October 31, 2014

Improper Splinting of Kids' Fractures Is Common, and Can Cause Serious Complications

A lot of parents with active kids are familiar with the emergency department of their local hospitals, thanks to the common incidence of broken bones and sprained ligaments. According to a new study by researchers at the University of Maryland School of Medicine, mom and dad should pay careful attention to how their child’s injury is treated initially.

More than 9 in 10 potential pediatric fractures, the researchers found, are splinted improperly in ERs and urgent care centers. Such errors can cause swelling and skin injuries, and can lead to long-term structural and mobility problems.

These mistakes are significant, given the frequency of broken bones among children and adolescents — nearly half of all boys and one-quarter of all girls experience a fracture before they’re 16. The patients in the UM study had a range of fractures affecting all extremities, including fingers, arms, ankles and knees.

The results were drawn from reviewing 275 cases of children as old as 18 who were treated initially at community hospital emergency rooms and urgent care facilities in Maryland, and evaluated later by pediatric orthopedic specialists at UM.

A splint is created from at least one strip of rigid material placed against the injured extremity, which is then wrapped with padding and an elastic bandage to hold it in place and immobilize the joint. ERs and urgent care centers use splints as temporary stabilizers for possible fractures, and to reduce pain.

After being splinted, patients are referred to an orthopedic specialist, who removes the splint and evaluates the problem completely.

Dr. Joshua M. Abzug, an orthopedic specialist at the UM School of Medicine and the study’s lead author, said in a news release, “Unfortunately, many practitioners in emergency departments and urgent care settings incorrectly applied splints, potentially causing injury.”

The most common mistake in splinting kids, according to the study, was wrapping the elastic bandage directly onto the skin. That happened in more than 3 in 4 patients. In nearly 6 in 10, the joints were not immobilized correctly, and in more than half, the splint was not the proper length. Skin and soft-tissue complications were observed in 4 in 10 patients.

According to a report on NPR, the study showed that in some cases, the elastic bandage had been wound too tightly, which impedes blood circulation.

Sometimes, the bandage placement opened a wound. And one patient’s foot was immobilized at the wrong angle to her leg, which complicates her ability to walk she’s ready a few weeks later.

Abzug told NPR that broken bone treatment has changed in the last decade or two. Before, when parents and kids landed in the emergency room after an injury, the same person who diagnosed the break probably would fix it. But today, with increasing medical specialization and a proliferation of urgent care centers, it's more common for the emergency caretaker who splints the break to instruct the parent to follow up with an orthopedist for more treatment the next day.

"For whatever reason, many parents don't follow up right away," Abzug told NPR. "Sometimes it's a problem with health insurance, or they can't take time off work, or they just didn't understand the instructions."

But if the splinting wasn’t correct, waiting too long can cause devastating complications, including permanent loss of motion or a need for skin grafts. If the bandage was applied too tight, waiting even one night can produce lasting damage.

If your child’s injury has been splinted, observe the process to ensure only the rigid piece and the padding, not the bandage, make contact with the skin. Don’t ignore your child’s complaints about comfort or pain. Major swelling or discoloration in the area around the splint is sign that something’s wrong.

See an orthopedist as soon as possible if the treating emergency practitioner did not completely diagnose and treat the injury.

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August 8, 2014

Emergency Surgery on the Weekend Is Riskier

If your child needs emergency surgery, here’s hoping it’s not on a weekend. A study published last month in The Journal of Pediatric Surgery suggests that kids undergoing emergency surgery on the weekend have more complications and deaths than if they’d had similar treatment during the week.

Researchers used a large national database, according to the New York Times, to compare 112,064 weekend surgeries on children younger than 18 with 327,393 such procedures on weekdays. All were coded as “emergencies,” and included appendectomies, brain shunts, hernias, bone fractures and abscess drainage.

Only about 1 in 100 had complications, and fewer than 1 in 1,000 died. But patients undergoing their surgeries on the weekend were:

  • 40% likelier to have an accidental puncture or cut;

  • 14% percent likelier to receive a transfusion; and

  • 63% likelier to die.

The lead author said that although mortality was low, over 20 years the number of weekend deaths would be about 50 more.

What can parents do about it? Obviously, you can't schedule when an accident is going to happen that requires surgery. But being aware that weekends carry higher complication rates can help make parents more alert to staffing issues and the need for vigilance by family members following an operation on a loved one. If something doesn't seem right, say so!

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July 11, 2014

24-Hour Pharmacists Make for a Safer ER for Kids

Medication errors are far too common among hospital patients, but one pediatric hospital is taking measures to reduce them and the sometimes life-threatening harm they can cause.

Making fewer medication mistakes, which, according to a story on NPR.org, contribute to more than 7,000 U.S. deaths every year, is a matter of more professionals remaining on the job for a longer period of time — specifically, hospital pharmacists. In the emergency department at Children's Medical Center in Dallas, pharmacists who specialize in emergency medicine review each prescription to ensure it's the correct one in the correct dose.

Children’s has 10 full-time emergency pharmacists, more than anywhere else in the country, and they’re on call 24 hours a day.

"Every single order I put in," Dr. Rustin Morse told NPR, "is reviewed in real time by a pharmacist in the emergency department prior to dispensing and administering the medication." Rustin is chief quality office and a pediatric ER doc.

That quality-control seems like a no-brainer, but especially in a busy ER, doctors treat fast and move on to the next patient. Writing down the name and quantity of a drug quickly invites mistakes. But in this ER, if that happens, it’s more likely a pharmacist will catch it.

Medication errors, as NPR notes, can be the result of poor handwriting, confusion between drugs with similar names, poor packaging design or confusion between metric or other dosing units. Often, more than one factor is involved.

That’s particularly dangerous for children because medication errors are three times more likely to occur with youngsters than adults. They absorb drugs at a different rate from adults.

So, for the nearly 20,000 drug orders processed at Children’s in a given week, pharmacists review all pertinent information — the child's weight, allergies, medications and health insurance coverage.

The electronic medical record system also automatically checks orders to prevent errors. You need both reviews, because neither human nor machine is infallible.

Dr. James Svenson, associate professor of emergency medicine at the University of Wisconsin, co-authored a study in the Annals of Emergency Medicine that found that even with an electronic medical record, 1 in 4 children's prescriptions had errors; 1 in 10 adult prescriptions also was wrong. So now, there’s a 24-hour ER pharmacist at Svenson’s hospital.

The reason most hospitals don’t embrace this practice is the usual one: money. "If you're in a small ER, it's hard enough just to have adequate staffing for your patients in terms of nursing and techs,” Svenson said, “let alone to have a pharmacist sitting down. If the volume isn't there, it's hard to justify."

But the investment has been proved to work. Researchers for the Journal of Pediatric Pharmacology and Therapeutics showed that prescription review can reduce the number of hospital readmissions. That not only saves money, but also lives.

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May 30, 2014

Preventable Injuries Bring Many Children to ERs

A recent report by the National Center for Health Statistics (NCHS) paints a clear portrait of what most often brings kids into the emergency department.

As you might expect, injury is the leading cause of death and also a major source of morbidity (the relative incidence of a disease within a population) among children and adolescents, and the emergency room is where a lot of these victims land first. The report looked at ER visits throughout the nation by children and adolescents 18 years and younger from 2009 to 2010. Different age groups for injury-related visit rates were: as old as 4; 5 to 12; and 13 to 18 (that is, preschool, school-age and teenagers).

The key findings?

  • The annual average of injury-related emergency department (ED) visits made by children and adolescents 18 years and younger was 11.9 million. (Total visits were about 33.7 million.)

  • The injury-related ED visit rate was 151 per 1,000 patients 18 years and younger. Rates were higher for males than for females for all age groups.

  • Injury-related ED visit rates among patients 5 to 12 and 13 to 18 were higher for non-Hispanic blacks than for other race and ethnic groups.

  • Leading causes of injury-related ED visits among both males and females included falls and striking against or being struck unintentionally by objects or people. Visit rates were higher for males than for females for both causes.

As far as cost was concerned, public funds (Medicaid or Children's Health Insurance Program) covered 41.7% of injury-related visits, and private insurance covered. 40.7%. Youngsters with no insurance represented 8.6% of visits.

“Child and adolescent injuries represent a serious public health problem in the United States,” the report concluded, and more than one-third were the result of injuries.

It’s not always, or usually, possible to foresee and forestall your child’s illness, but injuries are often the result of inattention or lack of preparation (see our recent blog, “Ensuring the Safety of Baby Gates.”) Preventing injuries requires covering a lot of bases that can seem overwhelming to parents.

Proven strategies include researching the safety and recall information for childrens’ products on sites including the Consumer Products Safety Commission, sponsored by the federal government. Visit the Safety Research & Strategies Inc. website, which investigates, analyzes and advocates about safety issues.

Other guidelines are provided by Healthy People 2020, a federal government initiative to improve the health of all Americans that includes preventing injury and violence and reducing their consequences.

And review our blogs about a wide range of products including car seats, sleep machines, recreational equipment and rides, medicines and more.

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May 2, 2014

Is Codeine Overused in Emergency Treatment of Kids?

A couple of years ago, we blogged about crowded emergency departments where children who present with bone fractures are made to wait too long to receive pain medicine.

There’s no excuse for unnecessarily prolonging anyone’s pain, but there’s also danger in giving the wrong painkiller to the wrong person at the wrong time.

According to a new study published in Pediatrics, the powerful opioid codeine is prescribed for children in at least half a million ER visits every year, despite recommendations to limit its use among youngsters.

That’s a big number, but, thankfully, it represents only a small fraction of all pediatric ER visits every year — about 3 in 100. But the researchers still are concerned that too many kids are getting the drug when better options are available.

As noted on Medline Plus, a drug information site from the National Institutes of Health, “Some children who took codeine to relieve pain after surgery to remove their tonsils and/or adenoids have had slowed breathing and have died during their treatment. Many children who have surgery to remove their tonsils and adenoids are being treated for obstructive sleep apnea (condition in which the airway becomes blocked or narrow and breathing stops for short periods during sleep). This condition makes these children especially sensitive to breathing problems. Codeine should not be used to relieve pain in children after surgery to remove the tonsils and/or adenoids. If your child's doctor prescribes codeine to relieve pain after this type of surgery, talk to your doctor about using a different medication to treat the pain.”

Many people might remember when codeine routinely was given as a cough remedy, when cough syrup was available without a prescription, limits on amount purchased or pharmacy screening. People still take it, even though there’s no evidence of its effectiveness for cough relief, and the American Academy of Pediatrics recommends against using it for the purpose, especially in light of the risks.

As summarized in a story by the Associated Press (AP), the concern is that codeine is a drug that some people absorb too quickly, which can cause dangerous side effects, including excessive sleepiness and difficulty breathing. Last year, a “black box warning,” the strictest possible, was issued by the FDA, alerting medical practitioners and consumers about the risk of life-threatening complications or death in children given the drug after the surgeries described above.

The drug, however, might be ineffective for pain relief in for as many as 1 in 3 patients.

The Pediatrics study authors analyzed 10 years of national data on ER visits for kids 3 to 17. Although the number of visits in which codeine was prescribed fell slightly during the study period, the authors estimated that the range of use was between 560,000 and 877,000 times. Unfortunately, information on any side effects was not included in the data.

One pediatric drug expert told AP that it's likely that the use of codeine for kids has diminished since the study ended, thanks mostly to the FDA's black box warning. But another said that some ER doctors might not have been aware of the pediatric guidelines for limiting codeine's use, especially if they recalled getting the drug when they were kids, when its use was more common, and they suffered no ill effects.

A physician a spokesman for the American College of Emergency Physicians said that codeine could be used safely for many children, especially older kids.

If your doctor suggests using codeine to alleviate you child’s cough, ask about alternatives, such as dark honey (only if the child is older than 1 — honey is dangerous for babies). If it’s suggested to relieve pain for injuries such as broken bones, ask about ibuprofen or hydrocodone instead.

If you and the ER doctor determine that the benefit of codeine outweighs the risk, make sure the staff monitors the child after he or she takes the drug. If there is no ill effect, and you’re given a prescription to fill later, make sure the medicine worked in the ER to relieve the pain — you don’t want to court danger by taking a risky medicine that doesn’t even work for a lot of people.

If your child takes codeine and develops breathing problems or unusual sleepiness, seek medical attention immediately.

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February 28, 2014

The Facts About Fever

Parents are wired to beware of fever in their children. But their fear often is misplaced.

According to Melissa Arca, a pediatrician writing on KevinMD.com, a moderately elevated temperature is not necessarily a bad thing; in fact, it can be beneficial. Lots of kid problems cause fever — the flu, colds, croup, ear infections…. The better you understand the reasons a child is feverish, and the purpose fever serves, the better you will be able to determine a minor problem from one that your doctor should address.

Arca offers four fever facts that should help you tell the difference between one that needs hot soup, and one that needs a doctor’s care.

1. Fever is a symptom, not a disease.

Fever is a reaction to illness. It’s a warning to rest and drink fluids. Treating your child’s fever won’t “cure” whatever infection he or she is fighting. “Think of it like disabling your car’s ‘oil change needed’ light,” Arca suggests. “Sure, you can turn off that light but it doesn’t negate the fact that your car’s oil still needs changing.”

Even if you suppress the fever — for example, with ibuprofen — the child still needs time to rest and recover from the infection.

2. Fever can wax and wane for three or four days.

Most fevers persist for a few days before they completely depart. So even if you treat it with acetaminophen or ibuprofen, expect it to recur after a few hours. That’s normal.

3. The number on the thermometer is not as important as how your child looks and feels.

Arca knows that most parents get a little panicked when their child’s temperature reaches 103 or 104. But that number does not communicate the seriousness of the illness. So resist the panic. Give the child a fever reducer for comfort and keep him or her well-hydrated. Fever makes the heart beat faster and increases the child’s insensible water loss (fluids lost through the skin and respiratory tract). Keep a bottle of water by the bed, and anywhere else your child is resting.

Remember, the goal is to help the child feel better, not to get rid of the fever.

4. A true fever is a temperature of 100.4°F (38°C) or higher.

Children’s temperatures naturally fluctuate throughout the day. So knowing what is a true fever is important.

In summary, resist the urge to treat a slight temperature elevation. Remember, says the National Institutes of Health, fever is an important part of the body's defense against infection because most bacteria and viruses that cause infections in people thrive at 98.6 °F. Many infants and children develop high fevers with minor viral illnesses, and although that’s a signal of the body waging battle, the fever is a weapon favoring the child. So unless you’re dealing with a temperature of 102°F or higher fever, let the fever run its course and provide comfort through fluids.

Brain damage from a fever generally doesn’t occur with fever less than 107.6 °F (42 °C). Untreated fevers caused by infection seldom exceed 105 °F unless the child is overdressed or trapped in a hot place.

Arca says these red flags demand a pediatrician’s intervention:

  • infants younger than 3 months with rectal temperatures of 100.4°F or higher;

  • fever that persists more than five days;

  • your child just doesn’t look well, is having difficulty breathing or has had a febrile seizure (one caused by fever);

  • your child’s fever is 105°F or higher. Although such a high temperature usually isn’t harmful, it merits a call to the pediatrician and the right dose of acetaminophen or ibuprofen.

Because acetaminophen, especially, can be harmful to youngsters, see our blog about proper dosages here.

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December 20, 2013

Ultrasound Versus CT Scan for Diagnosing Appendicitis in Kids

CT scans often are used to detect appendicitis, but a new study at the Children's Hospital at Montefiore Medical Center in New York suggests that ultrasound is equally adept at diagnosing this emergency condition. That’s important, because a CT image is an X-ray, which emits radiation; an ultrasound image, which involves sound waves, does not.

The research was published in the American Journal of Roentgenology, and concluded that not only is ultrasound safer than a CT scan and provides a comparable result, it does not increase the length of a hospital stay, another important consideration in medical treatment.

As reported on ScienceDaily.com, appendicitis is one of the most commonly experienced conditions among children in the U.S., and it’s becoming more frequent. Usually, a CT scan is the imaging technique used to evaluate patients with symptoms of appendicitis.

That’s inflammation of the appendix, a small pouch attached to the beginning of the large intestine. Appendicitis is the result of a blockage by a foreign object (food morsel, fingernail, etc.) feces or, rarely, a tumor, and the site becomes infected.

The study was a collaboration between radiologists and clinicians in pediatric surgery and emergency medicine. They increased the use of ultrasound as the first imaging option from 1 in 3 at the beginning of the study to almost 9 in 10 at the study's completion. Use of a CT scan as the first and only diagnostic test decreased from about 4 in 10 to fewer than 1 in 10 by the end of the study.

In a news release from Montefiore, co-author Jessica Kurian, M.D., said, "As more people become aware of the risks of medical radiation, there are increasing efforts to utilize nonradiation emitting imaging techniques as a first approach to diagnosis. Our research shows that using ultrasound first in the evaluation of appendicitis commonly produces actionable results and should be considered more frequently as clinicians try to limit medical radiation exposure in children."

As we explained in “More Evidence to Let Caution Be Your Guide in CT Scans,” radiation is cumulative, and the more you receive over the course of your life, the likelier you are to develop cancer. (See our backgrounder on radiation overdose injuries.) Sometimes, diagnosis via X-ray is necessary, but if there are options, such as ultrasound or MRI, they should be exercised. If your doctor suspects appendicitis is the cause of your child’s problem, and plans to perform a CT scan, ask instead for an ultrasound.

Symptoms of appendicitis can vary, and it can be difficult to diagnose in young children. Usually, the first symptom is pain that might be mild at first, but becomes sharper and more severe. Appetite falls off, and often there is nausea, vomiting and a low fever.

If the appendix ruptures, the pain might diminish briefly, but once the lining of the abdominal cavity becomes swollen and infected (a condition known as peritonitis), the pain escalates. Serious, later symptoms include:

  • chills

  • constipation

  • diarrhea

  • fever

  • nausea

  • shaking

  • vomiting.

Treatment is surgical removal of the appendix. If it’s removed before it ruptures, recovery is generally quick. If the appendix has ruptured, recovery is slower are more likely to involve complications such as infection.

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May 31, 2013

Feds Call for National Standards for Child Care Facilities

Earlier this month, the federal Department of Health and Human Services (HHS) announced stringent new health and safety standards for any child-care facility that receives government funding.

As reported in the Washington Post, reports of injuries and deaths in child-care facilities prompted the action. HHS officials said the new regulations also were developed because of emerging science on how critical the early years are for brain development and future success.

The regulations are meant to supersede individual state measures that critics claim are too lax and endanger children. As many as 1 in 5 children who receive the child-care subsidy, according to The Post, are in unlicensed and unregulated facilities that have no health and safety requirements.

The regulations will require workers in all subsidized child-care centers and homes to be trained in first-aid procedures, such as CPR, and safe sleeping practices. They demand quality-rating systems parents can access, and universal background and fingerprint checks of child-care workers. They also impose tough standards for monitoring and unannounced inspections to ensure compliance.

It has been 15 years since child-care rules were updated.

The regulations apply only to the 513,000 child-care centers and family homes that accept subsidies for the 1.6 million children who receive them through the federal Child Care and Development Fund, which expired in 2002. The HHS announcement, the paper said, was a surprise to Congressional representatives, including the bipartisan group of senators who have been negotiating a bill to reauthorize the child-care fund.

Nothing the feds do, it seems, can be devoid of politics. Sen. Barbara A. Mikulski (D-Md.) said that she appreciates the administration’s efforts, but that regulations are not enough. She wants Congress to reauthorize a child-care subsidy program “that not only addresses health and safety standards, but also improves the quality of our nation’s child-care programs.”

Rep. John Kline (R-Minn.) said, “The latest announcement by HHS is yet another effort to usurp Congress and move forward with the administration’s preferred policies.”

Many day-care centers in the U.S., The Post notes, are poorly run and often unsafe. And child care remains unaffordable for many people.

Current federal health and standards require only that:

  • subsidized providers prevent and control the spread of infectious diseases;

  • building and physical premises are safe;

  • providers have minimum health and safety training.

Beyond that, states pretty much impose whatever standards they wish. In South Dakota, for example, a family home child-care provider may care for as many as 12 children without a license or meeting any standards. In Virginia, that number is five. In Maryland and the District of Columbia, it’s one.

Many states, according to The Post, require only state, not federal, background checks of providers. That’s the standard in Virginia, where one infant died and only the commonwealth attorney’s investigation into the unlicensed family care provider’s home uncovered the fact that that the provider had several aliases and previous felony charges.

Some states exempt child-care centers run by religious organizations from meeting health and safety licensing standards. In Virginia, a 7-week-old boy was left for two hours in a small, overheated utility room with 14 other infants on a single foam pad while the caretaker ate lunch in another room. The baby died. Only one person at the facility, a janitor, had been trained to perform CPR.

Those child-care workers were charged with negligent homicide, but a judge dismissed the charges because of the center’s religious affiliation.

HHS officials said the proposed regulations couldn’t address all child-care ills; the $5 billion the government spends covers only about 18 in 100 low-income children who are eligible for the subsidy. But it’s a start.

If you want to know more about the sorry state of child care in America, link here to a recent investigative story in the New Republic. Some of its substantiated conclusions:

1. Most American day care centers are rated “fair” or “poor.”
2. Child-care workers are often poorly paid and minimally trained.
3. State regulators don’t have enough people to inspect facilities regularly — and often face pressure to keep appalling centers open anyway.
4. Child care remains extremely expensive for many families.
5. Governments in other countries spent a lot more on child care.

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October 26, 2012

How to Keep Your Kid Safe and Out of the ER on Halloween

If you can’t stand the idea of your children eating all that candy they collected on Halloween, maybe you can find consolation that at least they had to take a walk to get it.

OK, maybe not. But too much sugar might not be your biggest concern on this popular kid holiday.

"Nothing is scarier than a trip to the emergency room," Dr. Mark Cichon, chairman of Department of Emergency Medicine at Chicago’s Loyola University Health System, told ScienceDaily.com. "In a season devoted to frights, it is our goal to keep everyone safe."

Here, as published on ScienceDaily, are Cichon's tips to help keep your child from becoming one of the 9.2 million U.S. youngsters injured seriously enough every year to require ER treatment.

  • Don’t use common kitchen knives to carve a pumpkin—they’re difficult for an adult, much less a child, to manipulate on a hard rind. Invest in a pumpkin-carving kit.
  • Supervise anything that is burning, from candles to carved pumpkins to firepits. Fires ignite quickly and behave erratically.
  • Make sure costumes offer visibility and ease of movement. Masks, hats, wigs, glasses and hoods can obstruct vision, and restricting the legs and feet can cause trips and falls.
  • Dress for the weather. Make sure footgear is waterproof and has treads if it’s wet during the trick-or-treating adventure.
  • Make sure one adult in the trick-or-treating group wears a reflective safety vest. Make sure each child has a glow stick or flashlight. In other words, see and be seen. If you’re traveling with a group, stay together and put kids on the buddy system.
  • Drive slowly and cautiously on Halloween, especially on side streets.
  • Inspect the treats when you get home. Make sure the haul is age-appropriate—tiny pieces of candy are choking hazards for younger children. Reject anything unwrapped or, sadly, homemade, unless you know the chef.

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October 5, 2012

How to Treat Anaphylaxis When Kids Are at School

It might be the result of a bee sting or the ingestion of a peanut, but whatever the cause, when anaphylaxis occurs it can be life-threatening.

Anaphylaxis is an acute allergic reaction to a specific antigen (food, pollen, drugs, etc.); it’s the immune system’s whole-body response to the presence of an allergen it perceives as a threat. Symptoms generally occur immediately after exposure and might include respiratory distress, swelling of the lips, eyes and throat, rash, low blood pressure, bleeding and/or vomiting. It can result in cardiac arrest.

Parents of children with known allergies should ensure that their child’s school authorities are aware of the allergy and have a prescription on file for epinephrine in case of emergency. (Epinephrine is the hormone adrenaline and is the primary treatment for anaphylaxis.)

Epinephrine is generally safe, with few adverse effects, if given even when it is not needed.

But according to a recent story in the New York Times, school nurses can find themselves in a horrifying position if a child without such a prescription develops a sudden reaction to an undiagnosed allergy. If they inject epinephrine, they risk losing their nursing license for dispensing it without a prescription. Their only other option is to call 911 and hope the paramedics arrive in time.

Some states have passed laws to enable school caregivers to have epinephrine injectors on hand and to give a shot to any child with an emergency. Mylan, which markets Pfizer’s EpiPen, the most commonly used injector, is lobbying for such federal legislation. The company has lobbied individual state legislatures and has distributed free EpiPens this year to schools.

Sure, it’s a naked grab for market share, but it also makes medical sense.

As The Times reports, Mylan has spent millions on consumer advertising and has hired scores of sales representatives to help promote the product. It’s estimated that EpiPen sales will total $640 million this year, a 76 percent increase over last year, according to one analyst.

A study last year in the journal Pediatrics found that about 1 in 13 children had a food allergy, and nearly 40 percent of those with allergies had severe reactions.

Efforts to make epinephrine more widely available, The Times says, are an acknowledgment of the rising rates of food allergies among children and the handful of deaths from allergies across the country. Some children with known allergies carry their own epinephrine injectors to use themselves, if they’re old enough, or the devices are kept in their school nurse’s office.

It’s unclear why the rate of food allergies among children appears to be increasing. “I don’t think it’s overdiagnosis,” Dr. Scott H. Sicherer, a researcher at the Jaffe Food Allergy Institute at Mount Sinai Medical Center in Manhattan, told The Times.

A Mylan executive said schools were just the first place to make emergency epinephrine injectors more widely available. The company would like to see them as available as defibrillators—in restaurants, airplanes and other public places.

The Food Allergy and Anaphylaxis Network (FAAN) has not taken a position on placing injectors in public places other than schools, and Sicherer wondered about their suitability in settings such as restaurants, where staff might not be able to tell the difference among choking, a heart attack or anaphylaxis.

Next month, Sanofi plans to introduce a rival epinephrine delivery device, and in 2015, Teva may win approval of a less expensive generic version of the EpiPen, according to The Times. Sanofi’s Auvi-Q features voice instructions and Teva’s product, if approved by the FDA would closely mimic the EpiPen design and, like a generic drug, could be substituted by pharmacists even if doctors prescribed the EpiPen.

To learn about the latest developments in food allergies, visit the NAAN site. To learn about the widespread practice of bogus testing, see our blog about free allergy tests. To learn about the early signs of allergy, see our blog here.

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September 7, 2012

When Should an Emergency Department Transfer a Child for Specialized Care?

Of the 27 million trips children make to U.S. emergency departments each year, about 7 million are at a rural ED or one that’s a considerable distance from a dedicated children’s hospital. For children critically ill with certain problems, of course, prompt transfer to a pediatric intensive care until improves the chances for positive outcomes.

In recent years, according to Christopher Johnson, a pediatric intensive care physician writing on KevinMd.com, the medical establishment has begun to establish a system of transporting these sick kids to regional critical care centers. That’s good. Not so good, Johnson says, is an increasing tendency to routinely transfer children from an ED not dedicated to pediatric care to one that is. Such transfers aren’t always necessary from a medical point of view, and present unnecessary risks and costs.

This kid shuffle, Johnson warns, might be signaling an unwillingness of general purpose EDs to provide basic pediatric care. That’s unacceptable. Misfortune is an equal age-opportunity reality.

Johnson refers to a recent article published in the journal Pediatrics that studied what happened to children after they arrived at an emergency department. Researchers wanted to know how ED resources were being used in the younger demographic.

Of the children transferred from the facility where they presented to another that provided specialized care, nearly 1 in 4 was discharged directly from that ED, and 17 in 100 were admitted to the hospital for less than 24 hours.

Because a significant number of the transferred kids had been discharged to go home, they probably could have been treated appropriately at the ED that sent them someplace else.

Johnson says you shouldn’t overlook the fact that sometimes a pediatric subspecialist at the second facility (say, a pediatric cardiologist), simply has the expertise to make the call for discharge that a less qualified doctor doesn’t.

But, he adds, “I have certainly seen children flown in by helicopter from another hospital and then get sent home. They didn’t need the expensive (and sometimes dangerous) helicopter ride.”

Johnson suggests that continuing to regionalize pediatric care is important in addressing the potential patient harm of such resource abuse. Regionalizing, he says, enables doctors in nonpediatric EDs to have easy access to specialists by phone or telemedicine links for remote consultation. This happens now, but only informally; codifying the process would improve care.

Medical emergencies are difficult enough without having to wonder if the care you get is sufficient or the advice to transfer is sound. But if you find yourself in a situation in which the emergency department wants to send your child to a facility that specializes in pediatric care, ask why. Find out what the doctors suspect is the problem and why they are unable to treat it. Ask about the availability of a remote consultation with a specialist.

Sometimes, that’s not possible and sometimes a transfer is the best medicine. But if it’s not, there’s no reason to assume unnecessary risk or cost.

To learn more about emergency medicine—what requires immediate, critical attention—see our backgrounder.

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April 26, 2012

Good News for the No. 1 Killer of Children -- Accidental Deaths Are Way Down

The No. 1 killer of children is accidents. More than 9,000 children in the U.S. died in 2009 from what the Centers for Disease Control and Prevention (CDC) call “unintentional injury.”

As grim as is the reality of children who don’t live to see adulthood, the cold statistics are actually good news—death rates from unintentional injuries among people from birth to 19 declined almost 30 percent from 2000 to 2009, according to the CDC.

Despite the overall good news, a couple of causes of death did see an increase—suffocation rose 54 percent among babies younger than 1 year, and poisonings increased a whopping 91 percent among teenagers 15 to 19. The CDC attributes that stark reality to prescription drug overdoses.

The graphically colorful report in the CDC’s April issue of Vital Signs is the first such study to depict fatal unintentional injury trends by cause and by state for this age group.

The most common cause of accidental death is motor vehicle crashes. Other leading causes are:

  • suffocation;

  • drowning;

  • poisoning;

  • fires;

  • falls.

Thomas Frieden, director of the CDC, said, “Kids are safer from injuries today than ever before. In fact, the decrease in injury death rates in the past decade has resulted in more than 11,000 children’s lives being saved.”

Significantly, death rates from motor vehicle crashes declined 41 percent during the decade of study. The CDC attributes that improvement to improvements in the use of child-safety and booster seats, and the implementation of graduated licensing systems for teen drivers.

Differences in injury death rates varied enormously from state to state. Massachusetts notched fewer than five deaths per 100,000 children, versus New Jersey, South Dakota and Mississippi, which tallied 23 deaths per 100,000 kids.

Addressing the problem of infant suffocation the CDC says, requires widespread adherence to the American Academy of Pediatrics’ guidelines for safe sleeping environments. Those measures include infants sleeping alone, on their backs in cribs with no loose bedding or soft toys.

To reduce prescription drug poisoning, the agency says, providers must prescribe drugs appropriately, and parents must ensure their teens store and dispose of drugs properly, and they should monitor these practices. Also, teens must be discouraged from sharing medications. The CDC also recommends that states establish prescription drug monitoring programs. We recently wrote about prescription drug misadventures being responsible for a disproportionate number of childrens’ emergency room visits.

“Every four seconds,” said Linda C. Degutis, director of the CDC’s National Center for injury Prevention and Control, “a child is treated for an injury in the emergency department, and every hour, a child dies as a result of an injury. Child injury remains a serious problem in which everyone–including parents, state health officials, health care providers, government and community groups–has a critical role to play to protect and save the lives of our young people.”

For more information about preventing injuries to children and a copy of the CDC’s National Action Plan on Child Injury Prevention, compiled in conjunction with 60 partner organizations, link here.

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February 28, 2012

CT Scans for All Kids with Head Injuries?

From high-profile former NFL players to soldiers returning from Afghanistan, the emerging picture of head trauma is not pretty. And of course the lingering, often-delayed effects of traumatic brain injury (TBI) aren’t limited to adults.

We’ve talked about children at risk of concussion when they play sports, and how manufacturers are developing “anti-concussion” athletic equipment.

Writing on KevinMD.com, malpractice attorney Maxwell S. Kennerly suggested that some practitioners still aren’t taking head injuries to children seriously enough.

Last year, he noted, the Centers for Disease Control and Prevention (CDC) reported “a growing awareness among parents and coaches, and the public as a whole, about the need for individuals with a suspected TBI to be seen by a health-care professional.” He pointed to the CDC’s Heads Up initiative as exemplary of efforts to raise consciousness that seeing stars isn’t a badge of athletic honor, it’s a reason to seek medical care.

What remains questionable, Kennerly wrote, is how prepared emergency and primary care physicians are to handle the increased number of head trauma cases they’ll see as a result of greater awareness of the problem.

“Viewed through a narrow lens, the solution to a suspected brain injury is obvious,” he wrote. “[I] f a kid complains about anything relating to their head, give them a CT scan. But CT scans come with their own costs and risks, not least exposing a developing brain to a year’s worth of background radiation.”

Too often medicine overtreats patients because technology enables it, insurance pays for it and/or doctors are worried about being challenged if they fail to perform every test within reach. Often a more conservative approach is better for the patient.

But when it comes to kids and head injuries, in deciding whether to order a CT scan for a kid with new head trauma, Kennerly says the conservative treatment approach is wrong.

“I’m not here to tell you where the CT / no-CT line should be drawn,” Kennerly claimed. “I can tell you, however, how I would draw that line as a medical malpractice lawyer when a parent comes in and tells me their doctor didn’t order a CT scan after a minor head trauma and their child later developed serious sequelae [i.e., a brain injury]."

In the world of medical malpractice, such a circumstance is known as “failure to diagnose.” As Kennerly explained, laypeople—like jurors—might well respond to the concept of incremental risk a witness might offer to defend against the charge of failure to diagnose. “One head CT scan,” the witness might say, “has more radiation than 20,000 trips through the TSA scanner at the airport.”

That sounds scary. But is it scarier than risking chronic, lifelong problems with the ability to think, loss of memory, headaches, attention deficit, mood swings and the other markers of brain injury?

Kennerly cited an article published in the January issue of Critical Decisions in Emergency Medicine, “Evaluation of Minor Head Trauma in Pediatric Patients," that argues for CT scans for children who present with any evidence of brain trauma.

If you’re the parent of a child who has fallen from a great height, who has emerged woozy from a collision in soccer, who claims his or her vision is blurred from a bang on the noggin, take him or her to your physician or emergency room immediately. And if the child doesn't show full recovery of normal consciousness very quickly, without any symptoms of brain trouble, a CT scan could be in order.

A British website offers guidelines for CT scans for anyone younger than 16 with a head injury, and the CDC's Heads-Up site helps observers spot the signs of concussion. They are:

  • loss of consciousness;

  • loss of memory;

  • abnormal drowsiness or sluggishness;

  • nausea or vomiting;

  • bruise, swelling or laceration on the head, behind the ears;

  • bruising around the eyes ("panda" eyes);

  • fluid leakage from ears or nose;

  • confused, dazed or stunned appearance;

  • personality changes;

  • headache;

  • problems balancing or abnormal clumsiness;

  • double or blurry vision; or

  • abnormal sensitivity to light or noise.
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January 30, 2012

Controlling Infections in Pediatric ICUs

Hospital infections have been a hot topic for a few years now, and most hospitals have made strides toward cleaning up their microbial act. A recent story in Consumer Reports, however, presents a bad news-goods news scenario about hospital-acquired infections in pediatric intensive care units.

Pediatric ICUs, the consumer group found, often have higher infection rates than ICUs for adults. The most threatening infections are delivered by catheters, tubes that provide nutrition, fluids and medication. If not inserted and managed under completely sterile conditions, they can spread infection throughout the body. In 2009, 1 in 4 of such infections were fatal.

Children are more susceptible to infection because their immune systems are less developed. And the very ill kids in ICUs are particularly vulnerable.

Part of the difficult of infection control, Consumer Reports said, concerns lack of information: “Of the 423 pediatric intensive-care units in the U.S., information on bloodstream infection rates is publicly available for less than half.” You cannot solve a problem of which you’re unaware.

By analyzing information from 92 pediatric ICUs in 31 states and Washington, D.C., Consumer Reports concluded that they carried an infection rate 20 percent higher than national rates for adult ICUs.

That’s the bad news. The good news is that parents can do something to minimize the chances of their child contracting an infection courtesy of the ICU.

If your child requires ICU care, and if your proximity, doctor’s admitting privileges and insurance coverage permit you to choose among hospitals, examine their respective infection rates as charted on the Consumer Reports website.

In choosing a pediatrician, find out where he or she has admitting privileges, and how those hospitals have performed.

If you don’t have the luxury of choice—and even if you do—here’s the Consumer Reports prescription for keeping infections at bay.

Ask the staff how you can help. A nurse has several patients to care for; parents have one. Watch that the central line stays clean, and that everyone in contact with it scrubs it clean and uses sterile equipment to access it.

Make sure the hospital follows best practices for inserting and maintaining central lines. This means disinfecting the site and changing the dressings regularly and standardizing procedures for changing the catheter caps and tubes. Following a regular routine with the proper tools is more protective than re-inventing the wheel each time. It’s not your job to know each of the steps; simply asking about them can remind staff to be extra vigilant about adhering to the safety measures.

Ask if the central line is still needed. Smaller veins can make it more difficult to insert catheters into a child, so sometimes doctors prefer to leave it in until they’re sure it’s no longer necessary. And once a child has a central line, often it’s used for blood samples, reducing a child’s exposure to traumatic needle sticks. Those practices can be good medicine, but they’re not without risk.

Keep hands clean. Make sure you, visitors and the hospital staff wash their hands with soap or an alcohol-based solution before touching your child or the catheter.

Watch the catheter. The line can come into contact with a diaper; a fidgeting child might put the lines in his or her mouth.

Take notes. Keep track of how often hospital staff change the catheter or dressing and how long the catheter has been in.

Raise an alarm. If something seems amiss, trust your instincts. Voice them and make sure someone responds.

Share your story. If you or someone you care for has been harmed by a hospital-acquired infection, contact Consumer Union’s Safe Patient Project, which raises awareness about hospital safety. That site offers a wealth of information about how patients can influence their care and that of their loved ones in positive ways.

Another resource for hospital patients, and potential patients, is Consumer Reports hospital survival guide.

Also, see our Web page on hospital monitoring.

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January 24, 2012

Assessing the Quality of Hospital Care for Children with Asthma

Every year, more than 1.8 million people find themselves in a hospital emergency room to treat an asthma attack. Children account for nearly half that number, and of asthmatic people who go from the ER to an overnight hospital stay, more than 1 in 3 are kids.

As reported in the Patient Safety America Newsletter, three criteria to analyze the quality of care for children hospitalized for an asthma attack have been defined by the Joint Commission, an agency charged with assessing and regulating hospital practices. It also certifies health-care organizations and programs.

The measures of acceptable emergency treatment for asthma are:

  • drugs to relieve the acute symptoms;

  • administering corticosteroids to reduce inflammation; and

  • development of a complete home management plan.

These measures were studied and the results published in the Journal of the American Medical Association. Investigators looked at the records of more than 37,000 children treated in 30 children’s hospitals to determine how well those facilities complied with the treatment criteria and whether compliance reduced hospital readmissions or subsequent ER visits.

The news, mostly, was good—the first two measures notched 97% and 90% rates of compliance respectively.

The bad news lay in the follow-up: Compliance with a home management plan averaged only about 4 in 10 cases. But investigators determined that failure to comply with this measure had no effect on the rates of readmission or visits to the emergency room seven, 30 or 90 days after discharge from the hospital. Compliance did increase over the time in which measurements were compiled (early 2008 through the third quarter of 2010), so the state of this art appears to be improving.

But this curious outcome begs the question: If readmission/ER visits didn’t appear to be affected by noncompliance, why is No. 3 a quality measure at all?

Study authors offered several possible reasons for the lack of association between home-care follow-up and finding yourself back at the hospital.
1. The study didn’t look at how well the plan was implemented at home, nor could the investigators determine whether asthma patients were admitted to another hospital after their visit to the initial hospital.
2. Patients or their parents might not have understood the home-care plan and how to implement it. A commentary on this study noted that there is a "gulf" between patient-centered plans involving coaching and timely follow-up with parents, and often there is no written plan.
3. Readmission measures might be insensitive to the quality of care a child with asthma receives at home. Is it is time to search for other quality measures of care received by hospitalized children with asthma?

So if you’re the parent of a child with potentially life-threatening asthma, here’s how you can improve the chances of getting the best care should the need for an ER visit arise.

  • Identify in advance a nearby children’s hospital; it’s more likely to follow quality measures than a general hospital.

  • When your child is discharged, make sure you understand the follow-up care plan. There is no such thing as a dumb question. If the information isn’t offered in printed form, ask for it or take careful notes.

  • Get the name and contact information of someone who can answer any questions you have after you leave.

  • Inform your pediatrician of the care plan.

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January 15, 2012

Some Emergency Departments Deprive Injured Children of Effective Pain Relief

Anyone who has suffered a broken bone knows how painful it can be. Long bone fractures—those involving arms and legs—are common among children. Any parent wants to spare his or her kid from the intense pain of such an injury, but a recent study published in Academic Emergency Medicine has bad news in that regard.

Thanks to the crowded conditions in hospital emergency rooms, administering pain medication to children with long bone fractures is less effective and not as timely as it should be.

Researchers from the University of Colorado School of Medicine studied 1,229 patients treated in the emergency department of an academic children’s hospital for one year. They found that patients were 4 to 47 percent less likely to receive timely care and 3 to 17 percent less likely to receive effective care when the ER was crowded.

Previous studies have shown that adults consigned to crowded emergency rooms also get lower levels of pain meds. This study appears to be the first to investigate the affect of crowding on children with fracture-related pain.

It’s pretty much a no-brainer. As the lead author said, “When the emergency department gets busier, staff may be less responsive to the needs of individual patients, and as a result, patients have a higher likelihood of nontreatment and delays in treatment.”

Still, it’s not simply a function of too many people seeking care in an overburdened ER: Sometimes it’s hospital procedure. In some emergency departments, only doctors are authorized to prescribe pain meds, in others nurses are allowed to administer them to patients meeting certain criteria.

If the ER is crowded, the solution is to hire more staff. If that’s not feasible in this era of cut, cut, cut, the researchers say hospitals must “leverage the staff [they] have,” which means revising pain-management procedures by allowing nurses to administer analgesics and computers or phones to signal under-treated pain.

Because overcrowding is often the result of people seeking treatment for something that isn’t an emergency, the solution must be one of policy as well as practice. As the researchers said, “We as a nation need to get serious about this. Crowding needs to be a policy priority at every level.”

There should be incentives for patients to seek care at their own doctor’s office, including better compensation for primary care and disincentives for nonemergency use of emergency departments.

The best a parent can do is to anticipate the routine, if painful, medical emergencies children are disposed to experience. Call your doctor before you ever need ER attention, and ask him or her how you can ensure that your child receives pain mitigation in the event he breaks his leg at 9 o’clock at night.

  • Should you leave a message with his or her answering service asking him or her to run interference before you reach the hospital?

  • Are there are other measures you should take to cut through the crowd and get some relief?

  • Is being a squeaky wheel in the ER a good thing, or counterproductive?

No one wants to prolong a child’s pain; it’s a matter of finding a work-around when too many voices are clamoring for too few ears.

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