: 0.454-0.562) at the 3-month interview and 0.582 (95% CI: 0.526-0.639) at the 6-month interview. For both interview periods, scores ranged from 0.093 to 1.0 on a 0-1 value scale, where 0 represents death and 1 represents perfect health. Specific acute and chronic health problems from the QWB scale were present more often in patients with higher injury severity. Mortality risk, ICU length of stay, Glasgow Coma Scales, and parental reported summary scores from the CHQ all correlated correctly with the QWB scores.The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.

Objective Families with young children are at increased risk for home fires. Fire departments have used a number of approaches to increase the uptake of smoke alarms in high-risk homes with mixed success. This presentation will describe a pilot study that partnered a nurse home visiting program for high-risk, low-income families with a local fire department in Phoenix, AZ to instal smoke alarms. Methods During a regularly scheduled home visit, nurses with the Nurse-Family Partnership (NFP) at the Maricopa County Department of Public Health informed their clients about an opportunity to have smoke alarms installed in their home. Nurses sent a referral to the Phoenix Fire Department (PFD) for a free smoke alarm installation for free. PFD volunteers accompanied nurses during a following appointment to instal smoke alarms and to provide safety education. Mixed Methods were used for the evaluation, including a 3-month follow-up survey of knowledge, observation of smoke alarms, and in-depth interviews with key informants from NFP and PFD. Results 58 clients enrolled in the pilot study. To date, 41 smoke alarm installation visits and 33 follow-up surveys have been completed. Before the program, 56% (n = 23/41) of homes had no working smoke alarm. PFD installed 54 smoke alarms into 41 homes; every home had at least one smoke alarm by the end of the home visit. At follow-up, all homes maintained at least one smoke alarm. Clients increased knowledge scores by 30%. Interviewees from both NFP and PFD spoke highly of the program, found it to be consistent with their organisations’ missions, and would like it to continue. Final analyses of the full sample of follow-ups and of the qualitative interviews will be presented. Conclusion Pairing home visiting nurses with local fire departments can be a successful approach to increasing the number of high-risk homes with smoke alarms.

To document health-related quality of life (HRQOL) of children with traumatic brain injury (TBI) and to examine the relationship between TBI severity and HRQOL during the first year after injury.Prospective cohort study.Four pediatric level I trauma centers.Children with TBI (n = 330).Traumatic brain injury.A primary caregiver completed telephone interviews at baseline, 3 months, and 12 months to measure the child's HRQOL using the Pediatric Quality of Life Inventory. The HRQOL outcomes were modeled as a function of injury, patient characteristics, and family characteristics using longitudinal, multivariable regression.A considerable proportion of children had impaired HRQOL at 3 months (42% of children) and 12 months (40% of children) after injury. Multiple dimensions of HRQOL were negatively affected among children with moderate or severe TBI (decrease of 3.7 to 17.6) (P.05) and did not improve significantly over time. Concomitant lower extremity fractures and spinal injuries resulted in large declines in overall HRQOL, particularly at 3 months after injury (decrease of 12.9 and 8.1, respectively) (P.05). The HRQOL scores were also reduced by preexisting psychosocial conditions (decrease of 2.9 to 12.3), impaired family functioning (decrease of 5.1 to 6.8), having Medicaid coverage or being uninsured (decrease of 3.1 to 5.5), and single-parent households (decrease of 3.2 to 3.4) (P.05).Moderate or severe TBI resulted in measurable declines in children's HRQOL after injury. Injury-related factors impacted HRQOL more compared with patient and family characteristics during the first year after injury.

OBJECTIVES: Clothesline injury to the face and neck is a unique mechanism of injury seen in children and adolescents on all-terrain vehicles (ATVs). The purpose of this study was to describe this serious and avoidable injury pattern. METHODS: A search was made of the trauma registry at a major pediatric referral hospital for the years 1998 to 2003 to find cases of clothesline injury associated with ATV use. The data were deidentified and compiled by the research group. The study was deemed exempt by the local institutional review board. RESULTS: Seven cases of neck and/or facial injury were found associated with a child or adolescent on an ATV striking a wire fence or clothesline. All patients were white, including 5 boys and 2 girls. The mean age was 8 years (range, 2-14 years). In most cases (5/7), the child was driving across a field when the wire fence was struck. All patients had significant neck and/or facial lacerations, and 5 of 7 patients were taken to the operating room for wound closure. One patient had functional impairment, and all had lasting disfigurement. The mean initial hospital charges were US22,843 dollars. CONCLUSIONS: Clothesline injury to the neck and face associated with ATV use in children and adolescents is a unique and serious injury mechanism. Because all of these injuries in our series occurred in young children or adolescents who were driving or riding on the front of the ATV, it emphasizes the recommendation that children and young adolescents should not ride or drive ATVs.

OBJECTIVE. Recent school shootings and terrorist events have demonstrated the need for well-coordinated planning for school-based mass-casualty events. The objective of this study was to document the preparedness of public schools in the United States for the prevention of and the response to a mass-casualty event. METHODS. A survey was mailed to 3670 school superintendents of public school districts that were chosen at random from a list of school districts from the National Center for Education Statistics of the US Department of Education in January 2004. A second mailing was sent to nonresponders in May 2004. Descriptive statistics were used for survey variables, and the χ2 test was used to compare urban versus rural preparedness. RESULTS. The response rate was 58.2% (2137 usable surveys returned). Most (86.3%) school superintendents reported having a response plan, but fewer (57.2%) have a plan for prevention. Most (95.6%) have an evacuation plan, but almost one third (30%) had never conducted a drill. Almost one quarter (22.1%) have no disaster plan provisions for children with special health care needs, and one quarter reported having no plans for postdisaster counseling. Almost half (42.8%) had never met with local ambulance officials to discuss emergency planning. Urban school districts were better prepared than rural districts on almost all measures in the survey. CONCLUSIONS. There are important deficiencies in school emergency/disaster planning. Rural districts are less well prepared than urban districts. Disaster/mass-casualty preparedness of schools should be improved through coordination of school officials and local medical and emergency officials.

Context: The differential allocation of medical resources to adult patients according to characteristics such as race, gender, and insurance status raises the serious concern that such issues apply to critically ill children as well. Objective: This study examined whether medical resources and outcomes for children admitted to pediatric intensive care units differed according to race, gender, or insurance status. Design: An observational analysis was conducted with use of prospectively collected data from a multicenter cohort. Data were collected on 5,749 consecutive admissions for children from three pediatric intensive care units located in large urban children’s hospitals. Participants: Children aged ≤18 years admitted over an 18-month period beginning in June 1996 formed the study sample. Main Outcome Measures: Hospital mortality, length of hospital stay, and overall resource use were examined in relation to severity of illness. Standardized ratios were formed with generalized regression analyses that included the Pediatric Index of Mortality for risk adjustment. Results: After adjustment for differences in illness severity, standardized mortality ratios and overall resource use were similar with regard to race, gender, and insurance status, but uninsured children had significantly shorter lengths of stay in the pediatric intensive care unit. Uninsured children also had significantly greater physiologic derangement on admission (mortality probability, 8.1%; 95% confidence interval [CI], 6.2–10.0) than did publicly insured (3.6%; 95% CI, 3.2–4.0) and commercially insured patients (3.7%; 95% CI, 3.3–4.1). Consistent with greater physiologic derangement, hospital mortality was higher among uninsured children than insured children. Conclusions: Risk-adjusted mortality and resource use for critically ill children did not differ according to race, gender, or insurance status. Policies to expand health insurance to children appear more likely to affect physiologic derangement on admission rather than technical quality of care in the pediatric intensive care unit setting.

OBJECTIVE: This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988-1999 to describe the benefits of improved treatment. DESIGN: Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals. SETTING: Hospital inpatient stays from all types of U.S. community hospitals. PARTICIPANTS: The study sample included all children aged 0-21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately dollar 17 billion, whereas acute care hospitalization costs increased by dollar 1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a dollar 3.76 billion loss in economic benefits. CONCLUSIONS: More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.

Objective. To reduce the injudicious use of antibiotics, we developed an educational strategy that focused on parents of pediatric patients and their physicians. Methods. This intervention was conducted in 5 pediatric practices in Arkansas during a 9-month period. Baseline data on parent attitudes about antibiotics and physician practice habits were measured by questionnaire. During the following 36 weeks, an educational videotape about the judicious use of antibiotics was played in waiting rooms. The videotape on antibiotics used a standard script based on the recommendations of the American Academy of Pediatrics. The physicians and staff at each site were actors in the videotape. During week 2 and week 36 of videotape use, parent attitudes were measured again. After the baseline week, the physicians and staff in each site were provided a standard in-service review of the American Academy of Pediatrics recommendations for judicious use of antibiotics. A study nurse recruited patients, administered questionnaires, and reviewed charts onsite. Results. Parents who were exposed to the videotape were significantly less inclined to seek antibiotics for viral infections. Passively provided pamphlets were not read. No significant change in antibiotic prescribing by physicians was seen. Conclusion. Parent-focused passive education tools are effective at changing parent attitudes toward the use of antibiotics. Although physicians have blamed parent attitudes and demands for the overuse of antibiotics, changes in parent attitudes in this study were not associated with changes in prescribing rates. Changes in parent attitudes may be necessary but do not seem sufficient for changes in antimicrobial prescribing patterns.

This article documents the successful creation and promotion of a bill to fund a nurse home visitation program for high-risk mothers in Arkansas. It illustrates several key factors in successful advocacy by pediatricians working in an academic setting: a realistic time commitment; a community needs assessment, data assimilation, and review of existing resources; the identification and incorporation of stakeholders; a narrow focus on the area of greatest need; the backing of political partners; and favorable opportunities to advance child health issues.

Objective: To assess functional outcome and describe disability at discharge in children who have had trauma without significant head injury. Design: Retrospective cohort. Setting: National Pediatric Trauma Registry, 1988–1994. Participants: Patients of ages 7 to 18 years with Glasgow Coma Scale (GCS) 13 to 15 without significant anatomic head injury. Results: Functional Independence Measure (FIM) at discharge was used to assess patient outcome. There were 13,649 children meeting study criteria who had sustained 34,254 injuries. Fractures constituted 30% of all injuries. As measured by FIM, 1,522 (11.2%) patients had mild disability at discharge; 1,983 (14.5%) had moderate disability. After adjustment for age and injury severity, children with lower extremity fractures were more likely to be discharged with functional limitations than those without (relative risk, 5.43; 95% confidence interval: 5.06, 5.84). Of children with moderate disability at discharge, less than 50% were referred for rehabilitation evaluation and less than 25% for physical therapy. Conclusion: Functional dependence is present in a large proportion of injured children, even without significant head injury. Rehabilitation and other services may be underused in this population. Further study is required to fully assess the degree and duration of disability in these patients.

Objective To describe variation in the clinical management of minor head trauma in children among primary care and emergency physicians. Design A survey of pediatricians, family physicians, and emergency physicians drawn from a random sample of members of the American Academy of Pediatrics, the American Academy of Family Physicians, and the appropriate American Medical Association specialty listings, respectively. Physicians were given clinical vignettes describing children presenting with normal physical examination results after minor head trauma. Different clinical scenarios (brief loss of consciousness or seizures) were also presented. Information was gathered on initial and subsequent management steps most commonly used by the physician. Results Surveys were returned by 765 (51%) of 1500 physicians. Of these, 303 (40%) were pediatricians, 269 (35%) family practitioners, and 193 (25%) emergency physicians. For minor head trauma without complications, observation at home was the most common initial physician management choice (n = 547, 72%). Observation in office or hospital was chosen by 81 physicians (11%). Head computed tomographic (CT) scan was chosen by 7 physicians (1%) and skull x-ray by 24 physicians (3%) as the first management option. Most physicians (n = 445, 80%) who initially chose observation at home would obtain a CT scan if the patient showed clinical deterioration. In the original scenario, if the patient had also sustained a loss of consciousness, 383 physicians (58%) altered management. Of these, 120 (18%) chose CT, 13 (2%) chose skull x-ray, 1 (1%) chose magnetic resonance imaging, 141 (21%) chose inpatient observation, and 125 (19%) chose a combination of CT scanning and observation. With seizures, 595 (90%) altered management, with 176 physicians (27%) choosing CT scan, 5 (1%) skull x-ray, 60 (9%) inpatient observation, and 299 (45%) a combination of radiological evaluation and observation. Conclusions Most physicians surveyed chose clinic or home observation for initial management of minor pediatric head trauma. Clinical management was more varied when patients had sustained either loss of consciousness or seizures. Further study of the appropriate management of minor head trauma in children is needed to guide physicians in their care.

OBJECTIVE To determine the proportion of young children seen in primary care pediatric practices who meet clinical criteria for the diagnosis of sinusitis, and variations in the management of these patients' conditions. DESIGN Observational cohort study. SETTINGS Pediatric practices in the Seattle, Wash, area participating in the Puget Sound Pediatric Research Network, a regional practice-based research organization. PATIENTS Children, 1 to 5 years old, presenting for any reason to participating practices. METHODS Parents of all 1307 eligible children completed a survey specifically detailing the presence of nasal congestion or discharge and daytime cough, the duration of these symptoms, and whether the symptoms were improving. For patients meeting clinical criteria for sinusitis (nasal congestion and daytime cough persisting for > 9 days without improvement), the pediatrician recorded the presence/severity of other signs and symptoms, and the treatment prescribed. Severity of symptoms was reassessed using telephone interviews with parents at 48 to 72 hours, and again at 10 to 14 days, after the office visit. Study data were collected during 1-week to 3-week blocks at each office site during the winter months. RESULTS Data were collected on 1307 children; 121 had persistent respiratory symptoms meeting criteria for a diagnosis of sinusitis (9.3%, 95% confidence interval, 7.7%-10.9%). Patients who presented with cold/cough symptoms were significantly more likely to meet criteria for sinusitis than those who came for any other reason (17.3% vs 4.2%, respectively, P < .001). A physician study form was completed on 87 children with persistent symptoms; antibiotics were prescribed for 68 (78%) of these patients. Antibiotic-treated patients were more likely to have symptoms lasting longer than 29 days (P = .004) and to have purulent nasal discharge (P = .03), and were judged to be sicker at enrollment (P = .001) than untreated children. A concurrent otitis media was diagnosed in 40 (46%) of 87 patients; if the proportion of children with otitis media is excluded, 5% of children 1 to 5 years old who are seen in primary care pediatrics might be expected to receive antibiotics exclusively for a diagnosis of sinusitis. At 24 to 48 hours and at 10 to 14 days after the clinic visit, a trend was noted toward more rapid improvement among those children who were treated with antibiotics. CONCLUSION When the criteria are strictly adhered to, only a small proportion of young children seen during the winter months in primary care pediatric practices will be diagnosed with sinusitis.