Sandra J. Cunningham

Parental perceptions of access to care and quality of care for inner-city children with asthma.

The objective of this study was to describe perceptions of asthma care, morbidity, and health service utilization by parents of children with asthma presenting to an inner-city emergency department (ED). A cross-sectional survey was conducted in an urban pediatric ED, with a convenience sample of 466 parents of children receiving asthma treatment during a consecutive 6-week period in late fall 1995. Parents completed a 30-item survey including sociodemographic data, source of primary medical care and asthma care for their child, selected measures of access to care, and medications used by their child in the week prior to the ED visit. Perceived quality of asthma care was measured by six items (summary score = 0-6) reported to have been performed by the childs asthma doctor: discussion of home peak flow monitoring, child-specific triggers, dogs/cats, smoke, postexacerbation calling instructions, and provision of a written asthma management plan. Functional morbidity was measured by nights of poor sleep, days of cough, and school days missed due to asthma in the previous month. Among 325 patients with previously diagnosed asthma, 308 (97%) were reported to have a source of primary medical care. Of these, 126 respondents identified their primary care provider as the childs usual source of asthma care, while 158 identified the ED as the usual source. The groups did not differ by insurance status, ethnicity, or mean age of the child. Thirty-nine percent of children with the same provider for primary and asthma care compared with 15% of children reported to receive their asthma care predominantly in the ED had used inhaled steroids or cromolyn in the week prior to the ED visit (p < .0001). Children with the same provider for primary and asthma care had a higher mean quality score than children receiving asthma care in the ED (3.7 vs. 2.8, p < 0.0001), but there was no relationship between source of asthma care and functional morbidity. The ED remains the usual source of asthma care for many inner-city children. Among parents surveyed in the ED, there was a significant relationship between source of usual asthma care and quality of care, but a relationship between usual source of asthma care and functional morbidity could not be identified.

The effect of Lactobacillus GG on acute diarrheal illness in the pediatric emergency department.

Objective The purpose of this study was to evaluate the effectiveness of the probiotic Lactobacillus GG (LGG) in reducing the duration of acute infectious diarrhea in the pediatric emergency department. Methods We conducted a double-blind, randomized controlled trial of children 6 months to 6 years presenting to the pediatric emergency department with a complaint of diarrhea. Patients were randomized to receive either placebo or LGG powder twice daily for 5 days. With each dose, parents recorded the stool history in a home diary and were followed up daily by a blinded researcher. Groups were compared in terms of time to normal stool and number of diarrheal stools. Results Of 155 patients enrolled, 129 completed the study: 63 in the LGG group and 66 in the placebo group. There was no significant difference in the median (interquartile range) time to normal stool (LGG: 60 hours [37–111] vs placebo: 74 hours [43–120]; P = 0.37) or the number of diarrheal stools (LGG: 5.0 [1–10] vs placebo: 6.5 [2–14]; P = 0.19). Among children who presented with more than 2 days of diarrhea, the LGG group returned to normal stool earlier (LGG: 51 hours [32–78] vs placebo: 74 hours [45–120]; P = 0.02), had fewer episodes of diarrheal stools (LGG: 3.5 [1.0–7.5] vs placebo: 7 [3.0–16.3]; P = 0.02), and were 2.2 times more likely to return to normal stool (95% confidence interval, 1.3–3.9; P = 0.01) compared with children in the placebo group. Conclusions Lactobacillus GG may reduce the duration of acute diarrheal illness among children presenting with more than 2 days of symptoms.

Accuracy of weight estimates in pediatric patients by prehospital Emergency Medical Services personnel

OBJECTIVES Most medications administered to children are weight-based, and inaccurate weight estimation may contribute to medical errors. Previous studies have been limited to hypothetical patients and those in cardiopulmonary arrest. We aim to determine the accuracy of weight estimates by Emergency Medical Services (EMS) personnel of children receiving medications and to identify factors associated with accuracy. METHODS EMS records of children <18 years old receiving weight-based medications were merged with EMS staffing data and hospital records. The rate of accurate weight estimates, defined as a value within 20% of the actual weight, was evaluated as the primary outcome. Factors associated with patients and prehospital personnel were also evaluated. RESULTS 29233 transports occurring during the study period were reviewed, and 199 transports of 179 children were analyzed. The average experience of EMS personnel was 35.8 months (SD ±30.7). EMS personnel accurately estimated weights in 164/199 (82.4%) patients; estimated weights were within 10.8% (SD ±10.5) of the actual weights. Underestimated weights were associated with receiving doses outside of the therapeutic range. Inaccurate weight estimates were associated with age less than 10 years or cardiopulmonary arrest. There was a trend toward inaccurate weight estimates among children who presented with seizures. CONCLUSIONS EMS personnel are generally accurate in estimating weights of children. There was an association between underestimated weights and inaccurate medication dosing. Younger children or those presenting with seizure or cardiopulmonary arrest were more likely to have inaccurate weight estimates.

Providing immunizations in a pediatric emergency department: underimmunization rates and parental acceptance.

OBJECTIVES To assess the vaccination status and vaccinate eligible children with age-appropriate antigens. DESIGN Intervention. SETTING Pediatric emergency department in an urban, public hospital. PATIENTS Convenience sample of children, aged birth through 72 months. INTERVENTIONS Immunization of eligible children. MAIN OUTCOME MEASURES 1) Immunization coverage rates in the sample population, 2) Acceptance rates of immunization. RESULTS A total of 9321 children were enrolled over a 2-year period. Fifty-nine percent were documented to be underimmunized. Overall, 2514 children received a total of 6482 immunizations. Parents who carried portable immunization cards documenting that their child was underimmunized were almost five times more likely to accept immunization for their child than parents who lacked documentation (71% vs 15%, P < 0.0001). The estimated cost of providing immunizations in the emergency department was

A Validation Study of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) Tape–A New Weight Estimation Tool

47.15 per child immunized, or

Association between skin testing in the pediatric emergency department and adherence to follow-up in children with asthma

18.56 per immunization given. CONCLUSIONS The majority of children with documentation of immunization status were underimmunized. When documentation of underimmunization was available, parents were significantly more likely to accept vaccination. These data suggest that vaccinating children in nontraditional settings is feasible and support the creation of an accessible vaccine registry.

Internal Hernia as a Cause for Intestinal Obstruction in a Newborn

OBJECTIVE To evaluate the performance of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) tape, a new weight-estimation tool with a modifier for body habitus, in our increasingly obese population. STUDY DESIGN A convenience sample of children presenting to the pediatric emergency department of an urban public hospital was enrolled. A nurse or doctor assigned the patient a body habitus score and used the PAWPER tape to estimate the weight. The true weight was then recorded for comparison.The estimated weight was considered accurate if it was within 10% of the true weight. RESULTS We enrolled 1698 patients; 579 (34%) were overweight or obese. Overall, the estimated weight was accurate for 64% of patients (95% CI 61%-65%). For children with an above-average body habitus, the tape was accurate 50% of the time (95% CI 46%-55%). There was no significant difference in the accuracy of the PAWPER tape for children assessed during medical and trauma resuscitations. CONCLUSION Although the PAWPER tape may ultimately be useful, its initial performance was not replicated in our population. A simple, accurate method of weight estimation remains elusive.

Pediatric scooter-related injuries

BACKGROUND Efforts to enroll inner-city asthmatic children into continuity care after a pediatric emergency department (PED) visit are frequently unsuccessful. Providing parents with documentation of their childs allergic status and how this can be used to tailor an asthma management plan may improve adherence to scheduled continuity appointments. OBJECTIVE To determine whether skin testing children during PED visits for wheezing and providing parents with skin test results improves adherence to follow-up visits. METHODS A convenience sample of children aged 2 to 12 years with asthma who presented to the PED with wheezing were eligible. Enrolled children were randomized to group 1 (no skin test) or group 2 (skin test). At discharge, both groups scheduled asthma clinic appointments for within 1 week. Children in group 2 underwent skin testing with standard allergens, and parents were given documentation of skin test results. Adherence was assessed by computer confirmation of the patients asthma clinic visit. RESULTS Seventy-seven children were enrolled: 39 in group 1 and 38 in group 2. The mean age was 7 years; 69% had mild intermittent asthma. Twenty-four percent of children (9 of 38) in group 1 vs 46% (17 of 37) in group 2 were followed up in the asthma clinic (P < .05). Children in group 2 were 2.6 (95% confidence interval, 1.02-6.65) times more likely to keep appointments compared with children in group 1. CONCLUSIONS Parents who receive evidence in the PED of their childs allergic status and probable relationship to the childs asthma are more likely to adhere to scheduled continuity visits.

Systemic lupus erythematosus presenting as an intracranial bleed

BACKGROUND An internal hernia is a rare cause of intestinal obstruction, which can occur at any age. Children most often develop an internal hernia due to a congenital defect in the mesentery. While some patients are asymptomatic, others present to medical attention with vague abdominal symptoms, an acute abdomen, or in shock. CASE REPORT We report a case of a 5-day-old previously healthy baby who presented to our pediatric emergency department with bilious vomiting, grossly bloody stool, and abdominal distention. During an exploratory laparotomy, the patient was diagnosed with an internal hernia caused by a congenital mesenteric defect. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although internal hernia is an infrequent cause of intestinal obstruction in a newborn and requires emergent operative repair, it may be mistaken for other more common causes, such as necrotizing entercolitis, which are often managed medically. This case report aims to highlight some of the difficulties in diagnosis and key features that may assist the clinician in identifying these patients.

Role of clinical suspicion in pediatric blunt trauma patients with severe mechanisms of injury

Objectives: To describe the circumstances and injuries associated with nonmotorized scooter-related trauma and to assess parental and child awareness and use of safety equipment. Methods: All children <18 years of age presenting to an urban pediatric emergency department during a 15-month period with a nonmotorized scooter-related injury were identified. Data were collected by chart review or a detailed survey conducted by the treating clinician. Results: There were 101 children with a total of 159 injuries. The mean age was 8.7 years; 70% were male. Most injuries involved the head/face/neck (30.8%), upper extremities (31.3%), and lower extremities (30.3%). Fifty-two percent (51.5%) of all injuries sustained were contusions, 32.7% fractures, 17.8% lacerations, 9.9% sprains, and 5.9% oral injuries. A total of 6 patients were admitted to the hospital, 1 to the intensive care unit. Data from surveys (n = 63) revealed that most injuries resulted from striking a stationary hazard (36.5%) or spontaneously losing balance (28.6%). Although 71.4% of all parents were aware of scooter safety precautions and 66.7% reported that their child had access to safety equipment, only 15.9% of patients were wearing any equipment. Fractures were more common in children ≥8 years (P = 0.03); head and facial injuries were more common in children <8 years (P = 0.001). Conclusions: Scooter-related injuries result in substantial morbidity. Although injured patients and their parents report awareness of scooter safety equipment, few injured children wear their equipment.