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Abstract In 2006, the Institute of Medicine published a report titled “Emergency Care for Children: Growing Pains,” in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric‐specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time‐sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID‐19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

Acute agitation in youth is a challenging presentation to the emergency department. In many cases, however, youth can be behaviorally de-escalated using a combination of environmental modification and verbal de-escalation. In cases where additional strategies such as pharmacologic de-escalation or physical restraint are needed, using the least restrictive means possible, including the youth in the decision-making process, and providing options are important. This paper reviews specific considerations on the approach to a youth with acute agitation and strategies and techniques to successfully de-escalate agitated youth who pose a danger to themselves and/or others., Competing Interests: The authors declare they have no conflicts of interest., (© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objective: Rising prevalence of obesity has led to increased rates of prediabetes and diabetes mellitus (DM) in children. This study compares rates of prediabetes and diabetes using two recommended screening tests (fasting plasma glucose [FPG] and haemoglobin A1c [HbA1c])., Study Design: Data were collected prospectively from 37 multi-component paediatric weight management programs in POWER (Paediatric Obesity Weight Evaluation Registry)., Results: For this study, 3962 children with obesity without a known diagnosis of DM at presentation and for whom concurrent measurement of FPG and HbA1c were available were evaluated (median age 12.0 years [interquartile range, IQR 9.8, 14.6]; 48% males; median body mass index 95th percentile [%BMIp95] 134% [IQR 120, 151]). Notably, 10.7% had prediabetes based on FPG criteria (100-125 mg/dL), 18.6% had prediabetes based on HbA1c criteria (5.7%-6.4%), 0.9% had DM by FPG abnormality (≥126 mg/dL) and 1.1% had DM by HbA1c abnormality (≥6.5%). Discordance between the tests was observed for youth in both age groups (10-18 years [n = 2915] and age 2-9 years [n = 1047])., Conclusion: There is discordance between FPG and HbA1c for the diagnosis of prediabetes and DM in youth with obesity. Further studies are needed to understand the predictive capability of these tests for development of DM (in those diagnosed with prediabetes) and cardiometabolic risk., (© 2024 World Obesity Federation.)

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH., (Copyright © 2023 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Blood pressure (BP) assessment and management are important aspects of care for youth with obesity. This study evaluates data of youth with obesity seeking care at 35 pediatric weight management (PWM) programs enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). Data obtained at a first clinical visit for youth aged 3-17 years were evaluated to: (1) assess prevalence of BP above the normal range (high BP); and (2) identify characteristics associated with having high BP status. Weight status was evaluated using percentage of the 95 th percentile for body mass index (%BMIp95); %BMIp95 was used to group youth by obesity class (class 1, 100% to < 120% %BMIp95; class 2, 120% to < 140% %BMIp95; class 3, ≥140% %BMIp95; class 2 and class 3 are considered severe obesity). Logistic regression evaluated associations with high BP. Data of 7943 patients were analyzed. Patients were: mean 11.7 (SD 3.3) years; 54% female; 19% Black non-Hispanic, 32% Hispanic, 39% White non-Hispanic; mean %BMIp95 137% (SD 25). Overall, 48.9% had high BP at the baseline visit, including 60.0% of youth with class 3 obesity, 45.9% with class 2 obesity, and 37.7% with class 1 obesity. Having high BP was positively associated with severe obesity, older age (15-17 years), and being male. Nearly half of treatment-seeking youth with obesity presented for PWM care with high BP making assessment and management of BP a key area of focus for PWM programs., (© 2021 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Mild traumatic brain injury (mTBI) and concussion, a subtype of mTBI, commonly present to the emergency department (ED) and may present with symptoms identical to those associated with more severe TBI. The development and use of clinical decision rules, increased awareness of the risk of radiation associated with head computed tomography, and the potential for patient observation has allowed emergency clinicians to make well-informed decisions regarding the need for imaging for patients who present with mTBI. For patients who present to the ED with concussion, appropriate diagnosis, management, and education are critical for optimal recovery. This issue reviews the most recent literature on concussion and mTBI and provides recommendations for the evaluation, diagnosis, and treatment of mTBI and concussion in the acute setting.

Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.

Background: Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children., Objectives: The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors., Discussion: Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care., Conclusion: Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings., Competing Interests: The authors have no conflict of interest., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Purpose of Review: In September 2018, the Centers for Disease Control and Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children., Recent Findings: Based on a systematic review of the evidence that covers research published over a 25-year span (1990-2015), the CDC Pediatric mTBI Guideline strives to optimize the care of pediatric patients with mTBI. The guideline was developed using a rigorous methodology developed by the American Academy of Neurology., Summary: Clinical practice recommendations in the CDC Pediatric mTBI Guideline can help guide neurologists with critical diagnostic and management decisions and to implement evidence-based strategies for the recovery of their young patients with this injury.

This article provides recommendations for pediatric readiness, scope of services, competencies, staffing, emergency preparedness, and transfer of care coordination for urgent care centers (UCCs) and retail clinics that provide pediatric care. It also provides general recommendations for the use of telemedicine in these establishments. With continuing increases in wait times and overcrowding in the nation's emergency departments and the mounting challenges in obtaining timely access to primary care providers, a new trend is gaining momentum for the treatment of minor illness and injuries in the form of UCCs and retail clinics. As pediatric visits to these establishments increase, considerations should be made for the type of injury or illnesses that can be safely treated, the required level training and credentials of personnel needed, the proper equipment and resources to specifically care for children, and procedures for safe transfer to a higher level of care, when needed. When used appropriately, UCCs and retail clinics can be valuable and convenient patient care resources.

Importance: In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study., Objective: To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI., Evidence Review: Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search., Findings: Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking., Conclusions and Relevance: This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

Importance: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States., Objective: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI., Evidence Review: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015., Findings: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment., Conclusions and Relevance: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Many patients under the age of majority present to emergency departments (EDs) without parents or guardians. This may create concern in regard to evaluation of these patients without formal consent to treat. The Emergency Medical Treatment and Labor Act mandates that all patients presenting to EDs receive a medical screening examination and does not exclude these minors. Standards for who can provide consent for a patient vary from state to state and address important issues such as consent by parent surrogates, as well as adolescent emancipation, reproductive health, mental health, and substance use. This document addresses current federal and state legal implications of providing emergency care to minors, as well as guidance in obtaining consent, maintaining confidentiality, and addressing refusal of care., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Bullying is an important public health issue with broad implications. Although this issue has been studied extensively, there is limited emergency medicine literature addressing bullying. The emergency department (ED) physician has a unique opportunity to identify children and adolescents that are victims of bullying, and make a difference in their lives., Objective: Our aim is to discuss the role of the emergency physician (EP) in identifying patients who have been victims of bullying and how to provide effective management as well as referral for further resources., Discussion: This document provides a framework for recognizing, stabilizing, and managing children who have experienced bullying. With the advent of social media, bullying behavior is not limited to in-person situations, and often occurs via electronic communication, further complicating recognition because it may not impart any physical harm to the child. Recognition of bullying requires a high level of suspicion, as patients may not offer this history. After the stabilization of any acute or overt indications of physical injury, along with obtaining a history of the mechanism of injury, the EP has the opportunity to identify the existence of bullying as the cause of the injury, and can address the issue in the ED while collaborating with "physician-extenders," such as social workers, toward identifying local resources for further support., Conclusions: The ED is an important arena for the assessment and management of children who have experienced bullying. It is imperative that EPs on the front lines of patient care address this public health epidemic. They have the opportunity to exert a positive impact on the lives of the children and families who are the victims of bullying., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Prospective patient registries have been successfully utilized in several disease states with a goal of improving treatment approaches through multi-institutional collaboration. The prevalence of youth with severe obesity is at a historic high in the United States, yet evidence to guide effective weight management is limited. The Pediatric Obesity Weight Evaluation Registry (POWER) was established in 2013 to identify and promote effective intervention strategies for pediatric obesity., Methods: Sites in POWER provide multicomponent pediatric weight management (PWM) care for youth with obesity and collect a defined set of demographic and clinical parameters, which they regularly submit to the POWER Data Coordinating Center. A program profile survey was completed by sites to describe characteristics of the respective PWM programs., Results: From January 2014 through December 2015, 26 US sites were enrolled in POWER and had submitted data on 3643 youth with obesity. Ninety-five percent were 6-18 years of age, 54% female, 32% nonwhite, 32% Hispanic, and 59% publicly insured. Over two-thirds had severe obesity. All sites included a medical provider and used weight status in their referral criteria. Other program characteristics varied widely between sites., Conclusion: POWER is an established national registry representing a diverse sample of youth with obesity participating in multicomponent PWM programs across the United States. Using high-quality data collection and a collaborative research infrastructure, POWER aims to contribute to the development of evidence-based guidelines for multicomponent PWM programs.

Background: Lack of understanding of diagnosis and disease process remains a major complaint of caregivers who bring their children to the pediatric emergency department (PED). Misunderstanding of diagnosis and discharge instructions can lead to unnecessary return visits and health disparities., Objective: We attempted to determine if video discharge instructions when added to standard of care written and verbal instruction improved caregivers' comprehension of their child's diagnosis, disease process, and discharge instructions., Methods: Caregivers who presented to the PED with a child's chief complaint of fever or closed head injury (CHI) were included and randomized into a control or intervention group. Each group received standard discharge instructions, and the intervention group additionally viewed a video. Participants completed a post-test on knowledge and were followed 2 weeks post-visit to determine follow-up care., Results: Sixty-three caregivers participated in the study. Eleven participants had less than a high school (HS) education and 52 had more than a HS education. Thirty-one children presented with fever and 32 with CHI. The intervention group had significantly higher percentage of correct answers on postintervention tests (median [Mdn] = 88.89) than the control (Mdn = 75.73; p < 0.0001). Participants in the intervention group with less than a HS education (Mdn = 89.47) and more than HS education (Mdn = 88.89) had similar test scores (p = 0.13), whereas those in the control group with less than a HS education (Mdn = 66.67) had significantly lower test scores than those with more than a HS education (Mdn = 77.78; p = 0.03)., Conclusion: For caregivers with children who presented to the PED with fever and CHI, video discharge instructions improved caregiver comprehension of the child's diagnosis and disease process when added to verbal and written instructions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare knowledge and attitudes of human papillomavirus (HPV) and the vaccine between different cultures of African descent., Methods: A cross-sectional survey of 555 African-Americans and Afro-Caribbeans residing in the US and the Bahamas (BHM) was conducted., Results: General knowledge about HPV and the HPV vaccine differed between the two countries significantly. Bahamian respondents were less likely to have higher numbers of correct knowledge answers when compared to Americans (Adjusted Odds Ratio [Adj. OR] 0.47, 95% Confidence Interval [CI] 0.30-0.75). Older age, regardless of location, was also associated with answering fewer questions correctly (Adj. OR 0.61, 95% CI 0.40-0.92). Attitudes related to HPV vaccination were similar between the US and BHM, but nearly 80% of BHM respondents felt that children should not be able to receive the vaccine without parental consent compared to 57% of American respondents., Conclusions: Grave lack of knowledge, safety and cost concerns, and influence of parental restrictions may negatively impact vaccine uptake among African-American and Afro-Caribbean persons. Interventions to increase the vaccine uptake in the Caribbean must include medical provider and parental involvement. Effective strategies for education and increasing vaccine uptake in BHM are crucial for decreasing cervical cancer burden in the Caribbean.