DC Child Accident & Safety Blog

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.

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.

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.

Even though the number of lead poisoning cases is declining, the toxic metal remains a problem, particularly for children, as we have written about numerous times, most recently last week.

A federal panel, the Advisory Committee on Childhood Lead Poisoning Prevention, recently expressed its concern about blood levels in children by advocating for a lower acceptable threshold.

If adopted, it would be the first time in 20 years the Centers for Disease Control and Prevention (CDC) lowers the standard. The CDC has never failed to accept a panel advisory.

Lower blood level standards, as reported on the Huffington Post, would result in hundreds of thousands more children diagnosed with lead poisoning. The new blood level for children would be 5 micrograms of lead per deciliter versus the previous value of 10 micrograms.

Lead used to be a common component of paint and gasoline, but the metal has long been banned in the manufacture of both.

Children’s developing organs are particularly vulnerable to lead, especially the brain and kidneys. Depending on the blood level, lead can cause reduced intelligence, behavioral problems, impaired hearing, coma, convulsions and death.

Children often are exposed if they live in old, deteriorating homes or those undergoing renovation. The delivery systems include paint chips, lead-filled dust and soil contaminated by leaded gasoline.

As the panel’s report made clear, all children are at risk: “New findings suggest that the adverse health effects of BLLs [blood lead levels] less than 10 μg/dL in children extend beyond cognitive function to include cardiovascular, immunological, and endocrine effects. Additionally, such effects do not appear to be confined to lower socioeconomic status populations.

“Primary prevention is a strategy that emphasizes the prevention of lead exposure, rather than a response to exposure after it has taken place. Primary prevention is necessary because the effects of lead appear to be irreversible.”

Lowering the acceptable lead level in blood is a welcome adjustment for childrens’ advocates, who say that medical evidence has been mounting that even lower levels of lead poisoning can erode a child's ability to learn and cause behavior problems.

"This is long overdue," Ruth Ann Norton told the Huffington Post. She’s executive director of the Coalition to End Childhood Lead Poisoning in Baltimore.

The challenge in implementing the panel’s recommendations lies in the languishing economy. Many city and county health departments are responsible for providing services for lead-poisoned kids, and according to the Huffington Post, those departments have lost more than 34,000 jobs in the last three years because of budget cuts. And Congress has slashed the CDC's lead program from more than $30 million to $2 million.

Parents should be aware of the advisory panel’s recommendations for monitoring lead blood levels in children. If your ob/gyn and pediatrician don’t broach the subject, you should. The panel advises:

• Primary prevention must start with counseling, including prenatal if possible. This includes recommending environmental assessments for children before screening BLLs in children at risk for lead exposure.


• After confirmatory testing, children above the reference value of 5 μg/dL must continue to be monitored for BLLs and assessed for iron deficiency and general nutrition (for example, calcium and vitamin C levels) consistent with American Academy of Pediatrics (AAP) guidelines.


• Iron-deficient children should be provided with iron supplements. All BLL test results should be communicated to families in a timely and appropriate manner.



Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Lead Poisoning

Although significant strides have been made toward eliminating the threat of lead poisoning, the National Capital Poison Center points out that it is still a problem, especially for children.

Symptoms of lead poisoning can range from the relatively mild—abdominal discomfort—to the dire—seizures, coma and death. Children exposed to too much lead also can have lower IQ scores, difficulty with reading and math and behavioral problems including attention deficit disorders and delinquency.

Because some sources of the deadly metal are unexpected, the Poison Center has enumerated certain products for which parents should be especially watchful. They are:

• Jewelry and Cosmetics. Some imported cosmetics have been contaminated with lead, including kohl (used as eye liner) and sindoor (a red scalp powder).


• Imported medicines, traditional medicines and folk remedies. Azarcon and greta are used to treat empacho (stomach symptoms); both contain a substantial amount of lead. In one study, 64 percent of herbal medicines from India contained lead, which also shows up in folk remedies for arthritis, infertility, cramps and colic. Contaminated medicines might have been imported, or purchased overseas and brought into the U.S. by consumers.


• Imported food and candy. Tamarind candy and candy wrappers from Mexico have been contaminated with lead. Several spices and food products imported from India have been contaminated with lead.


• Bullets, lead pellets and hobby items. Licking bullets, swallowing lead pellets or shot or breathing fumes from melted lead for fishing weights can cause lead poisoning.


• Household items. Children have been poisoned by lead when acidic foods were stored or served on imported ceramic dishware and pitchers—acid promotes the leaching of lead from the ceramic glaze into the food. Lead poisoning has resulted from contaminated plastic mini-blinds. Curtain weights may contain lead. Antique cribs and furniture may be sources of lead-based paint.

Any lead is too much lead: There is no “normal” blood level. Children with lead exposure often complain of stomach pain, are fussy, can’t concentrate and have diminished appetite. The only way to diagnose lead poisoning is by a blood test.

To minimize the chances of your child being exposed to lead:

• Do not purchase inexpensive metal jewelry for children. In addition to lead, some also contain the toxic metal cadmium.


• Verify the source and safety of imported cosmetics and medicines, especially traditional and folk medicines, or don’t use them.


• Don’t allow children to lick or suck on hobby materials including bullets, pellets, fishing sinkers.


• Do not use imported ceramic plates, pitchers, etc. to store or serve food. Use them for decoration only.


• Replace old, plastic mini-blinds.


• If you live in a building constructed before the 1980s, consider having the paint tested for lead content, and also consider getting free lead blood screening tests for any children in the house. Here is more information from the U.S. Consumer Products Safety Commission on lead in housing.

To address concerns or questions about lead or the treatment of lead poisoning, call 800-222-1222. Local poison center experts answer phone call 24 hours a day.

If you give your baby acetaminophen to reduce fever and pain, pay close attention to the packaging.

Several months ago, we reported about the FDA’s interest in more accurate dosing information for children’s Tylenol . It’s still a hot topic. Last week, the feds issued a warning about the potential for dosing errors with liquid acetaminophen for infants. As explained on MedPage Today, in 2009 the FDA recommended introducing a new, single strength version of the drug. Adverse event reports from babies given the drug indicated that the problem was dosing errors.

Many manufacturers who made liquid acetaminophen in different strengths agreed to produce only a single concentration—160 mg/5 mL. The quantities refer to how much of the active ingredient (160 mg) is in each dose (5 mL). But the effort to simplify appears to have complicated things.

The recommendation to produce only a single dose was voluntary, and not every manufacturer followed it. Acetaminophen strengths of 80 mg/mL and 80 mg/0.8mL are still available for purchase. Some consumers have both versions of the drug, and some of the newer packaging is similar to the old. For the Little Fevers brand, the FDA noted, “both boxes … say ‘New’ on the front, but only one of the contains the new concentration of liquid acetaminophen.”

Parental tip: If your package of liquid acetaminophen includes a dropper, that’s the older version. The 160 mg/5 mL products include an oral syringe that is supposed to make dosing more precise. To eliminate the risk of giving the wrong dose, use only products with the syringe, and dispose of any other liquid acetaminophen. If you’re uncertain how to measure, contact a pharmacy or your doctor’s office.

We’ve all heard stories about the unthinking transmission of sexually explicit material via telephone texts. We’ve even been a bystander to the more notorious episodes (two words: Anthony Weiner).

But when the willing participants in such naughty trafficking are children, there is less smirking and more worrying.

But a recent study in the journal Pediatrics concluded that kids don’t text sex stuff as much as conventional thought suggests.

“Sexting”—sending or receiving risqué or even explicit photos or videos on a cellphone—is legally fraught when it involves a minor. It’s a criminal offense. It’s child pornography.

Researcher Kimberly J. Mitchell co-authored two studies in Pediatrics, one of which estimates that in 2008-2009, police in the U.S. investigated 3,500-some cases of sexual images sent by adolescents. In 1 of 3 of those cases, an adult received them.

But there doesn’t appear to be an epidemic of kids sending naked photos of themselves to here, there and everywhere, including the Internet. As a story on Reuters.com noted, youth sexting isn’t as common as earlier polls indicated.

A 2008 survey by the National Campaign to Prevent Teen and Unplanned Pregnancy found that 1 in 5 teens has sent or posted online nude or semi-nude pictures or videos of themselves. Mitchell and her colleagues got much smaller numbers in a 2010 national survey. According to phone interviews with more than 1,500 children 10 to 17 years old, only 2.5 in 100 had appeared in or produced nude or nearly nude photos or videos. And only 1 in 100 did so if only sexually explicit material -- naked breasts, genitals or rear ends -- was included. Around 6 or 7 in 100 adolescents said they'd received such images or videos.

"Overall, our results are actually quite reassuring," Mitchell told Reuters. "With any sort of new technology that kids become involved in there is a tendency to become easily alarmed. What we are instead seeing is that sexting may just make some forms of sexual behavior more visible to adults."

Her advice to parents is to make sure their kids understand the legal risks (being busted for transmitting child porn) and the digital risk of Internet exposure. If someone is a sexting recipient, delete the text immediate and certainly don’t redistribute it.

A spokesman for the National Campaign to Prevent Teen and Unplanned Pregnancy was gratified by the study’s finding, but also a bit skeptical. Bill Albert told Reuters the numbers didn’t surprise him because researchers surveyed younger kids as well as teenagers. As he pointed out, "I wonder if teens are being as truthful as they might be. … It's a good opportunity to sit down with your kid and talk about it."

What sort of misadventure do you think brings most young children into the emergency room? Most people would guess car accidents. Most people would be wrong.

It’s poisoning by drugs. According to the National Capital Poison Center, this stark reality is the result of more children having access to and swallowing prescription drugs at home.

More adults are using prescription medication, especially of the pain-killing variety such as oxycodone, hydromorphone, morphine, methadone and fentanyl. And older children with chronic conditions are adding to the prescription drug bottom line with meds to treat their attention deficit disorders and, increasingly, Type 2 diabetes.

The danger to the wee ones simply reflects the law of averages: The more medicines present in young children’s homes, the greater the likelihood they will find and swallow them.

The most dangerous prescription medicines for children are those that treat:

• diabetes;


• pain (opioids, or narcotics);


• anxiety, muscle spasms and sleep problems;


• heart disease and high blood pressure.

Medicines should be locked up, but that can be tough if the rightful patient requires frequent dosing. Travel also complicates safe storage. And even the most vigilant parent gets interrupted and distracted while taking medicines.

To minimize the incidence of childhood poisoning, researchers such as those involved in a Journal of Pediatrics study propose that packaging limit the amount of drug available (children can’t open many child-resistant blister packs at one time). Liquid medicines as well could be dispensed in single-dose containers.

Other poison-prevention measure suggested by the Poison Center:

• Use child-resistant packaging. Replace caps tightly after use.


• Lock all medicines up high, out of sight and reach of children.


• Take medicines when children aren’t looking—children imitate adults.


• When traveling, ensure that medicines are locked away from children.

If you think a child may have swallowed too much medicine or someone else’s medicine, call the poison center immediately at 800-222-1222.

We often take issue with careless, shallow and/or misleading media reports about health and safety issues. But in one high-profile case, the flashy TV doc got it right.

Consumer Reports investigated the claim of Dr. Mehmet Oz ("The Dr. Oz Show"), and found that, indeed, 1 in 10 of the juices tested contained more arsenic than is allowed in drinking water. One problem, investigators said, is that juice and similar beverages have no standards for arsenic content. Inorganic arsenic (that is, arsenic that does not occur naturally in some fruits) is carcinogenic. Lead content also was problematically high in many juices.

The EPA limits arsenic in drinking water to 10 parts per billion (ppb), and some health experts say that’s too high. According to AboutLawsuits.com, The FDA told Consumer Reports that it’s considering arsenic standards for juice. In September, the website reported, the FDA “believed apple juice consumption posed little or no risk, but since then it has received eight apple juice test samples with total arsenic levels of up to 45 ppb.”

Because arsenic and lead disproportionately damage smaller, growing brains, the American Academy of Pediatrics advises:

• Don’t give infants younger than six months any kind of juice.


• Limit juice for children 6 years and younger to six ounces a day.


• Limit juice for children older than 6 years to 12 ounces a day.

The FDA has approved two vaccines to ward off infection by some strains of the human papillomavirus (HPV), which can cause cancer. But until recently, the shot was promoted only for girls. (The vaccine is useless unless given before the onset of sexual activity.)

But the federal Advisory Committee on Immunization and Practices (ACIP) recently issued a recommendation that boys and young men also receive the vaccination to protect against genital warts and anal cancer. Males are at a lower risk of developing cancer from HPV, but they can transmit HPV to their partners.

We recently wrote about the lag in HPV vaccination for young people, but that was before the ACIP issued its recent report. The more often parents are made aware of the solid science, the more likely they are to protect their children’s future health.

According to a Kaiser Family Foundation fact sheet, HPV infection in the U.S. is widespread, with more than 6 million new infections annually. Approximately half of all sexually active men and women will get HPV at some point in their lives.

Currently, the vaccines are administered in three doses over 6 months, but research is underway to determine whether two might be sufficient to provide protection.

For 26 years the California Public Interest Research Group (CALPIRG) has issued a report about toy safety. We wrote about it last year, and this year’s summary, “Trouble in Toyland,” was released earlier this week. It identifies hazardous toys and offers safety guidelines for consumers. Specific toys are listed in the complete report.

CALPIRG’s work has resulted in 150-some recalls of toys that posed hazards for a range of reasons, including strangulation, choking, toxins, noise and sharp edges. But as a consumer watchdog, the organization knows the work isn’t done. Although championing the Consumer Product Safety Improvement Act (CPSIA) of 2008 for its advances in toy safety, CALPIRG also notes that this year, “policymakers delayed implementation of its most stringent lead standard rules and enacted some narrow exceptions,” and we concur.

That said, here’s what you need to know as you embark on the toy-buying season.

Lead
Lead is especially problematic for the central nervous system; childrens’ developing brains are particularly at risk. Seven toys exceed levels CALPIRG finds excessive (the organization’s threshold is much lower than the CPSIA standard).

Phthalates
Phthalates are of concern particularly for premature delivery and reproductive defects. The CPSIA has banned toys containing three phthalates and set temporary limits on three others, while tests continue. CALPIRG found two toys that laboratory testing showed to exceed limits allowed by the CPSIA by 42 and 77 times, respectively.

Choking
Choking is a major cause of toy-related deaths and injuries. CALPIRG found several toys that violated standard intended for children younger than 3, and several others that support its call for the small parts test to be made less permissive. Some toys intended for older children failed to provide choking hazards warnings required for small parts or small balls.

Noise
One-third of Americans with hearing loss can attribute it in part to noise. One in 5 U.S. children will have some degree of hearing loss by the time they are 12. CALPIRG found three toys it considers too noisy.

Among CALPIRG’s suggestions for improving toy safety are:

• The Consumer Product Safety Commission (CPSC) should review and, if necessary, expand its definition of a “small part” or “small toy” to include parts and toys that are larger than the current standard, but have been shown to pose a choking hazard to children.


• Cadmium should be limited in children’s jewelry. See our recent post about the dangers of this toxic chemical.


• Lead and phthalate standards in toys should be vigorously enforced, and lead standards should be lowered.


• The CPSC must ensure that its product incident database it provides the information consumers need to make informed choices in the marketplace.

Consumers must realize that not all toys are tested, and not all toys on store shelves meet CPSC standards. There is no comprehensive list of potentially hazardous toys. Examine toys carefully for potential dangers before you make a purchase.

It's also a good idea to screen all children for exposure to lead via a simple and inexpensive blood test at a physician’s office or public health agency.

Report unsafe toys or toy-related injuries to the CPSC at www.cpsc.gov and to www.saferproducts.gov or call the CPSC at 1-800-504-7923.

Last week, Johnson & Johnson surrendered. After sustained pressure from consumer watchdog groups, the manufacturer has decided to eliminate from its baby products any preservatives that might release even trace amounts of formaldehyde.

In a letter to the Campaign for Safe Cosmetics, the company’s vice president for product stewardship & toxicology reiterated the safety of all of its products, and called the reformulation a response to consumers. Two weeks before the company’s announcement, the Campaign had called for a boycott of Johnson & Johnson baby shampoo.

The removal of the offending ingredients—quaternium-15 and 1,4-dioxane—from all products worldwide will take about two years, but the baby shampoo will be reformulated first. Quaternium kills bacteria, but releases formaldehyde, a known human carcinogen. Dioxane is a suspected carcinogen.

In addition to the Campaign for Safe Cosmetics, the Breast Cancer Fund and the Environmental Working Group lobbied Johnson & Johnson to make the switch.