Risk of injury to child passengers in sport utility vehicles

Evaluation of procedural pain for neonates in a neonatal intensive care unit: a single-centre study

BACKGROUND

To evaluate the procedural pain experienced by neonates in a neonatal intensive care unit (NICU) setting and determine the corresponding pain grades.

METHODS

Two experienced nurses independently used the Neonatal Infant Pain Scale (NIPS) to evaluate the neonatal pain during procedures taking place in the tertiary NICU and two level-two neonatal care units in the Children's Hospital of Zhejiang University School of Medicine. The mean and distribution of NIPS pain scores and the corresponding pain grades of participants when experiencing clinical painful procedures were analysed.

RESULTS

A total of 957 neonates exposed to 15 common clinical painful procedures were included in the study. The clinical painful procedures experienced by 957 participants could be divided into three groups: severe pain (NIPS score 5-7: peripheral intravenous cannulation, arterial catheterisation, arterial blood sampling, peripherally inserted central catheter placement and nasopharyngeal suctioning), mild to moderate pain (NIPS score 3-4: finger prick, intramuscular injection, adhesive removal, endotracheal intubation suctioning, heel prick, lumbar puncture and subcutaneous injection) and no pain to mild pain (NIPS score 0-2: gastric tube insertion, enema and intravenous injection).

CONCLUSIONS

The neonatal pain response to clinical procedures in NICU had certain pattern and preintervention drug analgesia could be taken for painful procedures with clustered high NIPS pain scores. Meanwhile, full coverage non-drug pain relief measures could be taken for procedures that are with scattered pain scores, and real-time pain evaluation should be provided to determine whether further drug analgesia is required.

Factors Affecting Child Injury Risk in Motor-Vehicle Crashes

Current recommendations for restraining child occupants are based on biomechanical testing and data from national and international field studies primarily conducted prior to 2011. We hypothesized that analysis to identify factors associated with pediatric injury in motor-vehicle crashes using a national database of more recent police-reported crashes in the United States involving children under age 13 where type of child restraint system (CRS) is recorded would support previous recommendations. Weighted data were extracted from the National Automotive Sampling System General Estimates System (NASS-GES) for crash years 2010 to 2015. Injury outcomes were grouped as CO (possible and no injury) or KAB (killed, incapacitating injury, nonincapacitating injury). Restraint was characterized as optimal, suboptimal, or unrestrained based on current best practice recommendations. Analysis used survey methods to identify factors associated with injury. Factors with significant effect on pediatric injury risk include restraint type, child age, driver injury, driver alcohol use, seating position, and crash direction. Compared to children using optimal restraint, unrestrained children have 4.9 (13-year-old) to 5.6 (< 1-year-old) times higher odds of injury, while suboptimally restrained children have 1.1 (13-year-old) to 1.9 (< 1-year-old) times higher odds of injury. As indicated by the differences in odds ratios, effects of restraint type attenuate with age. Results support current best practice recommendations to use each stage of child restraint (rear-facing CRS, forward-facing harnessed CRS, belt-positioning booster seat, lap and shoulder belt) as long as possible before switching to the next step.

Brain-oriented care in the NICU: a case study

With the advances of technology and treatment in the field of neonatal care, researchers can now study how the brains of preterm infants are different from full-term infants. The differences are significant, and the outcomes are poor overall for premature infants as a whole. Caregivers at the bedside must know that every interaction with the preterm infant affects brain development-it is critical to the developmental outcome of the infant. The idea of neuroprotection is not new to the medical field but is a fairly new idea to the NICU. Neuroprotection encompasses all interventions that promote normal development of the brain. The concept of brain-oriented care is a necessary extension of developmental care in the NICU. By following the journey of 26-week preterm twin infants through a case study, one can better understand the necessity of brain-oriented care at the bedside.

Pain Prevalence and Treatment Patterns in a US Children's Hospital

OBJECTIVE

Hospitalized children experience significant pain despite improvement efforts. This study was undertaken to better understand the epidemiology of acute pain in hospitalized children and the extent to which existing measures reveal targets for improving pain management.

METHODS

A cross-sectional survey was used to audit pain assessment, intensity, prevalence, source, and treatment hospital-wide on a single day in 2011. Chart audits were performed on patients aged 0 to 21 years. All patients had the option to participate in a structured interview about their pain experience.

RESULTS

The audit included 112 children, 47 of whom were interviewed. Pain prevalence obtained by child/parent interview (72%) was more than twice that documented by nurses (30%). Infants, but not cognitively impaired children, had significantly lower rates of pain detection and analgesic ordering than older age groups. Procedural pain was the most frequently cited source of pain among interviewed patients and was poorly addressed in the medical record. Fifty percent of children with documented moderate-to-severe pain received scheduled pain medications. More than one-third of interviewed patients would have wanted more pain medication if it could have been safely given.

CONCLUSIONS

Specific gaps remain in the quality of pain management provided to hospitalized children. Focus on infant pain detection, assessment and management of procedural pain, and scheduled analgesic ordering are sensible targets for future process improvement efforts.

Temporal trends in motor vehicle fatalities in the United States, 1968 to 2010 - a joinpoint regression analysis

Background

In the past 40 years, a variety of factors might have impacted motor vehicle (MV) fatality trends in the US, including public health policies, engineering innovations, trauma care improvements, etc. These factors varied in their timing across states/localities, and many were targeted at particular population subgroups. In order to identify and quantify differential rates of change over time and differences in trend patterns between population subgroups, this study employed a novel analytic method to assess temporal trends in MV fatalities between 1968 and 2010, by age group and sex.

Methods

Cause-specific MV fatality data from traffic injuries between 1968 and 2010, based on death certificates filed in the 50 states, and DC were obtained from Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). Long-term (1968 to 2010) and short-term (log-linear piecewise segments) trends in fatality rates were compared for males and females overall and in four separate age groups using joinpoint regression.

Results

MV fatalities declined on average by 2.4% per year in males and 2.2% per year in females between 1968 and 2010, with significant declines observed in all age groups and in both sexes. In males overall and those 25 to 64 years, sharp declines between 1968 and mid-to-late 1990s were followed by a stalling until the mid-2000s, but rates in females experienced a long-term steady decline of a lesser magnitude than males during this time. Trends in those aged <1 to 14 years and 15 to 24 years were mostly steady over time, but males had a larger decline than females in the latter age group between 1968 and the mid-2000s. In ages 65+, short-term trends were similar between sexes.

Conclusions

Despite significant long-term declines in MV fatalities, the application of Joinpoint Regression found that progress in young adult and middle-aged adult males stalled in recent decades and rates in males declined relatively more than in females in certain age groups. Future research is needed to establish the causes of these observed trends, including the potential role of contemporaneous MV-related policies and their repeal. Such research is needed in order to better inform the design and evaluation of future population interventions addressing MV fatalities nationally.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-015-0035-6) contains supplementary material, which is available to authorized users.

Stress and ano-colorectal surgery in newborn/infant: role of anesthesia

PURPOSE

The best anesthesia for newborns/infants necessitating colorectal surgery remains questionable. Endovenous and locoregional anesthesiological approaches were compared to determine the influence on stress response.

METHODS

Patients with anorectal malformations or Hirschsprung's disease were randomized to inhalatory/epidural anesthesia (IPA) or inhalatory/endovenous anesthesia (IEA). Heart rate, blood pressure, oxygen saturation, serum concentrations of dehydroepiandrosterone, cortisol, and glucose were recorded 24 h before operation (T0), after tracheal intubation (T1), 120 min after skin incision (T2), 60 min (T3) and 24 h after operation (T4).

RESULTS

Seventeen patients were enrolled in the study, 8 receiving IPA, and 9 IEA. Heart rate, blood pressure, oxygen saturation remained stable and normal, without statistical differences between the two groups, during the study period. Similar cortisol and glucose levels showed no statistical differences between groups. Dehydroepiandrosterone values were significantly higher in IEA during anesthesia (T1-T3) compared with IPA (T1: 494.0 vs. 266.5, p < 0.05; T2: 444.0 vs. 201.0, p < 0.05; T3: 385.0 vs. 305.0, p < 0.05).

CONCLUSION

This study suggests that epidural and endovenous anesthesia are both effective in intra- and postoperative period. This preliminary report suggests that IPA is more efficient compared to IEA in controlling stress reaction related to surgery. Further larger studies are needed to confirm these findings.

The importance of vehicle rollover as a field triage criterion

BACKGROUND

The objective of this article was to review the importance of vehicle rollover as a field triage criterion. In 1987, field triage criteria were developed by the American College of Surgeons Committee on Trauma that have been propagated repeatedly over the subsequent 20+ years. The field triage decision scheme is based on abnormal physiology, obvious abnormal anatomy, mechanism of injury likely to result in severe injury, and other factors (age, etc.) and was supported by available science at that time. In 2005, the triage scheme was revised by a committee, and vehicle rollover as a crash scene triage criterion was dropped in 2006.

METHODS

The medical literature and data from the Department of Transportation/National Highway Traffic Safety Administration (NHTSA) Fatal Accident Reporting System and the National Automotive Sampling System were analyzed to determine the contribution of rollover to morbidity and mortality.

RESULTS

Vehicle rollovers represent a small but significant percentage of crashes; of the almost 12 million vehicle crashes reported by NHTSA in 2004, only 2.4% were rollovers, but these accounted for one-third of all crash-related occupant deaths and about 25,000 serious injuries every year. Rollovers are associated with the second highest number of vehicle occupant deaths by crash mode, three times the risk of injury when compared with other impact directions (p < 0.0001), specific types of injury such as head and spinal cord injuries, and a risk of death >15 times the risk in nonrollover crashes.

CONCLUSION

The data and literature unequivocally show a strong and disproportionate association between vehicle rollover and injury severity and death. Because it is difficult to devise simple, accurate decision rules for point of wounding and vehicle crash scene triage, simple, powerful relationships should be used when possible. Thus, the exclusion of rollover as a triage criterion seems to be ill advised.

The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collisions: 1996 to 2005

OBJECTIVES

We estimated the effectiveness of child restraints in preventing death during motor vehicle collisions among children 3 years or younger.

METHODS

We conducted a matched cohort study using Fatality Analysis Reporting System data from 1996 to 2005. We estimated death risk ratios using conditional Poisson regression, bootstrapping, multiple imputation, and a sensitivity analysis of misclassification bias. We examined possible effect modification by selected factors.

RESULTS

The estimated death risk ratios comparing child safety seats with no restraint were 0.27 (95% confidence interval [CI] = 0.21, 0.34) for infants, 0.24 (95% CI = 0.19, 0.30) for children aged 1 year, 0.40 (95% CI = 0.32, 0.51) for those aged 2 years, and 0.41 (95% CI = 0.33, 0.52) for those aged 3 years. Estimated safety seat effectiveness was greater during rollover collisions, in rural environments, and in light trucks. We estimated seat belts to be as effective as safety seats in preventing death for children aged 2 and 3 years.

CONCLUSIONS

Child safety seats are highly effective in reducing the risk of death during severe traffic collisions and generally outperform seat belts. Parents should be encouraged to use child safety seats in favor of seat belts.

Fatalities of children 0-7 years old in the second row

OBJECTIVE

The safety of children riding in the second-row of light vehicles remains an important issue. This study investigates fatal accidents of children 0-7 years old by seating position and principal direction of force. It considers the number of fatalities, exposure, and risk.

METHODS

The 1996-2005 FARS was analyzed for occupant fatalities by age (0-7 and >or= 8 years old), seating position (front, second, and third-row, and left, middle and right) and principal direction of force (1-12 o'clock PDOF, rollover, and other/unknown). Light vehicles were included with model year 1990+. The 1996-2005 NASS-CDS was similarly analyzed for occupant exposure. Fatality risk was defined as the number of fatalities in FARS divided by the exposure from NASS-CDS for each seating position and crash direction.

RESULTS

Two thirds (67.8%) of 0-to 7-year-old child fatalities occupied second-row-seats in FARS. A nearly equal number died in rollovers (20.3%), front impacts (20.2%), and side crashes (19.6%). About 354 deaths occur to second-row-seated children annually. A majority (76.6%) of children ride in the second-row based on tow away crashes in NASS-CDS. Most are exposed to front impacts (41.6%), followed by side impacts (16.5%). Rollovers are the lowest frequency (5.0%). However, fatality risk is highest in rollovers (1.37%), followed by right-side (0.47%) and left-side impacts (0.34%). Near-seated children in the second-row have a 3.04% fatality risk for right-side (3 o'clock) impacts. This is nearly twice the 1.53% risk for near-side second-row children in left-side (9 o'clock) impacts. Overall, right-side impacts have a 37% higher fatality risk than left-side impacts, irrespective of second-row seating position. The second-row has a 43.4% lower fatality risk than the front seat (0.30% v 0.53%) and the third-row is 58.5% lower (0.22% v 0.53%) for 0-to 7-year-old children. Overall, children seated behind the driver have an 8.1% lower fatality risk than those seated behind the right-front passenger, although the center second-row-seat has the lowest risk (0.27%). Children in the second-row have a 65-71% lower fatality risk than the driver with the lowest relative risk in the center second-row-seat (0.29) and highest in the second-row right position (0.35).

CONCLUSIONS

Children seated behind the driver have a lower fatality risk than those seated behind the right-front passenger. The higher risk to right second-row children is from near-side impacts at 3-4 o'clock and rollovers. In terms of priorities, rollovers, side impacts, and frontal crashes cause most fatalities. The highest risks for 0-to 7-year-old children in the second-row are in near-side impacts and rollovers.

Prevalence and issues in non-use of safety belts and child restraints in a high-income developing country: lessons for the future

OBJECTIVE

In United Arab Emirates (UAE), a high-income developing country, safety belt (SB) legislation was implemented in 1998, covering only front-seated adults on highways outside cities. We assessed wearing of SBs after 5 years, together with use of safety restraints by rear passengers and children, perceptions about SBs, and use of tinted glass.

METHODS

A cross-sectional survey in 2003-2004 in Al Ain, population 400,000 and the main desert city of UAE, used random sampling of petrol stations; about 80% of UAE's population is non-citizens. Five of 30 stations were selected, including 3 different speed zones; vehicles with children were over-sampled. Drivers were interviewed by questionnaire. Use of safety restraints and presence of tinted glass were verified by observation. Confounding and correlation were assessed by stratification and logistic regression.

RESULTS

The sample included 500 vehicles, containing 959 adults and 876 children; 382 vehicles had children. SBs were used by 29% of drivers, 14% of front-seat and 2% of rear-seat adult passengers. 23% of children were in front; only 4% in front and 1% in the rear were restrained. SBs were worn by only 11% of UAE-citizen drivers and 10% of off-duty police and military. Odds ratio for non-use by citizens was 3.55 (95% CI 1.96-6.42). Use was greater among older drivers (p < 0.0005, X(2) trend). Reasons for non-use of SBs included discomfort 42%, forgetfulness 25%, uselessness 17%, carelessness 13%, and dangerous 3%. Among citizens, 15% believed SBs are dangerous. Tinted glass was present in 68% of vehicles.

CONCLUSIONS

SB legislation failed to protect the population, with low use of restraints by citizens, military, and police, and virtually none among children and rear passengers. Lessons include the necessity of drafting laws that provide comprehensive and effective protection, study of cultural constraints to compliance with injury prevention measures, and locally effective interventions to prepare citizens and enforcers for the expected new behaviour. Highly tinted glass is widespread and poses a barrier to enforcement.

Occupant dynamics in rollover crashes: influence of roof deformation and seat belt performance on probable spinal column injury

Motor vehicle crashes are the leading cause of death in the United States for people ages 3–33, and rollover crashes have a higher fatality rate than any other crash mode. At the request and under the sponsorship of Ford Motor Company, Autoliv conducted a series of dynamic rollover tests on Ford Explorer sport utility vehicles (SUV) during 1998 and 1999. Data from those tests were made available to the public and were analyzed in this study to investigate the magnitude of and the temporal relationship between roof deformation, lap–shoulder seat belt loads, and restrained anthropometric test dummy (ATD) neck loads.

During each of the three FMVSS 208 dolly rollover tests of Ford Explorer SUVs, the far-side, passenger ATDs exhibited peak neck compression and flexion loads, which indicated a probable spinal column injury in all three tests. In those same tests, the near-side, driver ATD neck loads never predicted a potential injury. In all three tests, objective roof/pillar deformation occurred prior to the occurrence of peak neck loads (F_z, M_y) for far-side, passenger ATDs, and peak neck loads were predictive of probable spinal column injury. The production lap and shoulder seat belts in the SUVs, which restrained both driver and passenger ATDs, consistently allowed ATD head contact with the roof while the roof was contacting the ground during this 1000 ms test series. Local peak neck forces and moments were noted each time the far-side, passenger ATD head contacted (“dived into”) the roof while the roof was in contact with the ground; however, the magnitude of these local peaks was only 2–13% of peak neck loads in all three tests. “Diving-type” neck loads were not predictive of injury for either driver or passenger ATD in any of the three tests.