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Background Healthcare workers are at high risk of Covid-19 (C19) infection and received priority for C19 vaccinations. Therefore, we conducted a serosurvey to determine anti-C19 antibodies and evidence of C19 infection in health care employees who did or did not have direct contact with patients. Methods 49 participants provided finger stick blood samples collected onto filter papers and tested for antibodies to C19 using Bio-Plex Pro Human SARS-CoV-2 IgG reagents. Antibodies to C19 nucleocapsid (N), receptor-binding domain (RBD), spike 1 (S1), and spike 2 (S2) were measured. Samples were collected 8 to 11 months after C19 vaccines were made available. Results All participants received two doses of Pfizer BioNTech or Moderna RNA-based C19 vaccines, and all showed serological evidence of antibodies to C19 RBD, S1, and S2. Antibodies to N, considered a marker of C19 infection, were detected in 16 individuals, of whom 10 reported having a PCR documented C19 infections. 6 individuals had evidence of C19 infection of which they were not aware. Antibody levels were notably higher following infection and for not infected participants following Pfizer-BioNTech vaccination. There was a 20% higher infection rate in participants with direct patient contact. Conclusion This vaccinated population had significant rates of strong antibody responses to C19 infection and a notable rate of C19 infections, most notable in those providing direct patient care. Disclosures All Authors: No reported disclosures.

Since all-terrain vehicles (ATVs) were introduced in the mid-1970s, regulatory agencies, injury prevention researchers, and pediatricians have documented their dangers to youth. Major risk factors, crash mechanisms, and injury patterns for children and adolescents have been well characterized. Despite this knowledge, preventing pediatric ATV-related deaths and injuries has proven difficult and has had limited success. This policy statement broadly summarizes key background information and provides detailed recommendations based on best practices. These recommendations are designed to provide all stakeholders with strategies that can be used to reduce the number of pediatric deaths and injuries resulting from youth riding on ATVs.

All-terrain vehicles (ATVs) represent a serious and ongoing public health and safety concern for children and adolescents. Survey studies indicate that high proportions of youth ride ATVs in both rural and nonrural populations. The significant human and economic costs of pediatric ATV-related deaths and injuries result from a number of major risk factors that are highly common in pediatric ATV crashes: operating adult-size vehicles, riding with or as passengers, lack of protective equipment, and riding on public roads. Other less well-studied but potentially significant risk factors are speed, riding at night, alcohol use among older teenagers, and lack of training and supervision. Although potentially safer than adult ATVs, youth models present a number of safety concerns that have not been addressed with rigorous study. The most common ATV crash mechanism is a noncollision event—for example, a rollover. Common injury mechanisms include ejection from the vehicle, resulting in extremity and head injuries, and being pinned or crushed by the vehicle with resulting multiorgan trauma and/or compression asphyxia. Traumatic brain injury and multisystem trauma are the 2 most common causes of death and disabling injury. Taken together, a large multidecade body of evidence is the basis for the American Academy of Pediatrics policy statement recommendation that no child younger than 16 years of age ride on an ATV. Because children continue to be allowed to ride these vehicles, however, efforts to prevent pediatric ATV-related deaths and injuries require multipronged strategies, including education of both youth and parents, safety-based engineering, and enforcement of evidence-based safety laws.

This study investigated patterns of cortical organization in adolescents who had sustained a traumatic brain injury (TBI) during early childhood to determine ways in which early head injury may alter typical brain development. Increased gyrification in other patient populations is associated with polymicrogyria and aberrant development, but this has not been investigated in TBI. Seventeen adolescents (mean age = 14.1 ± 2.4) who sustained a TBI between 1–8 years of age, and 17 demographically-matched typically developing children (TDC) underwent a high-resolution, T1-weighted 3-Tesla magnetic resonance imaging (MRI) at 6–15 years post-injury. Cortical white matter volume and organization was measured using FreeSurfer's Local Gyrification Index (LGI). Despite a lack of significant difference in white matter volume, participants with TBI demonstrated significantly increased LGI in several cortical regions that are among those latest to mature in normal development, including left parietal association areas, bilateral dorsolateral and medial frontal areas, and the right posterior temporal gyrus, relative to the TDC group. Additionally, there was no evidence of increased surface area in the regions that demonstrated increased LGI. Higher Vineland-II Socialization scores were associated with decreased LGI in right frontal and temporal regions. The present results suggest an altered pattern of expected development in cortical gyrification in the TBI group, with changes in late-developing frontal and parietal association areas. Such changes in brain structure may underlie cognitive and behavioral deficits associated with pediatric TBI. Alternatively, increased gyrification following TBI may represent a compensatory mechanism that allows for typical development of cortical surface area, despite reduced brain volume.

BackgroundFirearm-related injuries are the second leading cause of death among US children. Given this, firearm injury prevention should be a key aspect of pediatric anticipatory guidance.ObjectiveWe assessed the impact of a firearm safety counseling workshop on pediatric resident knowledge, self-efficacy, and self-reported practice patterns.MethodsSixty of 80 residents (75%) participated in a 2-hour multimodal workshop, including video, didactics with experts, and role-play scenarios. Participants were invited to complete pre-workshop, immediate post-workshop, and 3- and 6-month post-workshop self-reported questionnaires evaluating knowledge, comfort, perceived barriers, and reported practice patterns. Data comparing pre- and 6-month post-workshop practice patterns were analyzed via Fischer's exact test. Remaining statistical analysis utilized a one-sided, unpaired Mann–Whitney U test. A binomial exact proportions test was used for open-ended responses.ResultsAfter the workshop, the percentage of participants with perceived concern regarding parental barriers decreased significantly (24% to 7%, P = .001). Participants 6 months post-workshop were 5.14 times more likely to counsel their patients on firearms during more than 75% of their well visits than prior to the intervention (P = .010). Participants reported greater comfort asking patients about firearms, with mean Likert scores increasing from 3.81 pre to 4.33 post (P = .022), which was similar to 3-month (4.39, P = .06) and 6-month evaluations (4.54, P = .003).ConclusionsEducation on firearm safety counseling improved pediatric resident comfort level in discussing the topic. This impact persisted 6 months after the workshop, implying a sustained change in attitudes and behaviors.

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.

In this paper, an infant sleep prevention solution based on semantic to access infant environmental hazards is presented. To promote safe sleep evaluation and implement sustainability in rural underserved communities, we use deep learning techniques to automatically assess photographs of the infant's sleep environment and report unsafe environments. To achieve this, we first built and labeled a dataset of 626 images from infants in various sleep positions and environments. The segmentation architecture is composed of a downsampling path responsible for extracting coarse semantic features, followed by an upsampling path trained to recover the input image resolution and finally, a pixel-wise classification layer. The trained model is also integrated into an android application to provides a sustainable evaluation/assessment tool. We achieve state-of-the-art results and demonstrated that the automated assessment system could identify safe/unsafe sleep environment using photographs.

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 Firearms contribute substantially to leading causes of death to US children ages 10–19 (suicide and homicide). Approximately 38% of US households have a firearm and many homes with children Objective To better understand knowledge, attitudes, beliefs, and firearm storage practices among youth living in households with firearms to support development of interventions to lower unsupervised child access to firearms. Methods We conducted focus groups (FG) of youth living in households of gun owners residing in 3 US states with high firearm ownership rates. Moderator guides framed discussions that included participant views about firearm storage, suggestions for messaging and dissemination methods for a safe storage campaign. Data were managed using HyperRESEARCH (v2.8.3). Transcribed data were coded to identify important themes. Prior to FG, subjects completed an anonymous survey to record demographic characteristics, gun ownership, use, and storage practices. Results 6 FG were conducted, including 30 youth ages 12–17 living in homes with firearms. Practical firearms training including safe storage information was endorsed. Acceptable sources of safety information were military and law enforcement. Youth did not support prevention messages in medical care contexts. Youth reported detailed awareness of firearm availability in their homes and violations of family rules about gun handling. Means restriction was not perceived as an effective way to prevent suicide and other gun injury. Conclusions Youth in households with gun owning parents supported safety education but their perception of risk from firearms in their homes was low. Firearm safety counselling was most acceptable from nonmedical sources and in context of ongoing training programs. Further education about the value of lethal means restriction is needed storage by this population.

Background Interventions to prevent sudden unexpected infant death (SUID) typically include education to increase knowledge, thereby improving parenting practice. However, health decision-making is based on a complex interplay of knowledge, attitudes, and beliefs related to intent to initiate behaviors. Further, based on the Health Belief Model, self-efficacy and locus of control are also linked to behavior change. Objective: This study examined the link between pregnant teens’ report on several safe sleep constructs thought to influence parent’s safe sleep behaviors and prenatal knowledge of safe sleep practices. Design/methods We recruited pregnant teens (13–19 years old) into a trial of an educational intervention for safe sleep during second trimester in a US state with high sleep-related SUID rates. A self-administered survey was completed before intervention. The survey included safe sleep constructs: attitudes (3 items), beliefs (4), self-efficacy (3), intentions (4), knowledge (3), and a standardized measure of knowledge of infant development (KIDI). Results 115 subjects completed baseline surveys, including 27 white (20%), 103 black (76%), and 5 other (4%) teens with median age 18 y±2. In regression analyses, the KIDI predicted safe sleep knowledge (R2=0.05, F(1, 112)=6.24, p Conclusions The prenatal period presents an important opportunity for educational intervention, as women develop knowledge and form beliefs that may shape early parenting behavior. The link between key safe sleep-related constructs may inform interventions before the birth. Our results suggest that safe sleep knowledge is associated with both key beliefs and with knowledge of general infant development. Interventions that target these beliefs may be more successful.

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.

OBJECTIVES/SPECIFIC AIMS: To explore rural African American parents’ and their community advisors’ perspectives on the Safety Baby Shower’s acceptability, feasibility, and adaptability. METHODS/STUDY POPULATION: Collaborating with a local community organization, we explored community advisors’ and expectant women’s SBS experiences to understand intervention delivery and adoption in a rural underserved community (RUC). The Consolidated Framework for Implementation Research guided our data collection and analysis using focus groups and key informant interviews. We used directed content analysis to generate themes and sub codes. RESULTS/ANTICIPATED RESULTS: Five focus groups (21 participants) and one key informant interview were conducted. Identified barriers that hinder feasibility and acceptability included resources, time/ flexibility, intervention location, cultural norms and beliefs, and the lack of a birthing hospital in the county. “Baby proofing”, “reinforcement products” and “teaching sleep safety on the same day as infant clinical appointment” are expectant mothers’ exemplars for what comes to their minds when asked to think about safety baby showers. To improve feasibility, both community advisors and expectant mothers suggested adaptations ranging from decentralizing or rotating intervention location, using different delivery sites such as churches, scheduling intervention outside business hours, to incorporating intervention into school health fairs and barbeque events. Social media emerged as a facilitator, and integrating safe sleep education into personal baby showers emerged as an implementation strategy. DISCUSSION/SIGNIFICANCE OF IMPACT: The community advisors and expectant mothers identified a wide spectrum of potential adaptations that have potential to improve safe sleep knowledge and practices. In the next study phase, identified themes will inform intervention adaptation and suggested implementation strategies will support uptake of the adapted SBS. Identifying transformative implementation strategies and conducting a community-informed SBS adaptation using a collective decision-making process between intervention experts and local community partners will support improved safety baby shower delivery, adoption and sustainability in RUCs.

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.

Background Smoke alarms have been demonstrated to reduce the risk of death in fire. It is recommend that families develop and practice fire escape plans. This study aims to utilise a smartphone app, Safety In Seconds, to deliver a theory-based tailored education to improve fire safety practices of 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. With assistance from a research assistant study participants downloaded the Safety In Seconds app onto their smartphone and were randomised to the intervention (fire safety) or control (car seat) 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, parents in the IG were more likely to report having long-life lithium battery smoke alarms (22% vs 16%; p=0.03) and having practiced a fire escape plan (65% vs. 71%; p=0.08). Conclusions Smartphone applications may be a promising tool to improve home safety behaviours.

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.

BACKGROUND: Booster seats reduce mortality and morbidity for young children in car crashes, but use is low, particularly in rural areas. This study targeted rural communities in 4 states using a community sports-based approach. OBJECTIVE: The Strike Out Child Passenger Injury (Strike Out) intervention incorporated education about booster seat use in children ages 4-7 years within instructional baseball programs. We tested the effectiveness of Strike Out in increasing correct restraint use among participating children. METHODS: Twenty communities with similar demographics from 4 states participated in a nonrandomized, controlled trial. Surveys of restraint use were conducted before and after baseball season. Intervention communities received tailored education and parents had direct consultation on booster seat use. Control communities received only brochures. RESULTS: One thousand fourteen preintervention observation surveys for children ages 4-7 years (Intervention Group [I]: N = 511, Control [C]: N = 503) and 761 postintervention surveys (I: N = 409, C: N = 352) were obtained. For 3 of 4 states, the intervention resulted in increases in recommended child restraint use (Alabama +15.5%, Arkansas +16.1%, Illinois +11.0%). Communities in 1 state (Indiana) did not have a positive response (-9.2%). Overall, unadjusted restraint use increased 10.2% in intervention and 1.7% in control communities (P = .02). After adjustment for each state in the study, booster seat use was increased in intervention communities (Cochran-Mantel-Haenszel odds ratio 1.56, 95% confidence interval [1.16-2.10]). CONCLUSIONS: A tailored intervention using baseball programs increased appropriate restraint use among targeted rural children overall and in 3 of 4 states studied. Such interventions hold promise for expansion into other sports and populations. Language: en

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

Background Although proven measures for reducing injury due to motor vehicle collision and residential fires exist, the number of families properly and consistently using child passenger restraints and smoke alarms remains low. This paper describes the design of the Safety In Seconds (SIS) 2.0 study, which aims to evaluate the impact of a smartphone app on parents9 use of child restraints and smoke alarms. Methods SIS is a multisite randomised controlled trial. Participants are parents of children aged 4–7 years who are visiting the Pediatric Emergency Department or Pediatric Trauma Service. Parents are randomised to receive tailored education about child passenger safety or about fire safety via the SIS smartphone app. A baseline and two follow-up surveys at 3 months and 6 months are conducted. Primary outcomes are: (1) having the correct child restraint for the child9s age and size; (2) restraining the child in the back seat of the car; (3) buckling the child up for every ride; (4) having the restraint inspected by a child passenger safety technician; (5) having a working smoke alarm on every level of the home; (6) having hard-wired or lithium battery smoke alarms; (7) having and (8) practising a fire escape plan. Discussion Finding ways to communicate with parents about child passenger and fire safety continues to be a research priority. This study will contribute to the evidence about how to promote benefits of proper and consistent child restraint and smoke alarm use. Trial registration number NCT02345941; Pre-results.

Since 2006, the National Institutes of Health has provided institutional infrastructure grants, called Clinical and Translational Science Awards (CTSAs), to support adult and pediatric clinical and translational research in United States institutions. A CTSA Consortium Child Health Oversight Committee workgroup developed metrics to measure the impact of CTSAs on child health (CH) research. A cross-sectional survey to collect metric data was distributed to the 46 institutions that received CTSAs during 2006-09. Thirty-seven (80%) institutions responded to the survey. Data regarding 7 metrics were reported by >70% of responding institutions: the proportion of overall funding (median, interquartile range; 0.12, 0.06–0.19) and pilot grants (0.15, 0.11–0.21) supporting CH research; the proportion of active clinical research center studies involving children (0.23, 0.15–0.35); the proportion of IRB-approved (0.24, 0.16–0.30) and funded (0.22, 0.18–0.30) studies involving children; the proportion of mentored research training awards to CH investigators (0.18, 0.11–0.28); and, the proportion of CTSA leadership positions held by pediatricians (0.18, 0.12–0.28). CTSAs provide substantial support for CH research, although additional investment in CH research is needed to improve the health of children. These metrics provide an initial means to track the impact of CTSAs on CH research.

The objective of this study was to summarize basic information on the characteristics of work-related A TV deaths among civilian persons 18 years of age or older in the U.S. from 1992 through 2007. Work-related ATV death data were obtained through the Bureau of Labor Statistics' annual Census of Fatal Occupational Injuries. From 1992 to 2007, 297 work-related ATV deaths occurred among persons over 17 in the U.S. Ninety-two percent were male, 93% were white, 23% were ages 18 to 34, 51% were ages 35 to 64, and 26% were agesor = 65. Half of the fatal incidents involved overturns resulting in head and chest injuries. Sixty percent of crashes occurred on farms and 20% occurred on highways. The fatality rate among agricultural production workers was significantly higher than the rates in all other industries. While more in-depth analysis of incident and exposure data for this growing problem will more clearly define personal risk and causal factors in the long term, in the short term, stronger emphasis must be placed on the development of prevention strategies, particularly focused on older workers in the agriculture production industry.

Purpose: All-terrain vehicle (ATV) injury is an increasingly serious problem, particularly among rural youth. There have been repeated calls for ATV safety education, but little study regarding optimal methods or content for such education. The purpose of this study was to determine if an ATV safety video was effective in increasing ATV safety knowledge when used in a community-based statewide hunter education program. Methods: During the baseline phase, surveys focusing on ATV safety were distributed to students in the Arkansas hunter safety program in 2006. In the intervention phase a year later, an ATV safety video on DVD was provided for use in required hunter education courses across Arkansas. The same survey was administered to hunter education students before and after the course. Findings: In the baseline phase, 1,641 precourse and 1,374 postcourse surveys were returned and analyzed. In the intervention phase, 708 precourse and 694 postcourse surveys were completed. Student knowledge of ATV safety after watching the video was higher than in preintervention classes. Knowledge of appropriate helmet usage increased from 95% to 98.8% (P Language: en

Although injury is a major cause of death and disability, concepts of injury prevention have not been present in the curricula of most medical schools. There have been recent calls in the literature, including a 2005 report from the Association of American Medical Colleges, for the addition of injury prevention concepts into medical school education. This report describes the process of development of a longitudinal injury prevention curriculum in one medical school. The curriculum committee felt that adding the material in a longitudinal fashion would better correlate the material to the rest of the curriculum as well as provide efficiency in the already crowded undergraduate programme of study. The report describes the content of the longitudinal curriculum developed as well as initial evaluation of the material.

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

Children ages 8-12 years, also called "Tweens," demonstrate a number of risk factors for motor vehicle injury, including lack of restraint use and front seating position, yet few interventions have targeted this group. We implemented a school-based educational intervention designed to increase awareness and encourage safer transportation of these children.A local school collaborated with the study team to develop educational materials based on the school mascot and allowed use of school-based media (bulletin boards, closed circuit TV, and newsletters) to deliver key messages about restraint use and back seating position. Selected students participated in delivering the message and in evaluation activities, increasing peer support for the program. Evaluation consisted of surveys of reported and observed restraint use and rear seating for children and restraint use for parents before and after the educational intervention.School support for the program was excellent and student enthusiasm was high. Parent awareness of safe positioning for children improved, with parents endorsing seat belts alone versus seat belts with a booster seat for children ages 5-8 falling from 37% to 25% (p0.004). Child report of restraint use increased from 78% to 89% (p0.001). Reported exposure to the campaign messages was high with 77% of parents and 89% of students recalling the campaign at the end of the year. Observed restraint use for both adults and children was somewhat lower than reported use. Restraint use by parents was about 80% both before and after the intervention. Restraint use by children increased from 71% to 91% (0.001). No changes were noted in front seating position for children.Short term positive changes in observed restraint use and knowledge about safer transportation of children were encouraging. Further study of the program, including a controlled study of the intervention, are needed to demonstrate longer term effectiveness.

Child passenger safety remains an important public health problem because motor vehicle crashes are the leading cause of death for children, and the majority of children ride improperly restrained. Using a mobile app to communicate with parents about injury prevention offers promise but little information is available on how to create such a tool. The purpose of this article is to illustrate a theory-based approach to developing a tailored, smartphone app for communicating child passenger safety information to parents. The theoretical basis for the tailoring is the elaboration likelihood model, and we utilized the precaution adoption process model (PAPM) to reflect the stage-based nature of behavior change. We created assessment items (written at ≤6th grade reading level) to determine the child's proper type of car seat, the parent's PAPM stage and beliefs on selected constructs designed to facilitate stage movement according to the theory. A message library and template were created to provide a uniform structure for the tailored feedback. We demonstrate how messages derived in this way can be delivered through new m-health technology and conclude with recommendations for the utility of the methods used here for other m-health, patient education interventions. Language: en

Objective: To discuss the successes and challenges associated with the implementation of a post-traumatic stress disorder (PTSD) screening tool in two pediatric emergency departments (ED). Methods: The STEPP screening tool has been developed previously on an inpatient population of motor vehicle trauma patients. It was applied here to the general ED population at two different pediatric trauma centers. Nurse screeners were trained and a convenience sample of patients with unintentional injuries who met study criteria were screened in the ED. Feedback from nurse screeners was obtained. Results: The process of implementing a screening tool to identify patients and their families significantly at risk for PTSD symptomatology presented some barriers, but overall acceptability of the process was high for both the emergency department staff and the patient. Recommendations for others considering implementation of screening programs in the ED are offered. Conclusions: Future research using screening protocols in the ED should, in their design, attempt to capitalize on the successes identified in the current protocol and circumvent barriers also encountered.

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.