Protocolized abuse screening to decrease provider bias and increase capture of potential events.

BACKGROUND: Early identification of child abuse is critical to prevent death and disability. Studies suggest implicit bias of providers may lead to overrepresentation of minority and impoverished children in child abuse reporting. At our institution, universal screening for sexual and physical abuse for all children under 18 years of age was implemented in 2016. A rigorous, objective evaluation protocol focusing on the mechanism of injury and exam findings to improve recognition and eliminate bias was implemented in 2019. FINDINGS: Demographics and clinical characteristics of patients less than 18 years of age were abstracted by chart review (2014-2015) and from a forensic database (2016-2022). International Classification of Diseases codes 995.5 (version 9) and T76.12XA (version 10) were used to identify patients before the establishment of forensic database. Relative frequency and patient characteristics of the three time periods (pre universal screening: 2014-2015, post universal screening: 2016-2019, post protocol implementation: 2020-2022) were compared using Chi-square tests and modified Poisson regression. Universal screening significantly increased the number of cases identified. The demographic profile of potential victims by race significantly changed over the reporting periods with an increased number of white children identified, consistent with state demographics. The proportion of publicly insured patients trended down with universal screening and protocol implementation, despite a significant increase in the number of children publicly insured in the state during this time. CONCLUSION: These single institutional results lend support to objective, evidence-based protocols to help eliminate bias surrounding race and poverty.

A Contemporary Review of Surgical Approach and Outcomes in Pediatric Hypertrophic Pyloric Stenosis.

INTRODUCTION: In order to define optimal resources and outcome standards for infant pyloromyotomy, we sought to perform a contemporary analysis of surgical approach (laparoscopic versus open) and outcomes. METHODS: The National Surgical Quality Improvement Project Pediatrics Participant Use File (NSQIP PUF) was queried from 2016 to 2020. Utilization of laparoscopy was trended over time. Complication rates and length of stay were compared by operative approach. RESULTS: 9752 pyloromyotomies were included in the analysis. The utilization of laparoscopy steadily increased over the study time period (66% to 79%) and was associated with a shorter operative time. On multivariate regression, the utilization of laparoscopy was associated with a lower risk of overall complications, length of stay, and superficial surgical site infections. Overall complication rates were lower than previously reported (2.02%). The most common complication was superficial infection (1.2%). CONCLUSIONS: In facilities reporting to pediatric National Quality Improvement Project, utilization of laparoscopy has steadily increased, and complication rates are lower than previously reported. Complication rates and length of stay were lower with the laparoscopic approach in this contemporary cohort. These results offer benchmarks for quality improvement initiatives. The laparoscopic approach should be standard in facilities performing this procedure.

Common Conditions II: Acute Appendicitis, Intussusception, and Gastrointestinal Bleeding.

Perforated appendicitis continues to be a significant cause of morbidity for children. In most centers, ultrasound has replaced computed tomography as the initial imaging modality for this condition. Controversies surrounding optimal medical and surgical management of appendicitis are discussed. Management of intussusception begins with clinical assessment and ultrasound, followed by image-guided air or saline reduction enema. When surgery is required, laparoscopy is typically utilized unless bowel resection is required. The differential diagnosis for pediatric gastrointestinal bleeding is broad but often made with age, history, and physical examination. Endoscopy or laparoscopy is sometimes needed to confirm a diagnosis or for treatment.

Clinical and radiographic predictors of the need for facial CT in pediatric blunt trauma: a multi-institutional study.

Background: Facial injuries are common in children with blunt trauma. Most are soft tissue lacerations and dental injuries readily apparent on clinical examination. Fractures requiring operative intervention are rare. Guidelines for utilization of maxillofacial CT in children are lacking. We hypothesized that head CT is a useful screening tool to identify children requiring dedicated facial CT. Methods: We conducted a multicenter retrospective review of children aged 18 years and under with blunt facial injury who underwent both CT of the face and head from 2014 through 2018 at five pediatric trauma centers. Penetrating injuries and animal bites were excluded. Imaging and physical examination findings as well as interventions for facial fracture were reviewed. Clinically significant fractures were those requiring an intervention during hospital stay or within 30 days of injury. Results: 322 children with facial fractures were identified. Head CT was able to identify a facial fracture in 89% (287 of 322) of children with facial fractures seen on dedicated facial CT. Minimally displaced nasal fractures, mandibular fractures, and dental injuries were the most common facial fractures not identified on head CT. Only 2% of the cohort (7 of 322) had facial injuries missed on head CT and required an intervention. All seven had mandibular or alveolar plate injuries with findings on physical examination suggestive of injury. Discussion: In pediatric blunt trauma, head CT is an excellent screening tool for facial fracture. In the absence of clinical evidence of a mandibular or dental injury, a normal head CT will usually exclude a clinically significant facial fracture. Level of evidence: III.

Computed Tomography Scan Utilization in Pediatric Trauma: Impact on Length of Stay and Incidence of False Positive Findings.

INTRODUCTION: Computerized tomography (CT) scans are the mainstay of diagnostic imaging in blunt trauma. Particularly in pediatric trauma, utilization of CT scans has increased exponentially in recent years. Concerns regarding radiation exposure to this vulnerable population have resulted in increased scrutiny of practice. What is not known is if liberal imaging practices decrease length of stay by eliminating the need for clinical observation, and the impact of false-positive rates from liberal use of CT scanning on clinical outcomes. METHODS: Medical records from a nonaccredited pediatric trauma center with a practice of liberal imaging were reviewed over a 2-year period. Total CT scans obtained were recorded, in addition to length of stay, age, and Injury Severity Score (ISS). Rates of clinically significant imaging findings were recorded, as were false positive findings and complications of imaging. RESULTS: Out of 735 children, 58% underwent CT scanning, and if scanned, received an average of 2.4 studies. Clinically significant findings were documented in 20% of head CTs, 2% of cervical spine CTs, 3.5% of chest CTs, 24% of facial CTs, and 14.7% of abdominal CTs. False-positive findings were found in 1.5% of head CTs, 1.2% of cervical spine CTs, 2.4% of chest CTs, and 2.5% of abdominal CTs. Liberal CT scanning was not associated with decreased length of stay. In contrast, obtaining CT scans on more than 4 body regions was independently predictive of longer length of stay, independent of ISS. CONCLUSIONS: False-positive rates of CT scans for trauma were low in this cohort. However, when scanning the cervical spine or the chest, for every 2 clinically significant findings obtained, there was at least one false positive result, calling into question the practice of liberal imaging of these regions. Liberal utilization of CT scan did not allow for more rapid discharge home, and for more than 4 CTs was independently associated with longer hospital stay.

Utilization of CT imaging in minor pediatric head, thoracic, and abdominal trauma in the United States.

BACKGROUND: Liberal use of CT scanning in children with blunt trauma risks unnecessary radiation exposure and cost. Recent literature questions the utility of whole-body CT in stable children without clinical evidence of significant injury, but this is often done based on injury mechanism. The purpose of this study is to quantify the utilization of CT scans of the head, chest, abdomen, and pelvis based on injury severity in these body regions and to assess the impact of American College of Surgeons (ACS) pediatric trauma center designation on CT utilization in children with minor or no injuries. METHODS: We queried the National Trauma Databank for 2014, 2015, and 2016 to identify all patients 14 years and younger. Using Abbreviated Injury Scale (AIS) score as a proxy for injury severity, we analyzed the number of head, thoracic, and abdominal CT scans done for patients at low levels of injury severity (AIS 0-2) in each of these body regions and according to trauma center level designation (ACS I, II, III, standalone pediatric I or II, and non ACS accredited). RESULTS: Of 257,661 children who were entered into the database for any reason, overall CT utilization was 20% for head, 5% for the chest and 9% for the abdomen and pelvis. Children with no injuries or minimal injury to the head were scanned 7% and 46% of the time, respectively, for the chest 3% and 13% and for the abdomen 6% and 30%. For all body regions and all levels of injury severity, level 1 stand-alone pediatric centers displayed significantly lower CT utilization rates than others. CONCLUSION: CT scan rates for children with minimal or no injuries to the head, chest, abdomen and pelvis are significant. Level 1 stand-alone pediatric trauma centers are least likely to perform these studies. Widespread education and acceptance of clinical guidelines for imaging in stable patients throughout trauma systems could alleviate this disparity. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Clinical and laboratory predictors of blood loss in young swine: a model for pediatric hemorrhage.

BACKGROUND: The pediatric patient's response to hemorrhage as a function of young age is not well understood. As a result, there is no consensus on optimal resuscitation strategies for hemorrhagic shock in pediatric patients, or on the identification of clinical triggers to prompt implementation. The study objective was to develop a model of pediatric hemorrhage using young pigs to simulate school-aged children, and determine clinical and laboratory indicators for significant hemorrhage. MATERIALS AND METHODS: 29 non-splenectomized female pigs, aged 3 months, weighing 30-40 kg, were randomized into groups with varying degrees of hemorrhage. Bleeding occurred intermittently over 5 h while the animals were anesthetized but spontaneously breathing. Various physiologic and biochemical markers were used to monitor the piglets during hemorrhage. RESULTS: Swine experiencing up to 50% hemorrhage survived without exception throughout the course of hemorrhage. 80% (4/5) of the animals in the 60% hemorrhage group survived. Need for respiratory support was universal when blood loss reached 50% of estimated blood volume. Blood pressure was not useful in classifying the degree of shock. Heart rate was helpful in differentiating between the extremes of blood loss examined. Arterial pCO2, pH, lactate, HCO3 and creatinine levels, as well as urine output, changed significantly with increasing blood loss. CONCLUSIONS: Young swine are resilient against hemorrhage, although hemorrhage of 50% or greater universally require respiratory support. In this animal model, with the exception of heart rate, vital signs were minimally helpful in identification of shock. However, change in select laboratory values from baseline was significant with increasing blood loss. LEVEL OF EVIDENCE: This was a level II prospective comparative study.

Analysis of Pediatric Trauma in Combat Zone to Inform High-Fidelity Simulation Predeployment Training.

OBJECTIVES: The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone. SETTING AND PATIENTS: A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014. INTERVENTIONS: Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management. MEASUREMENTS AND MAIN RESULTS: Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58). CONCLUSIONS: We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.

Pediatric Wartime Injuries in Afghanistan and Iraq: What Have We Learned?

The majority of the documented experience in pediatric trauma care during the past decade of conflict is from the inpatient Role 3 mission. Pediatric patients (defined as 14 years of age or less) accounted for 5% to 10% of combat admissions. Care for these patients was resource intensive and mortality rates significantly higher than those seen in pediatric hospitals in the United States. The largest documented experience to date with explosive injuries and massive transfusions in children were reported from this conflict. Improvements in logistic and personnel support was seen throughout the decade of conflict, however long-term outcomes and clinical practice guidelines to direct future care for these children are lacking.

Providing care to children in times of war.

The Geneva Conventions stipulate that an occupying power must ensure adequate health care delivery to noncombatants. Special emphasis is given to children, who are among the most vulnerable in a conflict zone. Whether short-term pediatric care should be provided by Military Treatment Facilities to local nationals for conditions other than combat-related injury is controversial. A review of 1,197 children without traumatic injury cared for during 10 years in Iraq and Afghanistan was conducted. Mortality rates were less than 1% among patients with surgical conditions and resource utilization was not excessive. In view of international humanitarian law and these outcomes, children with nontraumatic conditions can and should be considered for treatment at Military Treatment Facilities. The ability to correct the condition and availability of resources necessary to do so should be taken into account.

The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012.

BACKGROUND: Component balanced resuscitation and avoidance of crystalloids in traumatically injured adults requiring massive transfusion are beneficial. Evidence for children is lacking. METHODS: After institutional review board approval was obtained, the Department of Defense Trauma Database identified 1,311 injured children 14 years or younger requiring transfusion after an injury and admitted to a deployed US military hospital from 2002 to 2012. Logistic regression determined risk factors for high-volume (≥40 mL/kg) or massive (≥70 mL/kg) transfusions. The effects of crystalloid and balanced component resuscitation in the first 24 hours were assessed. RESULTS: Nine hundred seven patients had recorded data sufficient for analysis. Two hundred twenty-four children received high-volume transfusion, and 77 received massive transfusions. Mortality was significantly higher for massive transfusions and high-volume transfusions than others (25% vs. 10% and 19% vs. 9%, respectively). Age of less than 4 years, penetrating injury, and Injury Severity Score (ISS) greater than 15 were associated with high-volume transfusions; an ISS greater than 15 and penetrating injury were associated with massive transfusions. Increased crystalloid administration showed a significant positive association with hospital days and intensive care unit days for both massive and high-volume transfusions, as well as a significant positive association with increased ventilator days in patients with high-volume transfusions. Balanced component resuscitation was not associated with improved measured outcomes and was independently associated with a higher mortality when all transfused patients were considered. CONCLUSION: In this cohort, heavy reliance on crystalloid for resuscitation had an adverse effect on outcomes. Balanced component resuscitation did not improve outcomes and was associated with higher mortality when all transfused patients were considered. Further study is needed regarding efficacy and clinical triggers for the implementation of massive transfusion in children. LEVEL OF EVIDENCE: Prognostic study, level IV.

Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data.

BACKGROUND: Massive transfusion (MT) in pediatric patients remains poorly defined. Using the largest existing registry of transfused pediatric trauma patients, we sought a data-driven MT threshold. METHODS: The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head injury, and missing Injury Severity Score (ISS) were excluded. MT was evaluated as a weight-based volume of all blood products transfused in the first 24 hours. Mortality at 24 hours and in the hospital was calculated for increasing transfusion volumes. Sensitivity and specificity curves for predicting mortality were used to identify an optimal MT threshold. Patients above and below this threshold (MT+ and MT-, respectively) were compared. RESULTS: The Department of Defense Trauma Registry yielded 4,990 combat-injured pediatric trauma patients, of whom 1,113 were transfused and constituted the study cohort. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at 40.1-mL/kg and 38.6-mL/kg total blood products in the first 24 hours, respectively. With the use of a pragmatic threshold of 40 mL/kg, patients were divided into MT+ (n = 443) and MT- (n = 670). MT+ patients were more often in shock (68.1% vs. 47.0%, p < 0.001), hypothermic (13.0% vs. 3.4%, p < 0.001), coagulopathic (45.0% vs. 29.6%, p < 0.001), and thrombocytopenic (10.6% vs. 5.0%, p = 0.002) on presentation. MT+ patients had a higher ISS, more mechanical ventilator days, and longer intensive care unit and hospital stay. MT+ was independently associated with an increased 24-hour mortality (odds ratio, 2.50; 95% confidence interval, 1.28-4.88; p = 0.007) and in-hospital mortality (odds ratio, 2.58; 95% confidence interval, 1.70-3.92; p < 0.001). CONCLUSION: Based on this large cohort of transfused combat-injured pediatric patients, a threshold of 40 mL/kg of all blood products given at any time in the first 24 hours reliably identifies critically injured children at high risk for early and in-hospital death. This evidence-based definition will provide a consistent framework for future research and protocol development in pediatric resuscitation. LEVEL OF EVIDENCE: Diagnostic study, level II. Prognostic/epidemiologic study, level III.

Pediatric falls from buildings: defining the burden of injury in Hawai'i.

Falls from buildings, including houses, are an important cause of childhood injury in the United States; however, no study has previously examined the impact of this problem in Hawai'i. The objective of this study is to categorize the demographics and injury circumstances of pediatric falls from buildings in Hawai'i and compare to other US cities. Patients age 10 and under who were injured in nonfatal accidental falls from buildings in Hawai'i between 2005 and 2011 were identified retrospectively from a statewide repository of hospital billing data. The Hawai'i death certificate database was searched separately for deaths in children age 10 and under due to falls from buildings, with data available from 1991 through 2011. Data was reviewed for demographics, circumstances surrounding the injury, and level of hospital treatment. During the 7-year period for nonfatal injuries, 416 fall-related injuries were identified in children age 10 and younger. Of these, 86 required hospitalization. The rate of nonfatal injury in Hawai'i County was twice that of Honolulu and Maui Counties, and three times that of Kaua'i County. There were 9 fatal falls over a 21-year period. The population based incidence for nonfatal injuries was three-fold higher than that reported in the city of Dallas. The rate of hospitalizations following building falls was more than twice as high as the national average, and that of New York City, but similar to that of California. Strategies for education and environmental modification are reviewed, which may be helpful in reducing the incidence of pediatric falls from buildings in Hawai'i.

Pediatric inpatient humanitarian care in combat: Iraq and Afghanistan 2002 to 2012.

BACKGROUND: The purpose of this study was to define the scope of combat- and noncombat-related inpatient pediatric humanitarian care provided from 2002 to 2012 by the United States (US) Military in Iraq and Afghanistan. STUDY DESIGN: A review of the Patient Administration Systems and Biostatistics Activity (PASBA) database for all admissions from 2002 to 2012 by US military hospitals in Afghanistan and Iraq for children 14 years of age and younger provided data to analyze the use of medical care. North Atlantic Treaty Organization Standardization Agreement (STANAG) injury codes provided injury cause and the ICD-codes provided diagnosis. In-hospital mortality, blood usage, number of invasive procedures, and hospital stay were analyzed by country and injury category. RESULTS: There were 6,273 admissions that met inclusion criteria. In Afghanistan, there were more than twice as many pediatric noncombat-related admissions (2,197) as pediatric combat-related admissions (1,095). In Iraq, the difference was minimal (1,391 noncombat vs 1,590 combat). The most common cause of noncombat-related admission in both countries was injury: primarily motor vehicle related and burns, which varied significantly by age. Older patients (older than 8 years in Afghanistan and older than 4 years in Iraq) were more likely combat victims. Mortality was highest for combat trauma in Iraq (11%) and noncombat trauma in Afghanistan (8%). The in-hospital mortality in both countries was 5% for admissions unrelated to trauma. Resource use was highest for combat trauma in both countries. CONCLUSIONS: Noncombat-related medical care was the primary reason for pediatric humanitarian admissions to United States military combat hospitals in Iraq and Afghanistan from 2002 to 2012. Combat-related injuries have a higher mortality than noncombat injuries or other admissions.

Surgical interventions for pediatric blast injury: an analysis from Afghanistan and Iraq 2002 to 2010.

BACKGROUND: Acute blast injury requires aggressive operative intervention. This study documents therapeutic procedures required for children with blast injury in Afghanistan and Iraq from 2002 to 2010 at US military treatment facilities, to understand pediatric operative resources required after explosions. METHODS: The Joint Theatre Trauma Registry provides data for the previously mentioned population. The data were stratified by years of age as follows: 0 to 3, 4 to 8, 9 to 14, 15 to 19, older than 19 years. Therapeutic procedures were defined by DRG International Classification of Diseases-9th Rev. codes 0 to 86.99. These were analyzed by age, body region, and Abbreviated Injury Scale (AIS) score. RESULTS: A total of 5,026 patients with a known age requiring a total of 22,677 therapeutic procedures were analyzed; 25% (n = 1,205) were children 14 years or younger. On average, 4.5 procedures were required per patient and varied significantly by age. Soft tissue debridement, vascular access procedure, laparotomy, and thoracostomy were the most common procedures for all ages. For all body regions, severe injury (AIS score ≥ 3) was associated with an increased need for an invasive procedure (30-90%) in that region. Children 9 years to 14 years of age underwent significantly more procedures on average (5 procedures per patient) compared with adults (4.5 procedures per patient); children 3 years and younger underwent significantly less (3.15 procedures per patient). Children 4 years to 14 years of age were more likely than older patients to undergo a procedure for a severe head injury (40% vs. 29%), and those 9 years to 14 years old were more likely to undergo a procedure for severe thoracic injury (72%). After 4 years of age, procedures trend away from the head toward the extremity and amputation. CONCLUSION: Blast-injured children require significant operative resources during the acute phase of injury. In the event of an explosive attack, pediatric operative resources and expertise are required. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Pancreatic atrophy and diabetes mellitus following blunt abdominal trauma.

Following pancreatic trauma, loss of uninjured parenchyma as a result of surgical management is expected, and atrophy of parenchyma following nonoperative management has been described. While endocrine insufficiency as a sequela of pancreatic trauma has been reported in adults, it is not a described entity in children. We report a case of pancreatic atrophy following blunt injury in an 8 year old boy who presented 3 years later with diabetes mellitus. Further analysis revealed significant genetic predisposition to diabetes.

Blast injury in children: an analysis from Afghanistan and Iraq, 2002-2010.

BACKGROUND: Throughout history, children have been victims of armed conflict, including the blast injury complex, however, the pattern of injury, physiologic impact, and treatment needs of children with this injury are not well documented. METHODS: The Joint Theatre Trauma Registry provides data on all civilians admitted to US military treatment facilities from 2002 to 2010 with injuries from an explosive device. The data were stratified by age and analyzed for differences in anatomic injury patterns, Injury Severity Score (ISS), Revised Trauma Score (RTS), mortality, intensive care unit days, and length of hospitalization. Multivariate logistic regression was done to determine independent predictors of mortality. All operative procedures with a specified site were tabulated and categorized by body region and age. RESULTS: A total of 4,983 civilian patients were admitted, 25% of whom were younger than 15 years. Pediatric patients aged 8 to 14 years had a higher ISS and hospital stay than other age groups, and children younger than 15 years had a longer intensive care unit stay. Injuries in children were more likely to occur in the head and neck and less likely in the bony pelvis and extremities. Children had a lower RTS than the other age groups. Mortality correlated highly with burns, head injury, transfusion, and RTS. Adolescent patients had a lower mortality rate than the other age groups. Improvised explosive devices were the most common cause of injury in all age groups. CONCLUSION: Children experiencing blast injury complex have an anatomic pattern that is unique and an RTS that reflects more severe physiologic derangement. Injuries requiring transfusion or involving the head and neck and burns were predictive of mortality, and this persisted across all age groups. The mortality rate of children with blast injury is significant (7%), and treatment is resource intensive, requiring many surgical subspecialties. LEVEL OF EVIDENCE: Epidemiologic study, level III.