Michael G. Tunik

Abusive suffocation with foreign bodies is an uncommon form of child abuse. We present the case of a 2-month-old infant with colic who was forcibly suffocated with a baby wipe by a female babysitter. He presented to the emergency department in respiratory distress, and the foreign body was removed in the operating room by otorhinolaryngology. He was found to have intraoral lacerations and a left diaphyseal humeral fracture. To our knowledge, there is only 1 other collection of case reports of abusive suffocation with baby wipes. This case highlights the importance of considering abuse in cases of oral injury and foreign body aspiration in pediatric patients.

Objective The aim of this study was to evaluate current imaging approaches in children with suspected appendicitis (AP) in the pediatric emergency department (ED) of a major urban medical center. Methods Children aged 6 to 18 years who presented to a pediatric ED in 2016 with possible AP were identified by a keyword search. Charts were reviewed for the following: age, sex, time of evaluation, imaging study, results of imaging study, disposition, and outcome. Results We calculated mean values and SD for continuous data. Initially, 503 charts were identified. Of these 503, 292 children were identified as having possible AP. Mean age was 10.7 years (SD, 2.7); 50.6% presented between 5:00 pm and 8:00 am the next morning. Of the 287 US studies performed, 114 (39.7%) were definitively positive or negative. Of these, 46 (16.0%) were negative for AP and 68 (23.7%) were positive. There were 173 (60.3%) ultrasounds that were equivocal. Computed tomography scans were performed in 41 (13.9%) of the total 292 patients, and 2 (0.7%) of the 292 received magnetic resonance imaging. Patient dispositions were as follows: discharged home, 163 (55.8%); admitted for appendectomy, 69 (23.6%); admitted for observation, 37 (12.7%); and extended observation in ED, 10 (3.4%). There were 83 (28.4%) total surgical and interventional radiology cases and 209 (71.6%) nonsurgical cases. Of the 81 appendectomies, 79 (97.5%) had an abnormal appendix, and 2 (2.5%) had no AP. Of the 79 abnormal appendices, 22 (27.8%) were perforated, 55 (69.6%) were not, and 2 (2.6%) were unclear. Conclusions Computed tomography scans were performed in 13.9% of patients with suspected AP. The overall AP rate was 28.4%. We plan to increase the use of magnetic resonance imaging and other modalities to reduce overall computed tomography usage.

Nearly 500 000 febrile infants are evaluated in US emergency departments (EDs) and other outpatient settings annually.^1,2 Among febrile infants 60 days and younger, 8% to 13% have serious bacterial infections (SBIs) including urinary tract infections (UTIs), bacteremia, and bacterial meningitis.^3-5 Because missed SBIs, particularly bacteremia and meningitis, may lead to serious complications,^6,7 the treatment of febrile infants frequently involves lumbar punctures, broad-spectrum antibiotic administration, and hospitalization.

Background Traumatic injury is the leading cause of paediatric morbidity and mortality in the USA. We present updated national data on emergency department (ED) discharges for traumatic injury for a recent 7-year period. Methods We conducted a descriptive epidemiological analysis of the Nationwide Emergency Department Sample Survey, the largest and most comprehensive database in the USA, for 2006–2012. Among children and adolescents, we tracked changes in injury mechanism and severity, cost of care, injury intent and the role of trauma centres. Results There was an 8.3% (95% CI 7.7 to 8.9) decrease in the annual number of ED visits for traumatic injury in children and adolescents over the study period, from 8 557 904 (SE=5861) in 2006 to 7 846 912 (SE=5191) in 2012. The case-fatality rate was 0.04% for all injuries and 3.2% for severely injured children. Children and adolescents with high-mortality injury mechanisms were more than three times more likely to be treated at a level 1 trauma centre (OR=3.5, 95% CI 3.3 to 3.7), but were more no more likely to die (OR=0.96, 95% CI 0.93 to 1.00). Traumatic brain injury diagnoses increased 22.2% (95% CI 20.6 to 23.9) during the study period. Intentional assault accounted for 3% (SE=0.1) of all child and adolescent ED injury discharges and 7.2% (SE=0.3) of discharges among 15–19 year-olds. There was an 11.3% (95% CI 10.0 to 12.6) decline in motor vehicle injuries from 2009 to 2012. The total cost of care was $23 billion (SE=0.01), a 78% increase from 2006 to 2012. Conclusions This analysis presents a recent portrait of paediatric trauma across the USA. These analyses indicate the important role and value of trauma centre care for injured children and adolescents, and that the most common causes and mechanisms of injury are preventable.

Objectives: Computed tomography (CT) is often used in the emergency department (ED) evaluation of children with posttraumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBIs) and short‐term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBIs on CT and short‐term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED.Methods: This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 EDs in the Pediatric Emergency Care Applied Research Network. We evaluated children < 18 years with head trauma and PTS between June 2004 and September 2006. We assessed TBI on CT, neurosurgical interventions, and recurrent seizures within 1 week. Patients discharged from the ED were contacted by telephone 1 week to 3 months later.Results: Of 42,424 children enrolled, 536 (1.3%, 95% confidence interval [CI] = 1.2%–1.4%) had PTS. A total of 466 of 536 (86.9%, 95% CI = 83.8%–89.7%) underwent CT in the ED. TBIs on CT were identified in 72 (15.5%, 95% CI = 12.3%–19.1%), of whom 20 (27.8%, 95% CI = 17.9%–39.6%) underwent neurosurgical intervention and 15 (20.8%, 95% CI = 12.2%–32.0%) had recurrent seizures. Of the 464 without TBIs on CT (or no CTs performed), 457 had recurrent seizure status known, and five (1.1%, 95 CI = 0.4%–2.5%) had recurrent seizures; four of five presented with Glasgow Coma Scale scores < 15. None of the 464 underwent neurosurgical intervention. We found significant associations between likelihood of TBI on CT with longer time until the PTS after the traumatic event (p = 0.006) and longer duration of PTS (p < 0.001).Conclusions: Children with PTS have a high likelihood of TBI on CT, and those with TBI on CT frequently require neurosurgical interventions and frequently have recurrent seizures. Those without TBIs on CT, however, are at low risk of short‐term recurrent seizures, and none required neurosurgical interventions. Therefore, if CT‐negative and neurologically normal, patients with PTS may be safely considered for discharge from the ED.

Febrile infants aged 60 days or younger are at substantial risk of serious bacterial infections (defined as bacteremia, urinary tract infections [UTIs], and bacterial meningitis), estimated at 7% to 9% in this population.¹ Current guidelines recommend obtaining blood, urine, and cerebrospinal fluid (CSF) cultures, with consideration of antibiotic treatment and hospitalization until culture results are negative. Although these strategies aim to identify and treat all young febrile infants with serious bacterial infections, the costs and risks are high.² The lack of an optimal management strategy has led to substantial variation in the care for this vulnerable population, unnecessarily exposing many infants to potential harm.

Objective: The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma.Methods: This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes.Results: We enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI.Conclusions: The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.

Objectives: The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma.Methods: We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007–2010. Treating physicians documented race/ethnicity as white non‐Hispanic, black non‐Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra‐abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals.Results: Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non‐Hispanic (n = 5,847, 54.0%), black non‐Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non‐Hispanic, 32.7% of black non‐Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra‐abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non‐Hispanic than for white non‐Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non‐Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1).Conclusions: After blunt torso trauma, pediatric patients identified by the treating physicians as black non‐Hispanic were less likely to receive abdominal CT imaging than those identified as white non‐Hispanic. This suggests that nonclinical factors influence clinician decision‐making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging.