Tom F. Beattie

Socioeconomic status and adolescent injuries.

Injuries are the major cause of morbidity among children and adolescents in developed countries, but there is a lack of consensus on the relationship between socioeconomic status and risk of injuries. A self-complete questionnaire survey, to gather information on non-fatal injuries and sociodemographic details, was administered in schools during April-June 1994 to a national sample of 4710 Scottish adolescents aged 11, 13 and 15 years. Although there was no evidence of a socioeconomic gradient in the total incidence of medically attended injuries among adolescents, based on the Registrar Generals classifications of paternal occupation and a composite measure of family affluence, marked socioeconomic variation in the circumstances in which injuries occurred was observed. There were also socioeconomic differences in the extent and type of risk behaviours reported by adolescents, indicating differential rates of risk exposure. The finding that socioeconomic status affects the kinds of injury events adolescents experience and levels of risk behaviour has implications for the design of injury prevention strategies.

Can we abolish skull x rays for head injury

Objectives: To assess the effect of a change in skull x ray policy on the rate of admission, use of computed tomography (CT), radiation dose per head injury, and detection of intracranial injuries; and to compare the characteristics of patients with normal and abnormal head CT. Design: Retrospective cohort study. Setting: UK paediatric teaching hospital emergency department. Patients: 1535 patients aged between 1 and 14 years with a head injury presenting to the emergency department between 1 August 1998 and 31 July 1999 (control period), and 1867 presenting between 1 August 2002 and 31 July 2003 (first year of new skull x ray policy). Intervention: Hospital notes and computer systems were analysed and data were collected on all patients presenting with a head injury. Results: The abolition of skull x rays in children aged over 1 year prevented about 400 normal skull x rays being undertaken in period 2. The percentage of children undergoing CT rose from 1.0% to 2.1% with no change in the positive CT pick up rate (25.6% v 25.0%). There was no significant change in admission rate (10.9% v 10.1%), and a slight decrease in the radiation dose per head injury (0.042 mSv compared to 0.045 mSv). Conclusions: Skull x rays can be abandoned in children aged 1 to 14 without a significant increase in admission rate, radiation dose per head injury, or missed intracranial injury. The mechanism and history of the injury and a reduced Glasgow coma scale are probably the most important indicators of significant head injury in children.

Unintentional home injury in preschool-aged children: looking for the key-an exploration of the inter-relationship and relative importance of potential risk factors

OBJECTIVE To investigate the physical, social and psychological environment of families with preschool-age children to identify the most significant risk factors for unintentional injury. DESIGN A 1-year prospective case-control study, using a health-visitor-administered questionnaire. SETTING East and Midlothian, Scotland. SUBJECTS Seventy-nine children under 5 years of age presenting to an accident and emergency (A&E) department during 1998-1999 with an unintentional home injury and 128 matched controls. RESULTS Of 264 families, 207 responded (78.4% response rate). The main carers of cases had a lower level of educational attainment than controls (P<0.01). This factor explained the case carer leaving fulltime education earlier, being less likely to be married and more often in receipt of government benefits. Cases lived in households with larger numbers of children, were more likely to have a physical illness, were less likely to have had a non-medically attended injury in the previous year (P<0.01) but more likely to have had another A&E injury attendance. Case households had lower electrical socket cover utilization (P<0.01) and fewer thought their child had adequate access to safe play areas. The main carers of cases tended to have a more negative life event experience in the preceding 6 months, but showed no significant differences in physical or mental well-being or social support. Cases seemed to be slightly more deprived members of their community. CONCLUSIONS The main carers educational attainment and socket cover utilization were lower in case families. These risk factors could be used to target families for injury-prevention work. Initiatives to raise educational achievement in the general population could lead to reductions in childhood injuries.

Minor illness and injury: factors influencing attendance at a paediatric accident and emergency department

Aims: To gather information on children with minor illness or injury presenting to a paediatric accident and emergency (A&E) department and the decision making process leading to their attendance. Methods: Prospective questionnaire based survey of 465 children selected by systematic sampling from A&E attenders allocated to the lowest triage category. Results: The study population was statistically representative of the total population of A&E attenders. The lower deprivation categories were over represented. Educational attainment, childcare experience, and parental coping skills were important in relation to A&E attendance. More children attended with injury as opposed to illness. There were no significant demographic differences between those children who presented directly to A&E and those who made prior contact with a GP. Just under half the study population had made contact with a general practitioner (GP) before attending A&E. The majority of those children were directly referred to A&E at that point. GPs referred equivalent numbers of children with illness and injury. Conclusions: Parents and GPs view paediatric A&E departments as an appropriate place to seek treatment for children with minor illness or injury.

Incidence and distribution of injury among schoolchildren aged 11-15.

OBJECTIVES: To measure the incidence and age and sex distribution of self reported experience of injuries in the preceding 12 month period among a representative national sample of Scottish schoolchildren and to validate the findings against other data sources. DESIGN: Self completed questionnaire administered in schools, April-June 1994. SUBJECTS: 4710 pupils aged 11, 13, and 15 years drawn from a representative sample of 270 classes with returns from 224 classes (83.2% completion rate). OUTCOME MEASURES: Number, type, site, and severity of injuries reported. RESULTS: 41.9% of pupils reported a medically attended injury, with injury incidence significantly higher in boys than in girls. Using the abbreviated injury scale (maximum abbreviated injury score) one third of injuries were either moderate or severe. CONCLUSION: The incidence and distribution of self reported injury is consistent with estimates based on other data sources thus confirming the utility of this method of injury surveillance in this age group.

The association between deprivation levels, attendance rate and triage category of children attending a children's accident and emergency department.

Objective—To determine the relation between deprivation category, triage score and accident and emergency (A&E) attendance for children under the age of 13. Design—Retrospective study of all children attending an A&E department over one year. Setting—A paediatric teaching hospital in Edinburgh. Subjects—All children attending the A&E department who had a postcode and a triage score documented on attendance. The postcode was used to determine the deprivation category and the triage scored the severity of illness or injury. Main outcome measure—The relation between deprivation category, triage score and frequency of attendance. Results—There is a trend towards increased attendance in all triage categories for deprivation categories 6 and 7. Conclusions—Attendance at A&E is not only related to severity of injury but also to deprivation category. The reason why people from disadvantaged areas attend more frequently needs further evaluation.

Measures of injury severity in childhood: a critical overview

Many different methods for assessing injury severity have appeared in the literature. This paper discusses the commonly used measures, many of which are subjective and depend on clinical practice or sociological factors. Even if apparently objective measures are used their appropriateness for use in children is questionable. Particular problems occur with scoring or categorising events such as poisoning, choking, and near drowning. Researchers need to reach a consensus on injury severity reporting to ensure comparability between studies and programs for injury prevention.

Streptococcus A in paediatric accident and emergency: are rapid streptococcal tests and clinical examination of any help?

Background: Rapid streptococcal tests (RSTs) for streptococcal pharyngitis have made diagnosis at once simpler and more complicated. The American Academy of Pediatrics recommends that all RSTs be confirmed by a follow up throat culture unless local validation has proved the RST to be equally sensitive. Aims: To evaluate (a) RST as a single diagnostic tool, compared with RST with or without throat culture; (b) clinical diagnosis and the relative contribution of different symptoms. Methods: The study included 213 patients with clinical signs of pharyngitis. Throat swabs were analysed using Quickvue+ Strep A Test; negative RSTs were backed up by throat culture. Thirteen clinical features commonly associated with strep throat were analysed using backward stepwise logistic regression. Results: Positive results (RST or throat culture) were obtained in 33 patients; RST correctly identified 21. Eleven samples were false negative on RST. At a strep throat prevalence of 15.9%, sensitivity of RST was 65.6% (95% CI 46.8% to 81.4%) and specificity 99.4% (96.7% to 99.9%). Sensitivity of clinical diagnosis alone was 57% (34% to 78%) and specificity 71% (61% to 80%). Clinically, only history of sore throat, rash, and pyrexia contributed to the diagnosis of strep throat (p<0.05). Conclusion: The high specificity of RST facilitates early diagnosis of strep throat. However, the low sensitivity of RST does not support its use as a single diagnostic tool. The sensitivity in the present study is markedly different from that reported by the manufacturer. Clinical examination is of limited value in the diagnosis of strep throat. It is important to audit the performance of new diagnostic tests, previously validated in different settings.

Emergency analgesia in the paediatric population. Part I Current practice and perspectives

Children frequently present to the accident and emergency (A&E) department in pain. Most presentations are acute, but children with pain of longer duration also present. Children also often undergo painful procedures in A&E in the process of diagnosis or treatment. These papers review recent literature to examine factors involved in the provision of emergency analgesia in the paediatric population. This will include a discussion of current practice and make recommendations for future management of childrens pain and anxiety in the A&E department. Part I: Current practice and perspectives. Part II: Pharmacological methods of paediatric analgesia. Part III: Non-pharmacological methods of pain control and anxiolysis. Part IV: Paediatric sedation in accident and emergency.

An automated algorithm for determining respiratory rate by photoplethysmogram in children

Background: We have developed an automated algorithm to allow the measurement of respiratory rate directly from the photoplethysmogram (pulse oximeter waveform). Aim: To test the algorithms ability to determine respiratory rate in children. Methods: A convenience sample of patients attending a paediatric Accident and Emergency Department was monitored using a purpose‐built pulse oximeter and the photoplethysmogram (PPG) recorded. Respiration was also recorded by an observer activating a push‐button switch in synchronization with the childs breathing. The switch marker signals were processed to derive a manual respiratory rate that was compared with the wavelet‐based oximeter respiratory rate derived from the PPG signal. Results: Photoplethysmograms were obtained from 18 children aged 18 mo to 12 y, breathing spontaneously at rates of 17 to 27 breaths per minute. There was close correspondence between the wavelet‐based oximeter respiration rate and the manual respiratory rate, with the difference between them being less than one breath per minute in all children.