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Objective: Among children transported by ambulance across the United States, we used machine learning models to develop a risk prediction tool for firearm injury using basic demographic information and home ZIP code matched to publicly available data sources., Methods: We included children and adolescents 0-17 years transported by ambulance to acute care hospitals in 47 states from January 1, 2014 through December 31, 2022. We used 96 predictors, including basic demographic information and neighborhood measures matched to home ZIP code from 5 data sources: EMS records, American Community Survey, Child Opportunity Index, County Health Rankings, and Social Vulnerability Index. We separated children into 0-10 years (preadolescent) and 11-17 years (adolescent) cohorts and used machine learning to develop high-specificity risk prediction models for each age group to minimize false positives., Results: There were 6,191,909 children transported by ambulance, including 21,625 (0.35%) with firearm injuries. Among children 0-10 years (n = 3,149,430 children, 2,840 [0.09%] with firearm injuries), the model had 95.1% specificity, 22.4% sensitivity, area under the curve 0.761, and positive predictive value 0.41% for identifying children with firearm injuries. Among adolescents 11-17 years (n = 3,042,479 children, 18,785 [0.62%] with firearm injuries), the model had 94.8% specificity, 39.0% sensitivity, area under the curve 0.818, and positive predictive value 4.47% for identifying patients with firearm injury. There were 7 high-yield predictors among children and 3 predictors among adolescents, with little overlap., Conclusions: Among pediatric patients transported by ambulance, basic demographic information and neighborhood measures can identify children and adolescents at elevated risk of firearm injuries, which may guide focused injury prevention resources and interventions., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers., Background: ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown., Methods: This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival., Results: There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present., Conclusions: ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to assess current clinical outcomes in children with prenatally diagnosed congenital lung malformations (CLMs) and to identify prenatal characteristics associated with adverse outcomes., Summary Background Data: Despite a wide spectrum of clinical disease, the identification of fetal CLM subgroups at increased risk for hydrops and respiratory compromise at delivery has not been well defined., Methods: A retrospective cohort study was conducted using an operative database of prenatally diagnosed CLMs managed at 11 children's hospitals from 2009 to 2016. Statistical analyses were performed using nonparametric bivariate or multivariable logistic regression., Results: Three hundred forty-four children were analyzed. Fifteen (5.5%) fetuses were managed with maternal steroids in the setting of hydrops, and prenatal surgical intervention was uncommon (1.7%). Seventy-five (21.8%) had respiratory symptoms at birth, and 34 (10.0%) required neonatal lung resection. Congenital pulmonary airway malformation volume ratio (CVR) measurements were recorded in 169 (49.1%) cases and were significantly associated with perinatal outcome, including hydrops, respiratory distress at birth, need for supplemental oxygen, neonatal ventilator use, and neonatal resection ( P < 0.001). An initial CVR ≤1.4 was significantly correlated with a reduced risk for hydrops [area under the curve (AUC), 0.93; 95% confidence interval (CI), 0.87-1.00]. A maximum CVR <0.9 (AUC, 0.72; 95% CI, 0.67-0.85) was associated with a low risk for respiratory symptoms at birth., Conclusions: In this large, multi-institutional study, an initial CVR ≤ 1.4 identifies fetuses at very low risk for hydrops, and a maximum CVR < 0.9 is associated with asymptomatic disease at birth. These findings represent an opportunity for standardization and quality improvement for prenatal counseling and delivery planning., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU., Design: A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics., Methods: The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results., Results: The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written., Conclusions: This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Background: The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nursing Association have developed consensus guidelines for pediatric emergency department policies, procedures, supplies, and equipment. Kentucky received funding from the Health Resources and Services Administration through the Emergency Medical Services for Children program to pilot test the guidelines with the state's hospitals. In addition to providing baseline data regarding institutional alignment with the guidelines, the survey supported development of grant funding to procure missing items., Methods: Survey administration was undertaken by staff and members of the Kentucky Board of Emergency Medical Services Emergency Medical Services for Children work group and faculty and staff of the University of Kentucky College of Public Health and the University of Louisville School of Medicine. Responses were solicited primarily online with repeated reminders and offers of assistance., Results: Seventy respondents completed the survey section on supplies and equipment either online or by fax. Results identified items unavailable at 20% or more of responding facilities, primarily the smallest sizes of equipment. The survey section addressing policy and procedure received only 16 responses., Conclusions: Kentucky facilities were reasonably well equipped by national standards, but rural facilities and small hospitals did not stock the smallest equipment sizes because of low reported volume of pediatric emergency department cases. Thus, a centralized procurement process that gives them access to an adequate range of pediatric supplies and equipment would support capacity building for the care of children across the entire state. Grant proposals were received from 28 facilities in the first 3 months of funding availability.

Background: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years., Methods: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third., Results: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study., Conclusions: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Objective: We reviewed the presentation, treatment, and pathologic diagnoses of girls and young women less than 21 years old with noninflammatory ovarian masses that required surgery and established whether treatment had changed over time., Methods: We retrospectively reviewed charts of all girls and young women under 21 years old with International Classification of Diseases, 9th Revision (ICD-9) codes specific for noninflammatory ovarian masses treated at our institution from June 1980 to July 1998 (n = 140)., Results: The median age at surgery was 15 years (range 2 days-21 years). Ovarian cysts occurred in 57.9% (81 of 140) of patients, benign tumors (including mature cystic teratomas) in 30% (42 of 140), malignant tumors in 7.9% (11 of 104), and torsed but normal ovaries in 4.3% (six of 140) of the study sample. Patients older than 15 years were more likely to have ovarian cysts and benign tumors than younger patients (P =.019). There were no malignancies among girls with neonatal cysts. The incidence of ovarian torsion was 17.8% (25 of 140). Patients with ovarian cysts, mature cystic teratomas, and normal ovaries were more likely to have torsion than those with other benign or malignant tumors (P <.001). Operative approach and surgical procedure were compared before and after July 1, 1989. Laparoscopy was performed more commonly after July 1, 1989 (P =.009). However, patient age (P <.001) rather than time of surgery (P =.83) was the most important predictive factor in a multivariate analysis for use of laparoscopy. In addition, multivariate analysis revealed that patient age (P =.02) rather than time of surgery (P =.79) was also predictive of surgeon type (gynecologist or pediatric surgeon)., Conclusion: The most frequent cause of an ovarian mass requiring surgery in a girl or young woman under 21 years of age is an ovarian cyst, which justifies consideration of a laparoscopic approach. Patient age rather than time of surgery predicted operative approach and surgeon type. Caution should be exercised in patients over age 12 months with a complex mass on ultrasound and clinical evidence of hormonal activity, as these masses are usually malignant.

This study assessed effects of traumatic childhood death on parents. From July 1988 to September 1992, 48 of the 1,954 children admitted to our pediatric trauma center died. Interviews were requested with parents of children who died and were conducted by a chaplain in the homes of 29 parents (20 families). Interview assessments were based on Worden's "Mourning Tasks" and Demi and Miles's "Parameters of Normal Grief." Grieving was uncomplicated in seven parents (five families). Common elements included use of multifaceted non-family support networks to aid grieving, and no parents blamed themselves or God for the child's death. Grieving was pathologic in 22 parents (15 families). Dominant features included: (1) lack of a support network beyond the extended family; (2) an avoidant stance to grieving; and (3) view of God as distant and punitive. We provide nine indices that will enable hospital caregivers to anticipate the outcome of parental grieving, and offer suggestions for the physician who desires to be involved in parents' acute and rehabilitative grief recovery.

A prospective study was designed to evaluate the effects of education on the incidence of pediatric scald burns. Demographic data from our Trauma Registry identified the Zip code area of greatest risk. Eighty of 121 families with children in a large rental property were chosen randomly for the education program. Twenty of these families also had an anti-scald device installed in the bathtub faucet; all had two or more children under age 5 years. Families were surveyed before and after intervention. Safety knowledge improved post-education as judged by correct survey responses. Although 90% of the families had water heaters set at "warm" (< or = 120 degrees F), the actual temperature at the tap was above 130 degrees F in 71%. The anti-scald devices did work, but at 9 months all but one had been removed because of sediment buildup, which prevented water flow. In the year of the study, the number of scald burns from the target Zip code area decreased from 15 to 12. This was a pilot project for programs that can test public response to general safety education. An anti-scald device in conjunction with education works well in theory, but a better device needs to be engineered. In view of discrepancies between water heater settings and tap water temperature, housing authorities could play a vital role in implementing safety measures.

We reviewed 37 consecutive, hemodynamically stable patients (16 adults, 21 children) who had splenic injuries diagnosed by computed tomography (CT) scan to compare the CT evaluation with operative assessment of injury and eventual treatment. Computed tomographic scans and operative findings were graded by a splenic injury scoring system. Two patients were classified as having grade 1, 21 as grade 2, 11 as grade 3, and 3 as grade 4 splenic injuries. Computed tomography underestimated the degree of injury in 9 of 17 (53%) operated patients (mean CT score, 2.6; mean operative score, 3.3; p less than 0.01). Six of sixteen adults and 19 of 21 children were intentionally treated by observation. There were 5 treatments failures (20%), 3 due to bleeding and 1 each due to pancreatic injury and splenic abscess. The failure rate of observation was lower in children (16%) than in adults (33%), even though children had a higher Splenic Injury Score (2.4 versus 1.8). Patients who underwent an operation received twice as much blood as the observed group. There was no significant difference in Injury Severity Score or total fluid requirements between operated and observed patients. Operations increased in frequency in both adults and children as the injury score increased. This experience suggests that CT scan accurately determines the presence of splenic injury but commonly underestimates its severity. While children with grades 1 through 3 injuries are likely to be treated successfully with observation, adults who have more minor splenic injuries often fail observation and may be treated better by prompt operation.

This study was performed in order to test the hypothesis that abdominal computed tomography (CT) can assist in the decision to perform laparotomy in children following blunt trauma to the abdomen. Three hundred forty children with blunt abdominal trauma underwent evaluation with CT. Abdominal injuries were detected in 84 children (25%). These included: 75 injuries to solid viscera in 60 patients (30 splenic, 29 hepatic, 13 renal, and three pancreatic); four injuries to hollow viscera (three small bowel transections, and one rupture of the urinary bladder); and 23 skeletal injuries (21 fractures of the pelvis, and two lumbar spine subluxations). Injury to solid viscera was categorized as minor in 32 (43%), moderate in 18 (24%), or severe in 25 (33%) according to an assessment of the percentage of parenchyma involved. Hemoperitoneum was detected in 42 patients, and characterized as small in 18 (43%), moderate in nine (21%), and large in 15 (36%). CT was useful in establishing the location and extent of injuries, and in detecting the presence of blood or air in the peritoneal cavity. However, the extent of injury to solid viscera detected on CT did not correlate with the need for laparotomy. Of 46 moderate to severe anatomic injuries of the liver, spleen or kidney, only five (9%) required surgical intervention because of persistent bleeding or infection. Although laparotomy occurred more frequently in the presence of a large hemoperitoneum, only 6/24 (25%) with moderate to large hemoperitoneum required surgical exploration. This analysis confirms the usefulness of CT for detection of location and extent of injury in pediatric blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)