Firearm-related death and injury among children and adolescents

As the articles in this journal issue show, gun violence affects children and youth in many ways: psychologically, emotionally, financially, and legally. But first and foremost, gun violence affects children's physical safety. Therefore, this issue opens with an overview of the physical toll that firearms exact upon children and youth, reviewing the incidence of firearm-related injury and death among Americans under age 20. This article analyzes trends and current status in firearm death and injury, based on nationwide data collected by the federal government. Several key findings emerge from the data: Firearm death rates among children and youth in the United States have declined dramatically since 1993, but remain high compared with historical rates in this country and rates in other developed nations. A majority of these deaths are homicides. Certain groups of children and youth, especially adolescents, boys, minority youth, and those residing outside the Northeast, are particularly at risk for firearm death. The problem is most acute among black teenage males. Firearm injuries are much more likely to result in death than are other injuries for which children and youth visit emergency departments--a reflection of the extreme lethality of firearms. Given these findings, the authors call for a concerted effort to reduce youth firearm deaths to levels comparable to those of other industrialized nations, using a wide variety of approaches that span the public health, criminal justice, and educational spheres. They also recommend improved data systems to track firearm injury and death, so that researchers can better analyze these incidents and evaluate intervention strategies.     

Sudden death in children and adolescents

This article focuses on sudden unexpected cardiac death (SCD) in children and adolescents. The authors discuss the epidemiology of SCD in children and adolescents, its incidence and etiologies, and strategies for prevention. Because most of the episodes of SCD or sudden cardiac arrest in children and adolescents occur in asymptomatic individuals unknown to have an underlying abnormality before their "event," the issues in this article primarily focus on this group of individuals.     

Preventing injury and injury-related disability in children and adolescents

Injury is the leading cause of death and a prevalent source of disability and excess health expenditures in children and adolescents. There are predictable patterns to injury that provide clues to prevention. Epidemiologically-based theoretical frameworks are available to guide development of injury prevention strategies, to add structure to our observations, and focus to our prevention activities. While all-cause injury mortality rates have decreased in children and adolescents over the last 20 years, large ethnic disparities persist, indicating the need for intensified efforts in high-risk communities. Strong leadership from pediatric surgeons and pediatricians operating hospital-based community injury prevention programs has produced successful reductions in child and adolescent injury rates in resource-limited and minority neighborhoods. Among the program features considered essential are: (1) an ongoing injury surveillance system; (2) well-focused, multifaceted prevention activities, including both passive and active prevention approaches; (3) education; (4) enlistment of other health professionals, local government officials, community leaders, and the public; and (5) evaluation and refinement of prevention activities.     

Sudden cardiac death in infants, children, and adolescents

Although SCD is relatively uncommon, its psychosocial impact is devastating. This article has reviewed the potential causes of SCD in infants, children, and adolescents. Many patients who die from SCD have identifiable cardiac disease and are known to have been at risk; however, the existence of other cardiac abnormalities, such as hypertrophic cardiomyopathy or long QT syndrome, may not be known, and SCD may be the first symptom. The authors' contention is that many of the patients in this latter group (e.g., patients who have hypertrophic cardiomyopathy or LQLTS but who have no symptoms) can be screened with a careful, accurate, and detailed history, including family history and review of systems, and physical examination. Any patient with a positive family history, positive review of systems, or positive physical examination should receive further in-depth evaluation, such as an ECG and echocardiogram. These studies permit the detection of most, if not all, of the entities potentially associated with SCD in the pediatric population.     

Obesity in children and adolescents with acquired brain injury

OBJECTIVES: To measure the prevalence of obesity and to assess associated clinical factors in children and adolescents with acquired brain injury (ABI). STUDY DESIGN: This cross-sectional study included 88 subjects aged between 2.4-17.7 years attending the Brain Injury Clinic at a tertiary paediatric hospital. Body mass index (BMI) and BMI z-scores were calculated. Obesity and overweight were defined using the International Obesity Taskforce cut-points. Associations were examined between BMI z-scores and the following: ABI severity, mobility level, duration from injury and presence of radiological injury. RESULTS: The prevalence of obesity in this population (obese = 15%) was higher than those in Australian children and adolescents (1995 National Nutrition Survey) while the prevalence of overweight (19.3%) was comparable. There was a linear trend for the participants to have a higher BMI z-score with increasing level of mobility (F = 6.91, df 1.70, p = 0.011). CONCLUSION: There is no data about obesity in children and adolescents with ABI. The study with limited statistical power suggests that obesity is prevalent in this population and increases with increasing level of mobility. Further studies are required to address the issue of obesity and related complications in this population.     

Sudden cardiac death in children and adolescents: introduction and overview

Sudden unexpected cardiac death (SCD) in a child or adolescent is a devastating event with serious impact on the family, the school, and the community. This article reviews the epidemiology of SCD in children and adolescents and includes a discussion of its incidence and etiologies. It also discusses strategies for prevention.     

Neurobehavioural outcomes of mild head injury in children and adolescents

The vast majority of closed-head injuries (CHI) in children are of mild severity. Even if only a small proportion of children with mild CHI suffer persistent negative outcomes, then mild CHI is a serious public health problem. This paper summarizes the existing literature regarding the neurobehavioural outcomes associated with mild CHI in children and adolescents, focusing on the longstanding debate regarding post-concussive syndrome. The paper also discusses conceptual and methodological issues that arise in research on the outcomes of mild CHI, including the definition of mild CHI; selection of comparison groups; measurement of outcomes; assessment of risk factors; timing of outcome assessments; and prediction of outcomes for individual children. The paper describes an ongoing research project that may help to resolve some of the longstanding controversies and uncertainties regarding the outcomes of mild CHI in children and concludes with a review of likely future directions for research on the outcomes of mild CHI. The long-term goal of research in this area is to develop a comprehensive and integrated biopsychosocial model of outcomes that can help guide clinical management.     

Management of minor closed head injury in children and adolescents

In order to develop a systematic, evidence-based approach to minor closed head injury (CHI) in the pediatric patient, case records were reviewed of all 2,533 children and adolescents admitted to Cooper Hospital/University Medical Center for minor CHI during the years 1986 to 1992. A survey was taken during a 6-month period of 734 consecutive pediatric patients dischanged from the Emergency Department for minimal CHI (out of a total of 10,276 children during the entire 7 years of the study). Categories of minor CHI derived from studies in adults were used to group data. For each category of minor CHI, the frequency of various complications such as skull fracture, intracranial lesions, and need for neurosurgical intervention was determined. Also reviewed were survival and neurological outcome 6 months following injury. Children with moderate CHI had a 37% incidence of intracranial lesions on computed tomography (CT) scan and 9% of them required intracranial surgery. The incidences of intracranial lesions and surgical intervention in the mild CHI group were 12% and 2.6%, respectively. Children with Glasgow Coma Scale scores of 13 belonged in the moderate rather than the mild CHI group, as evidenced by their higher risk. Skull fracture was not highly correlated with intracranial pathology or the need for surgery. Age had no significant impact on the incidence of lesions, rate of surgery, or outcome. Both intracranial lesions and surgery were extremely rare in the minimal CHI group. We propose three categories of minor CHI based upon relative severity (minimal, mild, and moderate) and offer a simple management scheme for each category. Based on our experience with this approach, we estimate that 80% of children with minor CHI can safely be dischanged from the Emergency Department. Cranial CT scanning will be required in only 7% of cases, but when indicated, will be extremely valuable in guiding further care.     

Epidemiology of traumatic brain injury in children and adolescents in south-western Sweden

Abstract The objectives of this study were to outline the incidence, gender distribution, external causes, severity and early outcome of traumatic brain injury (TBI). The subjects were children and adolescents in the southwestern Swedish health care region, aged 0–17 y in 1987–1991 and fulfilling the criteria for TBI. Identification was made from the discharge registers of the hospitals in the region admitting patients with TBI, and outcome data were obtained from medical records. The mean incidence rate was 12/100 000 for TBI. The dominant external cause was traffic (60%), followed by falls (22%). At discharge, 49% of those surviving were healthy, 48% suffered from one functional impairment and 52% suffered from two or more impairments. In conclusion, although the incidence rate of TBI is low in Sweden, the condition causes permanent functional impairment in 6/100 000 cases every year.     

Violent death in children in a metropolitan county: changing patterns of homicide, 1958 to 1982

Death rates from homicide in children younger than 15 years of age in the United States have increased during the last 30 years. Previous studies have suggested a typology consisting of fatal child abuse in young children and community violence in older children. We reviewed the data from the Cuyahoga County, Ohio, coroner's office pertaining to homicides in children less than 15 years of age between 1958 and 1982 and obtained similar findings. The homicide rates for city children increased from 1.1 to 6.7/100,000 in the first 20 years and then stabilized. Nonwhite boys had the highest death rates except in one period. Assailants were usually adolescent and young adult men of the same race; however, 43% of children less than 5 years of age were killed by women. The older the child, the more likely the homicide was to have been committed by a nonrelative, outside of the home, and with a firearm. Overall, firearms are the leading cause of homicide (36.2%). The temporal characteristics of child homicides are also described.     

Doppler US measurement of the superior mesenteric artery blood flow in children and adolescents

Background

Blood flow volume in the superior mesenteric artery (SMA) measured by pulsed Doppler has been used in adults to evaluate Crohn disease but has not been utilized in children and adolescents.

Objective

To establish a cutoff point for normal SMA blood flow using pulsed Doppler US measurement in healthy children and adolescents.

Materials and methods

The study included healthy volunteers from an urban community, divided into two age groups, children (5–9?years) and adolescents (10–17?years). Anthropometric measurements included waist circumference and body surface area classified according to the z-score of body mass index. Heart rate, blood pressure, oxygen saturation and temperature were measured immediately before US evaluation.

Results

The average age of the 60 participants was 12.2?years. Of these, 21 (35%) were ages 5–9?years and 39 (65%) were ages 10–17?years; 21 (35%) were boys. Findings of the two examiners coincided for 58 of the 60 (96.7%) participants. SMA blood flow was significantly lower in the children (mean ± SD?=?556?±?122?ml/min) than in adolescents (mean ± SD 775?±?311?ml/min) (P?<?0.001). SMA blood flow showed statistically significant positive associations with body surface area.

Conclusion

We found that superior mesenteric artery blood flow is significantly lower in children than in adolescents and is associated with body surface area.     

US findings of adnexal torsion in children and adolescents: size really does matter

Background Adnexal torsion is rare, and symptoms are nonspecific. Clinicians often rely on US examinations to evaluate girls with abdominal or pelvic pain. Objective To determine which sonographic findings can predict adnexal torsion by comparing pediatric and adolescent patients with surgically confirmed torsion (cases) to those without torsion (controls). Materials and methods Cases and controls were identified retrospectively by searching 7 years of medical record and radiology databases. An adnexal ratio was calculated as the volume of the affected adnexa divided by the volume of the unaffected adnexa. Results We identified 61 menarchal subjects: 33 cases and 28 controls. Adnexal volume was larger in cases than in controls (185 vs. 37.8 ml, P < 0.001). A volume of >75 ml was more common in cases than in controls (64 vs. 15%, P < 0.001). No cases had an adnexal volume of <20 ml (P < 0.001). The adnexal ratio was larger in cases than in controls (16.1 vs. 6.7, P < 0.001). An adnexal ratio of >15 was seen in 40% of cases and in no controls (P = 0.08). Doppler US results were not predictive of torsion. Conclusion An adnexal volume of <20 ml is strong evidence against adnexal torsion in menarchal females. In this age group, the diagnosis of torsion cannot be established by US examination alone.     

Practitioner review: psychological sequelae of head injury in children and adolescents

Many children suffer an injury to the head at some time, but relatively few of these cause major problems. However, in a few cases the sequelae can be far reaching. This review considers how to evaluate the significance of a head injury. Factors to consider are (1) injury variables: cause, severity and type of injury; (2) child variables: premorbid functioning, age, and developmental level of the child both at injury and at assessment; and (3) the cognitive, behavioural, and emotional problems that may arise. Parental beliefs and knowledge about the injury as well as the overall effect of an injury on the family as a whole are also considered.