Sandra Herr

Complementary and alternative medicine use in children.

Objective Adults frequently use complementary and alternative medicines (CAM). Few studies have reported how often CAM therapies are used to treat children. The purpose of this study is to describe the use of alternative therapies by children visiting an emergency department (ED) and to identify sociodemographic factors that may influence the decision to use such therapies. Design Survey of families using a self-administered questionnaire. Setting An urban, tertiary care pediatric emergency department. Participants Convenience sample of families presenting to the ED for acute care. Main outcome measure Use of CAM therapies to treat children. Secondary measures include the type of therapies used, types of medical problems the therapies were used for, reasons for using such therapies, use of such therapies by the child’s caretakers, and sociodemographic characteristics of the children and families. Results A review of 525 completed surveys identified 63 caretakers (12%) who acknowledged that they had used at least one form of CAM therapy to treat any of their children. Homeopathic and naturopathic remedies were the most common therapies used. Parents most often used CAM therapies to treat respiratory problems in their children and were most influenced by word-of-mouth. Children who were treated with CAM therapies were more likely to have a caretaker who used such therapies. Twelve (40%) of 30 families who reported using either an herbal or homeopathic remedy, also used a prescription or over-the-counter medication at the same time to treat their child. Thirty-nine of 55 families (70.9%) reported informing their child’s physician of their use of CAM therapies. Conclusion CAM therapies are frequently used to treat children. Most parents who use CAM therapies to treat their children use such therapies themselves. Large proportions of children who are taking herbal supplements are also taking prescription or over-the-counter medications concurrently.

Femur fractures resulting from stair falls among children: an injury plausibility model.

Background. Stair falls are common among young children and are also common false histories in cases of child abuse. When a child presents with a femur fracture and a stair-fall history, a judgment of plausibility must be made. A lack of objective injury and biomechanical data makes plausibility determination more difficult. Our objective was to characterize key features associated with femur fractures from reported stair falls, to develop a model for assessing injury plausibility (IP). Methods. Children 2 to 36 months of age who presented with a femur fracture from a reported stair fall were studied prospectively. Detailed history recording, examinations, fracture characterization, and injury scene analyses were conducted, and biomechanical measures associated with injury prediction were calculated. With our proposed IP model, all cases were then scored for the detail of history, biomechanical compatibility of fracture morphologic features, time to seeking care, and presence of other injuries. Results. Twenty-nine children were diagnosed with a femur fracture resulting from a reported stair fall. The IP model made a clear distinction between 2 groups, designated plausible and suspicious. Significant differences were observed for the detail of history, biomechanical compatibility of fracture, time to seeking care, presence of other injuries, and total IP scores. In the plausible group, the minimal linear momentum associated with a transverse fracture was almost 10-fold greater than that for spiral or buckle fracture types. Conclusions. This study adds new information to the current body of knowledge regarding injury biomechanics and fractures among children. The IP model provides an objective means of assessing plausibility of reported stair-fall–related femur fractures and identifies key characteristics to facilitate decision-making.

Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department.

Objectives: Ultrasound (US) may be a useful tool for rapidly diagnosing fractures. Our objective was to determine the accuracy of US as compared with radiographs in the detection of nonangulated distal forearm fractures. Methods: Distal forearm US was performed and interpreted at the bedside by a pediatric emergency medicine physician before radiography in a prospective sample of children with possible nonangulated distal forearm fractures. A second pediatric emergency medicine physician with extensive US experience gave a final interpretation of the images. This second reviewer was blinded to both clinical and radiographic findings. The primary outcome was accuracy in the detection of fracture via the blinded reviewers US interpretation when compared with the radiologists clinical radiography results. Patient-reported FACES pain scores (range, 0-5) associated with both US and radiography were compared. Results: Of 101 enrolled patients, 46 had a fracture detected by the radiologist. When compared with radiographs, the blinded US interpretation had an overall accuracy of 94% (95% confidence interval [CI], 88%-99%). Sensitivity and specificity were 96% (95% CI, 85%-99%) and 93% (95% CI, 82%-98%), respectively. Positive predictive value was 92%, and negative predictive value was 96%. Mean FACES pain scores were higher following radiography than US (1.7 vs 1.2, respectively; P = 0.004). Conclusions: For the diagnosis of nonangulated distal forearm fractures in children, bedside US holds promise as a diagnostic modality, particularly with appropriate training. Ultrasound is at least no more painful that traditional radiographs. Pediatric emergency medicine physicians should consider becoming proficient in this application.

Charges and complications associated with the medical evaluation of febrile young infants.

Background: Since 1983, no study has evaluated the costs and complications involved in the inpatient evaluation of antibiotic therapy for febrile infants aged 29 to 60 days. Methods: A prospective quality indicator/quality assurance study of low-risk febrile young infants (FYIs) was conducted during a 16-month period after a retrospective pilot study. One investigator (C.C.) followed the medical course of enrolled FYIs, including 3 standardized scheduled phone follow-ups with the subjects parent and primary care provider (PCP) within the 2 weeks after discharge. Results: Sixty-two subjects were enrolled during the 16-month period (58 admitted and 4 discharged subjects). Two (3%) subjects who met low-risk criteria developed a serious bacterial infection, both urinary tract infections. No cases of true bacteremia or bacterial meningitis were diagnosed. Seventeen subjects (29.3%) developed a complication during the admission. The mean length of inpatient stay was 49.0 hours (range, 18.1-65.4 hours). The mean charge for hospitalization was

Classifying Injuries in Young Children as Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach

6202 (range,

A 19-month-old boy with recurrent respiratory distress.

2818-

Enhanced Urinalysis Improves Identification of Febrile Infants Ages 60 Days and Younger at Low Risk for Serious Bacterial Illness

9880). Scheduled phone follow-up was successful on days 2 (77.4%), 7 (85.4%), and 14 (83.9%) after discharge. All patients were reported as improved (100%), and most parents preferred discharge to admission (66%-70%). In the 2 weeks after discharge, only 45 (72.6%) of 62 subjects had followed up with their PCPs. Conclusions: This prospective quality indicator/quality assurance study demonstrates that inpatient evaluation of low-risk FYIs results in high charges and potentially preventable complications. Hospitalization is contrary to the wishes of most parents in this study; however, the rate of appropriate follow-up with a PCP in this study is concerning.

Use of Etomidate as an Induction Agent for Rapid Sequence Intubation in a Pediatric Emergency Department

Objective To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. Study design Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9‐member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5‐level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS. Results The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status. Conclusions A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.

Does Valsalva Retinopathy Occur in Infants? An Initial Investigation in Infants With Vomiting Caused by Pyloric Stenosis

We present a 19-month-old boy with a history of asthma who presented to the pediatric emergency department with noisy breathing and tachypnea partially responsive to albuterol. He was discharged to routine care at home. His parents brought him back the next day for persistent respiratory distress despite routine home albuterol. A check of electrolytes showed a low bicarbonate level.