Acute Care/Injuries

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In 2006, children and adolescents under age 18 had over 237 million ambulatory health care visits, including 24 million visits to hospital outpatient and emergency departments (EDs). Only 15 percent of visits to physicians' offices were for well-child care, while a high number of visits were for acute care.

Fifty-four percent of visits to hospital EDs by 5- to 14-year-olds are due to injuries, and injuries are the leading cause of death among those 1 to 24 years of age in the United States. AHRQ's research portfolio on acute care and injuries focuses on the effectiveness, quality, safety, and costs of care for children and adolescents.

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Use of corticosteroids along with antibiotics for children with bacterial meningitis may not improve outcomes.

Use of corticosteroids with or shortly before the first dose of antibiotics significantly reduces mortality among adults with bacterial meningitis but does not seem to be effective in children with the condition, according to this study. Researchers found no association between adjuvant steroids and children's time to death or hospital discharge. They examined data on 2,780 children (median age of 9 months) with bacterial meningitis cared for in 27 children's hospitals in various States. Mongelluzzo, Mohamad, Have, and Shah, JAMA 299(17):2048-2055, 2008 (AHRQ Grant HS16946).

Blood cultures taken from children show drug resistance to a class of antibiotics usually used for adults.

Children usually are not given the broad-spectrum antibiotics called fluoroquinolones because they cause joint toxicity. Nevertheless, two common bacteria—Escherichia coli and Klebsiella—showed fluoroquinolone resistance in 217 blood cultures taken from children at the Children's Hospital of Philadelphia. Eight of the cultures (2.9 percent) were resistant to two common fluoroquinolones, ciproflaxin and levofloxacin. These drugs are commonly used in adults, and ciproflaxin was recently approved for children to treat inhalation anthrax and problematic urinary tract infections. Kim, Lautenbach, Chu, et al., Am J Infect Control 36(1):70-73, 2008 (AHRQ Grant HS10399).

Antimicrobial stewardship program improves antimicrobial use among hospitalized children.

Use of an antimicrobial stewardship program (ASP)—in which an infectious disease consultant controls use of antimicrobials (antibiotics, antifungals, and antivirals) by hospital staff—can improve the appropriate use of these agents, according to this study. During the 4-month study period, physicians placed 652 calls to the ASP at one children's hospital. Nearly half of the calls required an intervention by the ASP to resolve drugbug mismatches, minimize unnecessary use of broad spectrum antibiotics, prevent duplicate therapy, and improve dosing. Metjian, Prasad, Kogon, et al., Pediatr Infect Dis J 27(2):106-111, 2008 (AHRQ Grant HS10399).

Safety and effectiveness of infliximab established for children with severe ulcerative colitis.

Researchers reviewed the charts of 27 children with ulcerative colitis who were treated with infliximab—a drug that blocks the inflammatory action of the body's tumor necrosis factor-a (TFA)— instead of undergoing surgical removal of all or part of the colon. Infliximab was found it to be a safe and effective therapeutic option for these children. Treatment was successful in 75 percent of acutely ill patients and 27 percent of chronically ill patients. Fanjiang, Russell, and Katz, J Pediatr Gastroenterol Nutr 44:312-317, 2007 (AHRQ Grant T32 HS00060).

Study identifies risk factors for poor outcome in children with catheterassociated bloodstream infections.

Of the 118 eligible patients (ages 0-9) with catheter-associated bloodstream infections due to Escherichia coli and/or Klebsiella who were identified from a hospital database, 16 (14 percent) had a poor outcome. Poor outcome was defined as recurrence of infection (eight patients) or death (eight patients). Receiving mechanical ventilation and/or total parenteral nutrition were independently associated with death or recurrence of infection. Catheter removal (64 children) did not affect either infection recurrence or death, but a significant proportion of children with catheter-associated bloodstream infection were treated successfully without catheter removal. Buckley, Coffin, Lautenbach, et al., Infect Control Hosp Epidemiol 28(11):1308-1310 (AHRQ Grant HS10399).

Pediatricians are more likely to identify child abuse if they are more knowledgeable and confident they can manage it.

A random survey was conducted among a national sample of pediatricians to determine their knowledge, attitudes, and experiences related to child abuse. They were asked their interpretation of the cause of injury to a girl in a deliberately vague vignette. Overall, nearly two-thirds of pediatricians expressed confidence in their ability to identify and manage patients injured by child abuse. Those with positive attitudes about child abuse screening were more likely to identify the vignette case as probable child abuse. Flaherty, Sege Price, et al., Child Maltreat 11(4):361-369, 2006 (AHRQ Grant HS10746).

Some abdominal injuries indicate child abuse in young children.

Using the National Pediatric Trauma Registry, researchers identified 664 cases of blunt abdominal injury not involving an auto accident in children up to age 4. Child abuse was suspected in 41 percent of cases and in 84 percent of deaths. Liver injury was the most common intraabdominal injury. The medical diagnosis of child abuse was significantly associated with mortality, malnourishment, young age, traumatic brain injury, hollow viscous (e.g., small bowel) and pancreatic injury, and other intra-abdominal injuries. Trokel, Discala, Terrin, and Sege, Pediatr Emerg Care 22(10):700-704, 2006 (AHRQ Grant HS00060).

Telemedicine appears effective for evaluating acute childhood illnesses.

Researchers randomly assigned 253 children to in-person evaluation of acute illness by study physicians and 239 children to evaluation by study physicians via telemedicine. Children were seen in a pediatric primary care practice or pediatric emergency department of a university affiliated medical center. Results were comparable for the two groups: study physicians made a diagnosis in 74.1 percent of telemedicine visits compared with 76.7 percent of in-person visits. McConnochie, Conners, Brayer, et al., Telemed J E Health 12(3):308-316, 2006 (AHRQ Grant HS10753).

Anatomic factors may play an important role in pediatric traumatic brain injury.

Significant traumatic brain injury (TBI) occurs in 5 to 10 percent of all patients with blunt head trauma. Among emergency department patients who underwent computed tomography (CT) for blunt head trauma at 21 hospital EDs, men, children younger than age 10, and elderly people were most likely to have significant TBI. The researchers note that children have a larger head-to-body ratio that may allow more energy from a traumatic impact to be distributed to the head. Almost half of children under age 10 with TBI have had a skull fracture. Also, certain mechanisms of injury (e.g., child abuse) may increase the risk of TBI. Holmes, Hendey, Oman, et al., Am J Emerg Med 24:167-173, 2006 (AHRQ Grant HS09699).

Certain clinical criteria can identify children with blunt head trauma who do not need a CT scan.

Seven clinical criteria can be used to identify pediatric victims of blunt head trauma who are at low risk for important intracranial injury (ICI) and thus are unlikely to need a CT scan. The seven factors are: evidence of significant skull fracture, altered level of alertness, neurologic deficit, persistent vomiting, presence of scalp hematoma, abnormal behavior, and blood coagulation problems. Children who do not meet at least one of these criteria are at low risk for ICI and thus are unlikely to require neurosurgical intervention or suffer significant long-term impairment. Oman, Cooper, Holmes, et al., Pediatrics 117(2), 2006; onlne at www.pediatrics.org (AHRQ Grant HS09699).

Placing children in a semi-recumbent position provides better images from echocardiography.

According to this study, placing children in a semi-recumbent position at a 70-degree angle with back support results in better quality images during exercise echocardiography procedures, compared with a 90-degree upright position. In the semi-recumbent posture with back support, children were able to maintain torso stability during cycling to facilitate better quality images in a shorter period of time. Chang, Qi, Larson, et al., Am J Cardiol 95:918-921, 2005 (AHRQ grant HS13217).

Child abuse is linked with increased risk of death in young children with abdominal injuries.

Between 1995 and 2001, more than half (61 percent) of traumatic abdominal injuries in young children 0 to 4 years of age resulted from motor vehicle accidents. Other significant causes were child abuse (16 percent) and falls (14 percent). Children who were abused and had abdominal and central nervous system injury were more likely than other children with abdominal trauma to die while in the hospital, according to this analysis of data on 927 cases of blunt abdominal injuries in young children. Trokel, DiScala, Terrin, and Sege, Child Maltreat 9(1):111-117, 2004 (AHRQ Grant T32 HS00060).

Instrument provides reliable information about children with brain injuries.

Researchers developed and tested a measure of neurologic outcome for use in triage and clinical decisionmaking for children who have suffered traumatic brain injuries. They tested the instrument—the Neurologic Outcome Scale for Infants and Children—in 100 children of varying ages. They found the instrument to be practical and reliable and applicable to infants and children with a broad range of neurologic deficits. Okada, Young, Baren, et al., Acad Emerg Med 10(10):1034-1039, 2003 (AHRQ Grant F32 HS00091).

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Adolescent Health

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Researchers are focusing on the distinctive health care needs of adolescents. Recent AHRQ-funded studies have focused on such adolescent prevention topics as screening for sexually transmitted diseases (STDs) and smoking cessation.

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Peer counseling with added incentives is a cost-effective way to get adolescents to adhere to a TB control program.

Activation of latent tuberculosis (TB) infection is more likely to occur during adolescence due to hormonal changes and altered protein and calcium metabolism associated with adolescent growth. Often, adolescents must be persuaded to complete treatment, since latent TB infection usually is asymptomatic. Researchers found that offering adolescents gifts, money, or outings with friends—combined with peer education counseling—increased their completion of TB treatment programs in a cost-effective way ($209 per quality-adjusted life year). Kominski, Varon, Morisky, et al., J Adolesc Health 40:61-68, 2007 (AHRQ Grant HS00046).

Adolescent females are willing to undergo chlamydial screening during urgent care visits.

A survey of 365 ethnically diverse adolescents (58 percent female) aged 13-18 revealed that sexually active adolescent and young adult females are willing to be screened for Chlamydia during urgent care visits, especially if their clinician can speak their language and clearly explain the meaning of confidentiality. This is important because two-thirds of sexually active adolescents use urgent care visits exclusively for their health care during a given year. Thus, limiting screening to well-care visits will miss the majority of adolescents at risk for chlamydial infection, note the researchers. Miller, Tebb, Williams, et al., Arch Pediatr Adolesc Med 161(8):772-782, 2007 (AHRQ Grant HS10537).

Intervention programs that focus on already violent youth found to be most effective.

Tertiary intervention programs are more likely to report effectiveness than primary and secondary programs for reducing violent behaviors among adolescents, according to this study. Tertiary programs focus on youths who have already engaged in violent behavior, while primary programs focus on reducing risky behaviors (e.g., substance abuse) and secondary programs focus on at-risk youths (e.g., those living in poor neighborhoods). Overall, nearly half of interventions evaluated were effective; two of six primary interventions, three of seven secondary interventions, and both tertiary interventions were effective. Limbos, Chan, Warf, et al., Am J Prev Med 33(1):65-74, 2007 (AHRQ contracts 290-97-0001 and 290-02-0003).

Today's teenage smokers are more likely to engage in risky behaviors than their peers in the early 90s.

Researchers analyzed data from national youth risk behavior surveys from 1991 to 2003 and found that the risk profile of the adolescent smoker has changed. Today's young smokers are more likely to engage in risky sexual behaviors, risky alcohol-related behaviors, and to not use a seatbelt or bicycle helmet than adolescent smokers in the early 1990s. Camenga, Kelin, and Roy, J Adolesc Health 39, 2006; onlne at http://www.adolescenthealth.org/journal.htm (AHRQ Grant HS14418).

Quality improvement teams can improve chlamydia screening among male adolescents.

Routine screening for Chlamydia trachomatis (CT) infection is recommended for sexually active young women aged 15-25 years. Only the American Medical Association recommends routine screening of sexually active male adolescents. This study involved more than 1,000 sexually active male adolescents aged 14 to 18 who were seen in pediatric clinics in the San Francisco Bay area. Those youths seen in clinics that had a quality improvement team were much more likely to be screened for CT infection than those seen in clinics without such a team. Researchers found that 4 percent of those screened had CT infection. Tebb, Pantell, Wibbelsman, et al., Am J Public Health 95(10):1806-1810, 2005 (AHRQ Grant HS10537).

Hospital type and location affect discharge disposition of adolescents hospitalized for suicide attempts.

Adolescents who are hospitalized after a suicide attempt are more likely to be discharged to a psychiatric, rehabilitation, or chronic care facility if they are hospitalized in a facility that caters to children and/or is located in the Northeast United States. This suggests that factors other than the medical and emotional needs of vulnerable adolescents are driving care. Levine, Schwarz, Argon, et al., Arch Pediatr Adolesc Med 159:860-866, 2005 (AHRQ Grant HS00002).

Two factors predict risk for repeat suicide attempts among youths.

Two factors predict which youths referred for emergency psychiatric hospitalization because of suicide attempts will try to commit suicide again: more severe clinical depression and caregivers who exert more parental control. This study involved 70 youths aged 10 to 17 who had attempted suicide and their families. Most of the families were economically disadvantaged. Huey, Henggeler, Rowland, et al., J Clin Child Adolesc Psychol 34(3):582-589, 2005 (AHRQ Grant HS10871).

Wisconsin study finds hundreds of hospitalizations for self-poisoning among adolescents.

The researchers analyzed Wisconsin hospital discharge files for 2000-2002. They focused on medication-related injuries for intention to commit suicide, medications used, discharge status, and risk factors for self-poisoning (such as mental illness and eating disorders). During the 3-year study period, there were nearly 3,000 hospitalizations for medication-related injuries—of which 1,150 involved self-poisoning—among Wisconsin youths 12 to 17 years of age. Marbella, Yang, Guse, et al., Wis Med J 104(7):59-64, 2005 (AHRQ Grant HS11893).

Physician attitudes and other factors affect decisions about use of growth hormone therapy.

Growth hormone (GH) therapy is usually reserved for the shortest 1.2 percent of U.S. children at about age 10. The height goal is usually average height for a 16-year-old male (68.3 inches) or 14-year-old female (62.6 inches). A GH-deficient youngster who has received GH for several years typically shows gradual tapering of growth beginning in mid-adolescence. Some physicians advocate discontinuing therapy when the potential for continued growth decreases, while others seem to value even small gains as the final height goal approaches. The average cost of GH therapy is $26,000 per year. Cuttler, Silvers, Singh, et al., Med Care 43(12):1185-1193, 2005 (AHRQ grant HS00059).

Adolescents with special health care needs seldom receive adequate transition from pediatric to adult-oriented care.

Each year, 750,000 adolescents with special health care needs become adults and must transition to adult-oriented health care. Researchers analyzed data for 4,332 adolescents aged 14 to 17 years and found that about 50 percent of parents had discussed transition issues with their child's doctor. Adolescents with special needs who were older, female, had more complicated needs, and had a high-quality relationship with their doctors were more likely to receive adequate health care transition. Scal and Ireland, Pediatrics 115(6):1607-1612, 2005 (AHRQ grant HS15511).

Most teens with chlamydial infections get antibiotics but may not receive counseling and other care.

Researchers reviewed the medical charts of 111 sexually active teens, aged 14 to 19, who tested positive for Chlamydia trachomatis in 2001 at five pediatric clinics in California. All but four teens received appropriate antibiotics in a timely fashion, but counseling about high-risk sex, testing for other sexually transmitted diseases, and other services were provided less often. Only 36 percent of the patients were tested for other sexually transmitted diseases, and significantly fewer boys than girls received counseling about safer sex. Hwang, Tebb, Shafer, and Pantell, Arch Pediatr Adolesc Med 159:1162-1166, 2005 (AHRQ Grant HS10537).

Certain practice factors are associated with more frequent screening and counseling of adolescents about risky behaviors.

In this study, specialized clinician training and charting tools were associated with increases in rates of screening and counseling of adolescents about risky behaviors, such as substance abuse, unsafe sex, and risky vehicle use. Ozer, Adams, Lustig, et al., Pediatrics 115(4):960-968, 2005 (AHRQ grant HS11095).

Certain factors increase the likelihood of posttraumatic stress disorder (PTSD) in adolescents who suffer a serious injury.

Researchers surveyed adolescent trauma patients aged 12 to 19 who had been hospitalized following a serious injury to assess their outcomes at various points up to 24 months postdischarge. They found that perceived threat to life and intentional or violence-related injury doubled the likelihood that the youths would experience PTSD. Girls and older adolescents had higher rates of PTSD than boys and younger adolescents, and low socioeconomic status was strongly associated with long-term PTSD. Holbrook, Hoyt, Coimbra, et al., J Trauma Injury Infect Crit Care 58:764-771, 2005 (AHRQ Grant HS07611).

Adolescents underuse primary care and seldom receive counseling about risky behaviors.

Researchers used data from two surveys (1993-2000) to examine adolescents' use of outpatient care and receipt of preventive counseling. They focused on counseling on three health topics: diet, exercise, and growth/development; and five risk-reduction topics: tobacco use/exposure, skin cancer prevention, injury prevention, family planning/contraception and prevention of sexually transmitted diseases. Only 39 percent of routine visits included counseling for diet and/or exercise. Counseling for other topics ranged from a low of 3 percent to 20 percent, with skin cancer prevention, HIV/STD transmission, and family planning/contraception ranking the lowest. Ma, Wang, and Stafford, J Adolesc Health 36:441e1-441e7, 2005 (AHRQ Grant HS11313).

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