M. Denise Dowd

Policy Statement—Child Passenger Safety

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats for most infants up to 2 years of age; (2) forward-facing car safety seats for most children through 4 years of age; (3) belt-positioning booster seats for most children through 8 years of age; and (4) lap-and-shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health-supervision visit.

Impact of rapid influenza testing at triage on management of febrile infants and young children

Objective: To determine the impact of an emergency department (ED) triage protocol for rapid influenza testing of febrile infants and children on additional diagnostic testing, ED charges and patient time in the ED. Methods: A trial of triage-based rapid influenza A and B testing of febrile infants and children 3 to 36 months of age presenting to an urban ED during December 2002 to March 2003 was performed. Children with a temperature of 39°C or higher or history of fever 102°F or higher at home were included. Those with obvious focal infection, potential immunodeficiency, and indwelling medical devices were excluded. The intervention group, tested for influenza at triage (TT) was compared with a nonintervention group consisting of those receiving usual care (SP). A subanalysis comparing influenza-positive children was performed. Results: Of 1007 eligible subjects a total of 719 (71%) patients were in the SP group and 288 in the TT group. There were significant differences in respiratory syncytial virus rapid test (RSV; 18%-7%) and chest radiographs (CXRs; 26%-20%) tests in the TT group. In addition, significant increases in obtaining a complete blood count (relative risk [RR] 12.0; 95% confidence interval [CI] 2.9-49), blood culture (RR, 12.0; 95% CI, 3.0-51.0), RSV testing (RR, 0.9.2; 95% CI, 3.4-25.0), urinalysis (RR, 5.7; 95% CI, 2.0-16.0), CXR (RR, 2.2; 95% CI, 1.04-4.5), time in the ED (195 vs 156 minutes; 95% CI, of the difference 19-60), and medical charges (

Relationship between socioeconomic factors and severe childhood injuries.

666 vs

Short vertical falls in infants.

393; 95% CI, of the difference 153-392) were seen among those testing positive for influenza in the SP group. Conclusions: A triage protocol for rapid influenza testing for febrile infants and children appears to significantly decrease additional testing, time in the ED, and charges in children testing positive for influenza.

The teen driver

The objective was to examine the relationship between injury rates and socioeconomic factors for children in Hamilton County, Ohio, using small-area analysis. The subjects were county residents less than 15 years old who were hospitalized or died of injuries between January 1, 1993, and December 31, 1995; they were identified through a population-based trauma registry. The census tract was the unit of analysis; the rate of injury per 100,000 population was the dependent variable. Risk factors included median income, level of education, percentage below the poverty level, percentage unemployment, percentage non-Caucasian, and percentage families headed by females. There were 2,437 children meeting the case definition; injuries per census tract ranged from 0 to 2,020.2 per 100,000 per year. Census tracts with higher injury rates had lower median incomes, more people with less than a high school education, more unemployment, more families headed by females, more people living below the poverty level, and more non-Cancasians han those with lower rates. In a regression model, percentage of people living below poverty level, percentage of those who did not graduate from high school, and percentage unemployment were significant risk factors for injuries, P<.001. Since small-area analysis examines associations on an ecological level rather than an individual level, these studies should always be interpreted with caution because an association found at the level of the census tract may not apply at the individual level. Inverventions to reduce injuries should target socioeconomically disadvantaged children living below the poverty level and those in areas with fewer high school graduates and more unemployment.

Validation and Refinement of the Difficult Intravenous Access Score: A Clinical Prediction Rule for Identifying Children With Difficult Intravenous Access

OBJECTIVE To define injuries from short vertical falls (SVF) in infants, and to compare those with minor or no injuries to those with significant injury. DESIGN Descriptive, retrospective chart review. SETTING Pediatric emergency department (PED) of an urban teaching hospital. SUBJECTS Infants < or = 10 months treated between January 1990 and December 1992 presenting with a SVF (< or = 4 feet). RESULTS 167 patients met the definition. The mean age was 5.2 months; 56% were male. The mechanisms of injury included rolling off a bed (55%), being dropped from a caretakers arms (20%), rolling off a couch (16%), and falling from other objects (10%). The majority of patients (85 %) had minor or no injury. Significant injuries were sustained by 15% (n = 25), including 16 with a closed head injury (12 with skull fractures), two with intracranial bleed, and seven with a long bone fracture. Subsequently, the two patients with intracranial hemorrhages were confirmed as being from child abuse. After excluding cases of suspected abuse, the only characteristic found to be independently associated with significant injury was being dropped by the caretaker (odds ratio: 6.4 vs rolling or falling from furniture, 95% CI: 2.0, 21.5). CONCLUSION The most common mechanism of a SVF was rolling off a bed. Most patients sustained minor or no injury. No child sustained an intracranial hemorrhage from a SVF. The child with intracranial injury and/or multiple injuries warrants an investigation. Being dropped appears to be a greater risk for significant injury than rolling off or falling from furniture.

Policy Statement—Prevention of Drowning

Motor vehicle–related injuries to adolescents continue to be of paramount importance to society. Since the original policy statement on the teenaged driver was published in 1996, there have been substantial changes in many state laws and much new research on this topic. There is a need to provide pediatricians with up-to-date information and materials to facilitate appropriate counseling and anticipatory guidance. This statement describes why teenagers are at greater risk of motor vehicle–related injuries, suggests topics suitable for office-based counseling, describes innovative programs, and proposes preventive interventions for pediatricians, parents, legislators, educators, and other child advocates.

Chest Radiographs in the Pediatric Emergency Department for Children ≤18 Months of Age with Wheezing

OBJECTIVES The difficult intravenous access (DIVA) score, a proportionally weighted four-variable (vein palpability, vein visibility, patient age, and history of prematurity) clinical rule, has been developed to predict failure of intravenous (IV) placement in children. This study sought to externally validate and refine the DIVA score. METHODS Patients undergoing peripheral IV placement by pediatric emergency department (ED) nurses were enrolled. The outcome of interest was defined as failure of cannulation on first attempt. Proposed refinement predictor variables include history of newborn intensive care unit (NICU) stay, operator experience characteristics (years since graduation, years of pediatric nursing experience, and IVs started per month), and skin shade. Adjusted multivariate models were constructed using logistic regression. Receiver operating characteristic (ROC) curves were constructed and areas under the curve (AUC) calculated for each model. RESULTS A total of 366 subjects were enrolled (mean age = 5.4 years, SD ± 5.6 years) and of them, 118 (32.2%) subjects failed the first IV attempt. The original four-variable model tested in this data set resulted in an AUC of 0.72 (95% confidence interval [CI] = 0.67 to 0.78). Patients with a DIVA score of 4 or greater had more than 50% likelihood of failed first IV attempt. A three-variable rule (vein palpability, vein visibility, and patient age) was evaluated and found to possess similar discriminating ability (AUC = 0.72, 95% CI = 0.67 to 0.78). CONCLUSIONS This study validated the previously derived four-variable DIVA score. A simpler three-variable rule was as predictive of failed IV placement on first attempt as the four-variable rule. Validation in nonpediatric EDs is needed to thoroughly evaluate generalizability.

Attitudes and Beliefs of Adolescents and Parents Regarding Adolescent Suicide

Drowning is a leading cause of injury-related death in children. In 2006, fatal drowning claimed the lives of approximately 1100 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning.

Supervision and risk of unintentional injury in young children

There are no widely accepted predictors of pneumonia in wheezing infants and toddlers who present to the emergency department (ED). A 10-month retrospective review of ED visits of wheezing children ≤18 months of age revealed the following chest radiograph (CXR) results: normal (21 %), findings consistent with uncomplicated bronchiolitis or asthma (61%), focal infiltrates (18%), and other abnormalities (<1%). Patients with focal infiltrates on CXR were more likely to have the following: a history of fever (p=0.03, OR 2.1, 95% CI 1.0, 4.4), temperature ≥38.4° (p=0.01, OR 2.5, 95% CI 1.1,5.8) or crackles on examination (p<0.0005, OR 3.9, 95% CI 1.7,9.0). Selective use of CXRs has the potential to save health care dollars and limit unnecessary radiation. Clin Pediatr. 1999;38:395-399