Danielle Laraque

Epidemiology and Prevention of Traffic Injuries to Urban Children and Adolescents

Objectives. To describe the incidence of severe traffic injuries before and after implementation of a comprehensive, hospital-initiated injury prevention program aimed at the prevention of traffic injuries to school-aged children in an urban community. Materials and Methods. Hospital discharge and death certificate data on severe pediatric injuries (ie, injuries resulting in hospital admission and/or death to persons age <17 years) in northern Manhattan over a 13-year period (1983–1995) were linked to census counts to compute incidence. Rate ratios with 95% CIs, both unadjusted and adjusted for annual trends, were calculated to test for a change in injury incidence after implementation of the Harlem Hospital Injury Prevention Program. This program was initiated in the fall of 1988 and continued throughout the study period. It included 1) school and community based traffic safety education implemented in classroom settings in a simulated traffic environment, Safety City, and via theatrical performances in community settings; 2) construction of new playgrounds as well as improvement of existing playgrounds and parks to provide expanded off-street play areas for children; 3) bicycle safety clinics and helmet distribution; and 4) a range of supervised recreational and artistic activities for children in the community. Primary Results. Traffic injuries were a leading cause of severe childhood injury in this population, accounting for nearly 16% of the injuries, second only to falls (24%). During the preintervention period (1983–1988), severe traffic injuries occurred at a rate of 147.2/100u2009000 children <17 years per year. Slightly <2% of these injuries were fatal. Pedestrian injuries accounted for two thirds of all severe traffic injuries in the population. Among school-aged children, average annual rates (per 100u2009000) of severe injuries before the intervention were 127.2 for pedestrian, 37.4 for bicyclist, and 25.5 for motor vehicle occupant injuries. Peak incidence of pedestrian and bicyclist injuries occurred during the summer months and afternoon hours, whereas motor vehicle occupant injuries showed little seasonal variation and were more common during evening and night-time hours. Age-specific rates showed peak incidence of pedestrian injuries among 6- to 10-year-old children, of bicyclist injuries among 9- to 15-year-old children, and of motor vehicle occupant injuries among adolescents between the ages of 12 and 16 years. The peak age for all traffic injuries combined was 15 years, an age at which nearly 3 of every 1000 children each year in this population sustained a severe traffic injury. Among children hospitalized for traffic injuries during the preintervention period, 6.3% sustained major head trauma (including concussion with loss of consciousness for ≥1 hour, cerebral laceration and/or cerebral hemorrhage), and 36.9% sustained minor head trauma (skull fracture and/or concussion with no loss of consciousness ≥1 hour and no major head injury). The percentage of injured children with major and minor head trauma was higher among those injured in traffic than among those injured by all other means (43.2% vs 14.2%, respectively; χ2 = 336; degrees of freedom = 1). The percentages of children sustaining head trauma were 45.4% of those who were injured as pedestrians, 40.2% of those who were injured as bicyclists, and 38.9% of those who were injured as motor vehicle occupants. During the intervention period, the average incidence of traffic injuries among school aged children declined by 36% relative to the preintervention period (rate ratio: .64; 95% CI: .58, .72). After adjusting for annual trends in incidence, pedestrian injuries declined during the intervention period among school aged children by 45% (adjusted rate ratio: .55; 95% CI: .38, .79). No comparable reduction occurred in nontargeted injuries among school-aged children (adjusted rate ratio: .89; 95% CI: .72, 1.09) or in traffic injuries among younger children who were not targeted specifically by the program (adjusted rate ratio: 1.32; 95% CI: .57, 3.07). Conclusion. Child traffic injuries, particularly those involving pedestrians, are a major public health problem in urban communities. Although the incidence of child pedestrian injuries is declining nationally and internationally, perhaps attributable to declines in walking, this trend may not be applicable in inner city communities such as northern Manhattan, in which walking remains a dominant mode of transportation. Community interventions involving the creation of safe and accessible play areas as well as traffic safety education and supervised activities for school-aged children may be effective in preventing traffic injuries to children in these communities. Additional controlled evaluations are needed to confirm the benefits of such interventions.

Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary Care Practice

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Childrens Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3nnThe task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them.nnThis report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma.nnMost primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … nnAddress correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Preventing sexual risk behaviors and pregnancy among teenagers: linking research and programs.

Recent trends in adolescent sexual behavior offer mixed messages. It is very encouraging that teenagers’ overall rates of sexual activity, pregnancy and childbearing are decreasing, and that their rates of contraceptive and condom use are increasing. 1 However, the proportion of young people who have had sex at an early age has increased. 2 Moreover, while adolescent females’ contraceptive use at first sex is rising, their use at most recent sex is falling. 3 There is general consensus that the proportion of teenagers who engage in behaviors that put them at risk of pregnancy and of HIV and other sexually transmitted infections (STIs) remains too high. Each year, approximately one million young women aged 15–19—or one-fifth of all sexually active females in this age-group—become pregnant; the vast majority of these pregnancies are unplanned. 4 In the United States, the risk of acquiring an STI is higher among teenagers than among adults. 5 Moreover, rates of unprotected sexual activity, STIs, pregnancy and childbearing continue to be substantially higher among U.S. adolescents than among young people in comparable industrialized countries. 6 Research has also begun to highlight an alarmingly high rate of involuntary sex among young people. In the 1995 National Survey of Family Growth, 13% of 15–19-year-old females reported that they had been forced to have sex. 7 When asked about their first sexual experience, 22% of 15–44-year-old women for whom it occurred before age 15 reported that the act was involuntary, as did 16% of those who first had sex before age 16. Involuntary sexual activity is typically unprotected and thus puts its victims at very high risk of pregnancy and STIs. Finally, recent research and clinical observations suggest that a substantial proportion of teenagers, including those who report having never had vaginal sex, are engaging in oral sex. 8 This trend has negative implications for teenagers’ sexual health because many seem unaware that STIs can be acquired through unprotected oral sex.

Injury Risk of Nonpowder Guns

Nonpowder guns (ball-bearing [BB] guns, pellet guns, air rifles, paintball guns) continue to cause serious injuries to children and adolescents. The muzzle velocity of these guns can range from approximately 150 ft/second to 1200 ft/second (the muzzle velocities of traditional firearm pistols are 750 ft/second to 1450 ft/second). Both low- and high-velocity nonpowder guns are associated with serious injuries, and fatalities can result from high-velocity guns. A persisting problem is the lack of medical recognition of the severity of injuries that can result from these guns, including penetration of the eye, skin, internal organs, and bone. Nationally, in 2000, there were an estimated 21840 (coefficient of variation: 0.0821) injuries related to nonpowder guns, with approximately 4% resulting in hospitalization. Between 1990 and 2000, the US Consumer Product Safety Commission reported 39 nonpowder gun–related deaths, of which 32 were children younger than 15 years. The introduction of high-powered air rifles in the 1970s has been associated with approximately 4 deaths per year. The advent of war games and the use of paintball guns have resulted in a number of reports of injuries, especially to the eye. Injuries associated with nonpowder guns should receive prompt medical management similar to the management of firearm-related injuries, and nonpowder guns should never be characterized as toys.

Epidemiology and prevention of severe assault and gun injuries to children in an urban community

OBJECTIVESnTo describe the epidemiology of severe assault and gun injuries to children in an urban population and consider the impact of a comprehensive injury prevention program.nnnMATERIALS AND METHODSnPediatric injury deaths and hospital admissions for Northern Manhattan (1983-1992) were linked to census counts to compute incidence. Poisson regression was used to compare trends in incidence of assault and gun injuries before and during a community-wide pediatric injury prevention program in Central Harlem.nnnMAIN RESULTSnThe incidence of severe nonfatal assault injury was 60.94/100,000/year, 10 times the fatality rate. The incidence of all gun injuries was 31.13. In adolescence, guns were the leading cause of both fatal and severe nonfatal assault injury, and were the most lethal method of assault (case-fatality = 18.5% for gun vs. 1.2% for all non-gun assault injury). Rates of assault and gun injuries declined by nearly 50% in the intervention community, while they increased in a neighboring community.nnnCONCLUSIONSnComprehensive interventions may be effective in curbing the incidence of severe assault injuries to urban youth. Further controlled evaluations are needed to confirm the effectiveness of programs such as this and to better understand the prevention of violent injuries.

Children who are shot: A 30-year experience

Three data sets describe the pattern of gunshot injuries to children from 1960 to 1993: The Harlem Hospital pediatric trauma registry (HHPTR), the northern Manhattan injury surveillance system (NMISS) a population-based study, and the National Pediatric Trauma Registry (NPTR). A small case-control study compares the characteristics of injured children with a control group. Before 1970 gunshot injuries to Harlem children were rare. In 1971 an initial rise in pediatric gunshot admissions occurred, and by 1988 pediatric gunshot injuries at Harlem Hospital had peaked at 33. Population-based data through NMISS showed that the gunshot rate for Central Harlem children 10 to 16 years of age rose from 64.6 per 100,000 in 1986 to 267.6 per 100,000 in 1987, a 400% increase. The case fatality for children admitted to Harlem Hospital (1960 to 1993) was 3%, usually because of brain injury, but the majority of deaths occurred before hospitalization. During the same period, felony drug arrests in Harlem increased by 163%. The neighboring South Bronx experienced the same increase in gunshot wound admissions and felony arrests from 1986 to 1993. The NPTR showed a similar injury pattern for other communities in the United States. In a case-control analysis. Harlem adolescents who had sustained gunshot wounds were more likely to have dropped out of school, to have lived in a household without a biological parent, to have experienced parental death, and to have known of a relative or friend who had been shot than community adolescents treated for other medical or surgical problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Inappropriate use of nonculture tests for the detection of Chlamydia trachomatis in suspected victims of child sexual abuse : A continuing problem

The introduction of nonculture tests for detection of Chlamydia trachomatis has revolutionized the management of chlamydial infections in sexually active adolescents and adults. However, these tests are insufficiently specific for use in genital and rectal sites in children; false-positive tests can be frequent. We report here 4 cases involving inappropriate use of nonculture tests in children in New York City during 1998. Two cases involved the use of enzyme immunoassays with vaginal specimens. In both cases the initial results were positive, however, cultures forC trachomatis performed later were negative. In the third case, the DNA probe test for C trachomatis was used. The fourth child was being evaluated for sexually transmitted diseases after rape. Although the pediatrician sent a rectal culture to a large commercial laboratory it was later determined that the laboratory was using an enzyme immunoassay for culture confirmation leading to a false-positive result. At the least the use of these inappropriate tests resulted in unnecessary retesting and at the worst, unnecessary hospitalization, erroneous reports of sexual abuse and possibly unjustified prosecution and incarceration. Because of the social and legal implications it is important that practitioners be aware of these recommendations and require that commercial laboratories adhere to approved C trachomatisculture methods.

Benign Transient Hyperphosphatasia and HIV Infection

The disorder, benign transient hyperphosphatasia, has been defined previously as a condition occurring in a normal child with spontaneous, transient elevation of alkaline phosphatase. We report three cases of hyperphosphatasia in patients with congenital HIV infection and underlying liver disease which appear to satisfy the criteria for benign transient hyperphosphatasia despite the presence of chronic disease. These three children, when compared with three normal children with transient hyperphosphatasia exhibited similar patterns of change in serum alkaline phosphatase. Extreme elevation of serum alkaline phosphatase in HIV infected patients does not of itself suggest alterations in clinical status nor indicate the need for extensive evaluation.