Pediatric Appendicitis Practice Guidelines

Reena Blanco, MD
rnarwan@emory.edu

Alesia Fleming, MD, MPH
aflemi2@emory.edu

 

Acute appendicitis is the most common, non-traumatic surgical emergency encountered in children. Early identification can lead to timely removal preventing perforation and its complications.  Abdominal pain is a common symptom in the emergency department.  To help differentiate the surgical from medical emergencies, CHOA emergency medicine, surgery and radiology teams collaborated to develop the suspected appendicitis clinical guideline.

The broad goals of the team were to:

  • Identify children with the highest risk of appendicitis
  • decrease utilization of abdominal CT to diagnose appendicitis
  • Increase utilization of the Pediatric Appendicitis Score (PAS).
  • Streamline and standardize clinical evaluation
  • Decrease time to diagnosis and definitive care

 

The guideline was implemented in 2013 using the PAS as a common language tool to better communicate across services.  Patients 5 years and older with abdominal pain for less than 72 hours** suspected of having appendicitis are evaluated according to the pathway with screening labs, given an initial IV fluid bolus and pain medication.  After this, the PAS score is calculated and used to further guide care and communicate across services for next steps.

Patients with a PAS of 0-4 have a low suspicion for appendicitis. The physician should consider other diagnoses. There is always a risk that the patient may develop further symptoms as disease progresses therefore if discharged home, these patients need to be seen by their PCP within 24 hours for re-evaluation.

A PAS of 5-7 is equivocal for appendicitis and diagnostic imaging or surgical consult is warranted.  The guideline promotes US as the exam of choice for initial evaluation.  Ultrasound has a sensitivity is 98% and specificity is 92% in identifying appendicitis in those where the appendix was clearly seen. In addition to eliminating exposure to ionizing radiation ultrasound can evaluate female patients for ovarian torsion which is part of the differential of appendicitis.  The exact correlations between radiation exposure and cancer in children is not known, and utilizing alternative imaging modalities such as ultrasound limit exposure to ionizing radiation.

If the patient has a PAS >8 there is a high suspicion for appendicitis, imaging is not required, and surgery should be immediately consulted.

The guideline does not represent a professional care standard and physicians will need to be prudent in determining most appropriate care, but it does offer an approach to abdominal pain that should help with efficiency of care and ultimate outcome of our patients.

 

**exclusions outlined in clinical practice guidelines on md.choa.org under

clinical excellence->clinical practice guidelines

 

 

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Streptococcus Pharyngitis Q and A-Ask the Expert?

By Chris Van Beneden, MD MPH. GetSmart@cdc.gov

By Chris Van Beneden, MD MPH. GetSmart@cdc.gov

By Katherine Fleming-Dutra, MD GetSmart@cdc.gov

By Katherine Fleming-Dutra, MD GetSmart@cdc.gov

By Craig Shapiro, MD cshapi2@emory.edu

By Craig Shapiro, MD cshapi2@emory.edu

 

1. What are the different types of diseases that Group A strep causes?

Streptococcus pyogenes are gram-positive cocci that grow in chains. They are β -hemolytic, meaning that they exhibit a clear zone of hemolysis when grown on blood agar plates. They belong to group A in the Lancefield classification system for β-hemolytic Streptococcus, and thus are also called group A Streptococcus. Group A Streptococcus can cause a variety of infections, the most common of which is streptococcal pharyngitis or strep throat. Group A Streptococcus can also cause scarlet fever, skin infections like impetigo and cellulitis, non-suppurative complications of streptococcal infections such as acute rheumatic fever and post-streptococcal glomerulonephritis, and invasive diseases such as pneumonia, septic arthritis, septicemia, meningitis, necrotizing fasciitis, streptococcal toxic shock syndrome, and musculoskeletal and surgical wound infections.

2. What causes the rash of scarlet fever?

Scarlet fever, or scarlatina, is a strep infection that occurs with a characteristic scarlatiniform rash. The characteristic rash is red with fine papules (“sandpaper”), appearing initially on the trunk and spreading peripherally over hours to days to cover almost the entire body. Most often scarlet fever occurs with streptococcal pharyngitis but it can occur with streptococcal wound infections or impetigo. It is caused by a particular strain of group A Streptococcus that produces a pyrogenic exotoxin, which leads to the rash.

3. Should we treat patients just based on the scarlatiniform rash?

Because the differential diagnosis of scarlet fever includes viral pharyngitis with a viral exanthema and other mucocutaneous syndromes such as Kawasaki Disease and Stevens-Johnson syndrome (SJS), the diagnosis of scarlet fever should be confirmed with a rapid antigen detection test (i.e. rapid strep test) performed on a throat swab or throat culture prior to antibiotic treatment.

4. If a patient has a positive strep test, do we have to treat?

CDC encourages clinicians to follow the Infectious Diseases Society of America (IDSA) 2012 Clinical Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis. These are national, evidence-based recommendations regarding how to diagnose and treat streptococcal pharyngitis.

Streptococcal pharyngitis is usually self-limited, even if not treated with antibiotics. However, IDSA recommends treatment with antibiotics for patients with streptococcal pharyngitis because it speeds recovery, limits transmission of group A Streptococcus to others, and most importantly, decreases the risk of acute rheumatic fever and suppurative complications (e.g., peritonsillar abscess, mastoiditis).

It is important to emphasize that IDSA recommends treatment for patients with symptomatic streptococcal pharyngitis that has been confirmed to be due to group A Streptococcus using a positive rapid antigen detection test (also called a rapid strep test) or throat culture. This is because asymptomatic colonization with group A Streptococcus is very common. In the winter, as many as 20% (1 in 5) of children can be asymptomatically colonized in the oropharynx with group A Streptococcus and will test positive by rapid strep test or throat culture. However, children with asymptomatic colonization typically do not need antibiotic treatment; these children do not have symptoms, are much less likely to transmit group A Streptococcus to others, and are very unlikely to develop suppurative or nonsuppurative complications, such as acute rheumatic fever.

A rapid strep test or throat culture should only be performed in children who have signs and symptoms of streptococcal pharyngitis. Because colonization is common, testing children who do not have signs and symptoms of strep throat leads to many false positives and unnecessary antibiotic use. IDSA states that patients with clear viral symptoms—including cough, runny nose, hoarseness, oral ulcers, conjunctivitis—do not need to be tested for group A Streptococcus because these are symptoms of viral pharyngitis.

Antibiotics have risks too—including allergies, side effects, and promotion of antibiotic resistance. Correctly selecting the patients who need a strep test can help us protect our patients from avoidable adverse drug events and antibiotic resistance.

5. Some children keep getting recurrent streptococcal pharyngitis. Why is that?

It is not uncommon to see a child several times a year with sore throat and positive test results for group A Streptococcus. Many children who appear to have recurrent streptococcal pharyngitis actually have recurrent episodes of viral pharyngitis and are asymptomatically colonized with group A Streptococcus. They test positive for group A Streptococcus because they are colonized. Repeated antibiotic treatment in these children is unnecessary because they are less likely to transmit group A Streptococcus to others and are very unlikely to develop complications. However, identifying carriers can be difficult. How to determine whether someone is a carrier is addressed in the Infectious Diseases Society of America guidelines and the Red Book.

6. What are the signs/symptoms of group A Streptococcus infection?

The main signs and symptoms of streptococcal pharyngitis are sore throat with a sudden onset, pain with swallowing, and fever. Streptococcal pharyngitis also commonly presents with patchy exudates on the tonsils and anterior cervical lymphadenopathy. Streptococcal pharyngitis may include headache, abdominal pain and vomiting, but these symptoms occur in the presence of sore throat symptoms.

Streptococcal pharyngitis does not cause cough, runny nose, hoarseness, oral ulcers or conjunctivitis. These are symptoms that more commonly occur with viral pharyngitis, and therefore neither strep testing nor antibiotics are needed for patients with these symptoms.

7. What ages commonly get strep pharyngitis?

Streptococcal pharyngitis is most common among children 5 to 15 years of age, but it can occur in adults. It is very rare in children younger than 3 years of age, as streptococcal disease in children less than 3 years of age rarely manifests as pharyngitis. Instead, young children with group A Streptococcus infection may get a mucopurulent rhinitis associated with fever, irritability, and poor appetite.

8. Which ages groups should be tested for strep pharyngitis?

Streptococcal pharyngitis is most common among children 5 through 15 years of age. Because children less than 3 years of age rarely get streptococcal pharyngitis and acute rheumatic fever is very rare in children less than 3 years, IDSA guidelines recommend against routinely testing children less than 3 years of age for streptococcal pharyngitis, as this may lead to false-positive tests and unnecessary antibiotic use. In select symptomatic children less than 3 years of age who have other risk factors for GAS pharyngitis, such as children who have an older sibling with confirmed streptococcal pharyngitis, IDSA guidelines state that testing can be considered.

9. What is the risk of scarlet fever in adults?

Scarlet fever can occur in adults if infected with the strain of group A Streptococcus that produces a pyrogenic exotoxin. However, scarlet fever is most common in children 5 to 15 years of age.

10. Is there any benefit to treating patients <2 years old?

The vast majority of children less than 3 years of age should not be tested for streptococcal pharyngitis, as this can lead to false-positive tests and unnecessary antibiotic use. In select children less than 3 years of age, such as symptomatic children who have an older sibling with confirmed streptococcal pharyngitis, IDSA guidelines state that testing can be considered.

11. When do you treat asymptomatic siblings of a child with a positive strep test? Is there a lower age limit for that? (I.e. would you treat a 6 month-old who’s 4 yea- old sibling has strep?)

IDSA guidelines specifically recommend against streptococcal testing or treating asymptomatic household contacts of patients with streptococcal pharyngitis. One-third of household contacts of children with streptococcal pharyngitis will become symptomatic, in which case testing and treatment is indicated. However, studies have shown that treating asymptomatic household contacts with penicillin is not effective at preventing them from later developing symptomatic streptococcal pharyngitis. Treating asymptomatic household contacts needlessly exposes them to the risks of antibiotics without benefiting them.

12. Is there a website/poster that is available from the CDC that we can share with our colleagues or patient families?

For more information about group A Streptococcus, please visit: http://www.cdc.gov/groupastrep/diseases-public/index.html

For more information about appropriate antibiotic use and the Get Smart: Know When Antibiotics Work Program, please visit: http://www.cdc.gov/getsmart/ Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86–102.

Committee on Infectious Diseases. Group A streptococcal infections. In Kimberlin DW, Brady MT, Jackson MA, Long SS, editors. 30th ed. Red Book: 2015 Report of the Committee on Infectious Diseases. Elk Grove Village (IL): American Academy of Pediatrics; 2015:732–44.

Questions answered by: Katherine Fleming-Dutra, MD, Craig Shapiro, MD, and Chris Van Beneden, MD MPH.

Dr. Fleming-Dutra is a pediatric emergency physician with the Get Smart: Know When Antibiotics Program in the Office of Antibiotic Stewardship at the Centers for Disease Control and Prevention (CDC). Dr. Shapiro is pediatric infectious diseases physician and director of the Antibiotic Stewardship Program at Children’s Healthcare of Atlanta. Dr. Van Beneden is a medical epidemiologist and expert on group A Streptococcus in the Respiratory Diseases Branch in the Division of Bacterial Diseases at CDC.

CHOA Heavy Menstrual Bleeding Guideline

By Amy Pattishall apattis@emory.edu

By Amy Pattishall
apattis@emory.edu

 

Heavy Menstrual Bleeding Guideline

Children’s Healthcare of Atlanta Emergency Department (ED) implemented one of its newest guidelines, for Heavy Menstrual Bleeding (HMB), in August 2016. This guideline represents a collaboration of several specialties, including Pediatric Emergency Medicine, Urgent Care, Hematology, Adolescent Medicine and Gynecology, with the goals of:

* Establishing a uniform process for evaluation and management of adolescents with HMB

* Reducing repeat visits to the ED for the same concern

* Expediting diagnosis of congenital bleeding disorders

* Improving the quality of life for adolescents experiencing HMB

* Providing improved opportunities for adolescent and gynecology follow up care

Why is such a guideline necessary?

Many adolescents with HMB present to the ED for evaluation, whether they are symptomatic or not. Evidence shows that patients presenting with HMB receive variable workups, potentially delaying diagnosis of bleeding disorders. This guideline helps to ensure that all adolescents at risk for a bleeding disorder receive appropriate laboratory evaluation and follow up with hematology or gynecology. HMB can also cause chronic iron deficiency anemia and affect adolescents’ quality of life. We hope the guideline will help improve patients’ quality of life by standardizing treatment for HMB.

Which patients are included in the guideline?

Any menstruating female with concern for HMB meets inclusion criteria. Patients with previously diagnosed bleeding disorders are excluded. The guideline incorporates an evidence-based screening tool to determine if laboratory workup for a congenital bleeding disorder is necessary, which is considered positive if the patient answers “yes” to any of the screening questions.

Screening Questions (Adapted from Claire Phillip Screening tool; AMJOG 2011):

1. On average does your period last 7 or more days?

2. Do you experience “flooding” or overflow bleeding through your tampon or pad?

3. Do you need to change your pad or tampon more than every 1-2 hours at times during your period?

4. Have you ever been treated (PO iron, IV iron, blood transfusions) for iron deficiency anemia in the past?

5. Do you have a family history of a bleeding disorder?

6. Have you had excessive bleeding with a dental extraction or dental surgery?

7. Have you had excessive bleeding with a miscarriage or following delivery of a child?

How do providers use the guideline?

The guideline stratifies patients based on severity of anemia and symptoms to help determine need for admission and IV versus oral medications. Recommendations on hormone and adjunct treatment (iron, anti-emetics, stool softeners) are included, as well as contact numbers for follow up at Emory Fellows’ Family Planning/Gynecology clinic, the Adolescent Medicine clinic at Hughes Spalding, and the CHOA Hematology clinic.

The HMB guideline, along with the full evidence summary, can be accessed on the CHOA Physician Portal: md.choa.org.

For Bronchiolitis, Less is More

 

By Shabnam Jain sjain@emory.edu

By Shabnam Jain
sjain@emory.edu

 

Bronchiolitis is a self-limited, viral lower respiratory tract infection that affects infants and young children.  It is the most common cause of hospital admission in infants in the US. In 2014, the American Academy of Pediatrics published a clinical practice guideline (CPG) entitled The Diagnosis, Management, and Prevention of Bronchiolitis.(1)   The CPG excludes infants under 1 month of age, those with hemodynamically significant cardiac disease, significant pulmonary disease, or major chronic conditions. Based on this CPG, in 2015 the AAP Section on Emergency Medicine developed a clinical algorithm for bronchiolitis in the ED setting, addressing some newer therapies that can be considered in severe or undifferentiated presentations. (2) It also offers criteria for which patients can be discharged from the ED and may be helpful for primary care providers in making decisions on whom to refer to the ED. Children’s Healthcare of Atlanta has its own guidelines as well. (3)  These resources may be useful for the generally healthy infant with bronchiolitis with the following recommendations applicable to pediatric outpatient practice:

 

  1. Diagnosis and severity assessment is made on the basis of history and physical exam and assessment of risk factors. Routine chest X-rays and RSV testing are not recommended. 
  2. Management: Albuterol may improve respiratory score (subjective), but has no effect on clinical course, disease resolution, admission, or length of stay.  It does however, increase adverse effects (tremors, tachycardia) which outweighs any small potential benefits. Albuterol is not recommended for routine use in bronchiolitis.  Furthermore, there is no benefit from routine use of epinephrine in inpatients or outpatient settings. Epinephrine may be used as a rescue agent in severe disease.  Finally, steroids have no role in the management of bronchiolitis.
  3. Oxygen and Pulse oximetry: There is poor correlation between respiratory distress and oxygen sats.  Transient hypoxemia is common in bronchiolitis; pulse oximetry has been associated with perceived need for admission and is a primary determinant of inpatient LOS. Providers may choose not to give O2 if sats >90%  and may choose not to use continuous pulse oximetry
  4. Antibiotics are not indicated unless there is a concomitant bacterial infection.

 

Patients who meet the following are generally considered appropriate for discharge home:

  • Room air sats consistently ≥ 90% while awake or >88% while asleep
  • Able to handle secretions or need bulb suctioning only
  • Adequate activity & hydration
  • Parents able to follow-up with PCP within 48 hours or access emergency care if needed

 

For the previously healthy, mild to moderate bronchiolitis patient, the current strategy is: Don’t just do something, stand there!

 

  1. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502 – October 01, 2015.    http://pediatrics.aappublications.org/content/134/5/e1474
  2. Jain S, Stack A, Baskin M, et al. Clinical Algorithm for Bronchiolitis in the Emergency Department Setting    http://www2.aap.org/sections/pem/PDF/AAPSOEMCOQTBronchiolitisGuideline.pdf
  3. Children’s Healthcare of Atlanta (Clinical Excellence page). https://md.choa.org/clinical-excellence/clinical-practice-guidelines/bronchiolitis

Fever, Viral Symptoms and Testing for Viruses

 

Burgerpic

by Becky Burger, MD

BeckyBurger@emory.edu

As we approach respiratory viral season, we wanted to share our emergency department guideline for performing viral testing via the Respiratory Viral Panel (RVP) test. The RVP is a nasal swab test that detects viruses including influenza, RSV, and several other viruses. The turnaround time for the RVP result is between one and three hours. We have found that these tests sometimes delay disposition and often don’t change management of the patient in the ED. Our quality improvement committee developed the guidance below to optimize RVP testing in the ED.   Please note that we do not perform the new molecular rapid influenza test in the emergency departments at Children’s.

For ED patients being discharged home:

  • RVP usually not indicatedHealthy patients with viral symptoms.   This is because of the following reasons:
  • Prolonged positivity of RVPs from prior illnesses (unrelated to current symptoms)
  • Multiple positives
  • False sense of security
  • Management can usually be based on clinical grounds (e.g. treating influenza in high-flu season)
  • RVP may be done on a case-by-case basisPatients with underlying chronic medical condition, or patients in the age range 4-8 week old with fever etc. where a positive test may change management– in such instances, RVP is helpful only if we wait for result of the test for further decision making such as extent of work up, admission vs. discharge, etc.

For ED patients who require admission:

  • RVP indicatedImmunocompromised patients (such as transplants and certain chronic medical conditions) and other patients at high risk for complications of infection.
  • RVP usually not necessaryImmunocompetent patients (with or without chronic medical problems) – inpatient team may choose to order it themselves if desired.
  • All inpatient rooms at Children’s are private rooms so we don’t need to use RVPs for cohorting purposes.  Also, all respiratory illness patients need appropriate infection control precautions regardless of the result of the RVP.

We do not recommend referral to the emergency department just for RVP testing in well appearing children who have symptoms consistent with viral respiratory infection. For patients with symptoms concerning for influenza who are at higher risk (based on age, severity, or underlying medical conditions), treatment with antiviral medications can be started without the need for lab confirmation of influenza, (particularly during high flu prevalence).

If you have any questions about RVP testing, feel free to contact: Becky Burger, MD, BeckyBurger@emory.edu

Zika virus: Overview and Testing

jbpic

By Jacob Beniflah

jacob.beniflah@emory.edu

By now you have undoubtedly heard from both patients and the media about Zika virus. The information out there can be confusing and contradictory. With the help of the CDC, we will give a general overview.

Zika virus is spread primarily by the Aedes species mosquito which is mostly a daytime biter but also bites at night. Active Zika virus transmission has been confirmed in all of North America (except Canada), Central America, South America and the Caribbean. The US has, as of 8/31, reported 35 locally spread cases (all in 2 areas of Miami-Dade country) and 2686 travel-associated cases.

Infection with Zika virus can be completely asymptomatic. If a patient shows symptoms they are usually mild and include fever, rash, joint pain, conjunctivitis, muscle pain, and headaches. Most people will only have symptoms for a few days to a week. Long term effects include a known risk of birth defects. Currently, a strong association between Guillain-Barre and Zika virus is being researched but nothing is conclusive yet.

Zika virus should be suspected in an infant or child who has traveled or lived in an affected area within the past 2 weeks and have 2 or more of the following: fever, rash, conjunctivitis, or arthralgia.

Testing at this time is only done thru the Georgia Department of Health (GDH). CHOA does not do in-house testing and will send samples to the GDH. A provider wishing to send testing must first call the GDH’s Epidemiology section for an approval code. During the day call 404-657-2588 or after-hours at 770-578-4104.

There is no current treatment for Zika. Treatment is with standard supportive care but the CDC recommends avoiding NSAIDs such as aspirin or ibuprofen until Dengue has been ruled out.

 

 

 

 

 

 

Kids shooting kids: Today’s reality and empowering parents with the ASK campaign

scpic

by Sofia Chaudhary

schaud3@emory.edu

A 2-year old child has wandered into his parent’s bedroom and found an unlocked, loaded gun hidden in the top nightstand drawer.  Seconds later a shot is fired and the parent runs into the room to find their child lifeless.  As pediatricians we have all heard or encountered a similar story- all involving a child having access to an unlocked, loaded firearm.  According to the American Academy of Pediatrics, around 40% of homes with children in the US have a gun with an average of one child under age 10 being killed or disabled by a gun every other day (Pediatrics 2016-1).  In 2014 firearm injury was the 2nd leading cause of injury death in ages 15-19, 4th leading cause for ages 5-9 and 10-14, and 8th leading cause for ages 1-4 (CDC-2016-2).  Although mortality rates are high there is a larger rapid rise of unintentional pediatric injuries from firearms.  In a study reviewing an 8-month period of US pediatric firearm related injuries in 2014: two thirds were non-fatal, 50% of the victims were younger than 13 years of age, 25.3% younger than age 7, 84.3% were the child victims themselves or a family member/friend.  Of note 77% of events took place at the residence and 68% of the families  were the gun owners (J. Trauma Acute Care Surg. 2015-3).

Perhaps the most chilling recent headline from the Washington Post stated “Toddlers have shot at least 23 people this year.” Georgia was the top state with 8 listed self-inflicted shooting, with children ages 2 to 3 with hand guns all found within the home, parental purse, or vehicle (Washington Post-2016-4).  Many non-gun owner caregivers are not aware that there is indeed an accessible and loaded firearm in their home. In 2000, a study in Pediatrics found that in gun-owning homes with children, non-gun owners (87% women) reported significantly lower rates of a gun being stored loaded (7%) and unlocked (2%) in comparison to gun owners (21% loaded, 9% unlocked).  Those with a handgun were more likely to store it loaded and unlocked (Pediatrics-1999-5).  Parental perception of their child’s potential behavior around a firearm is also misleading.  In a survey published in Pediatrics 52% of the parent gun owners stored their firearms loaded or unlocked of which 75% believed that their 4 to 12-year-old child would be able to tell the difference between a toy gun and a real gun, and 23% thought that their child could be trusted with a loaded gun (Brady Center 2016-6)

In the US today 1.7 million children and teens live in a home with a loaded and unlocked gun (AAP-2016-7). One in every 25 admissions to pediatric trauma centers is due to a gunshot wound with major urban trauma centers reporting an increase of 300 percent in the number of pediatric gunshot wounds treated (AAP-2016-8).  Despite this national public health crises, in 2004 Congress banned the CDC from continuing gun violence related research and in 2011 the state of Florida passed a Privacy of Firearm Owners Act prohibiting pediatricians from asking patients and families about firearms in the home-this is currently under review and being appealed later this month.  As pediatricians our first priority is in providing developmentally appropriate advice on how parents can keep their child healthy and safe.  These safety measures include keeping medications out of reach, using appropriate car passenger seats according to age, vaccinating their children, wearing protective helmets when riding wheeled objects, and keeping guns locked and out of reach with the ammunition stored separately.   An AAP policy statement from 2012 reiterates the safest measure to prevent firearm related injuries being the absence of guns from homes and that pediatrician counseling on safe gun storage practices has shown significant reduction in injury. On June 21st the AAP is joining the Brady Campaign and asking parents to ASK (Asking Saves Kids) to save lives.  This campaign is asking parents to ask if there is an unlocked gun where their child plays.  It is encouraging parents to ask these questions as they would discuss other topics for a playdate such as supervision, TV/internet access, or food allergies.  I encourage each and every one of you to not only continue to ASK your patient’s families about firearm storage practices in their homes but also that they in turn ASK their kid’s playmates.

For more information for parents on firearm safety please visit: healthychildren.org

 

References:

  1. American Academy of Pediatrics. Reduce the Risk of Gun Injury. Available at: https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Reduce-the-Risk-of-Gun-Injury.aspx Accessed: April 27, 2016.
  2. WISQARS. Center for Disease Control. Injury Prevention and Control: National Center for Health Statistics (NCHS), National Vital Statistics System. 10 Leading Causes of Injury Deaths by Age Group Highlighting Violence- Related Injury Deaths, United States- 2014. Available at: http://www.cdc.gov/injury/images/lc-charts/leading_causes_of_injury_deaths_violence_2014_1040w760h.gif Accessed: June 1, 2016.
  3.  Faulkenberry J, Schaechter J. Reporting on pediatric unintentional firearm injury-Who’s responsible.  J. Trauma Acute Care Surg. 2015 79 (3): S2-S8.
  4. The Washington Post. Toddlers have shot at least 23 people this year. Posted May 1, 2016. Available at: https://www.washingtonpost.com/news/wonk/wp/2016/05/01/toddlers-have-shot-at-least-23-people-this-year/  Accessed: May 27, 2016.Azrael D, Miller M, Hemenway D.  Are Household Firearms Stored Safely? It Depends on Whom You Ask. Pediatrics. 2000; 106 (3).
  5. Farah M, Simon H, Kellerman A. Firearm in the Home: Parental Perceptions. Pediatrics. 1999; 104 (5): 1059-1063.
  6. Brady Center to Prevent Gun Violence. Keeping Kids and Families Safe. Available at: http://www.bradycampaign.org/our-impact/campaigns/keep-kids-and-families-safe Accessed: March 27, 2016. 
  7. American Academy of Pediatrics. Handguns in the Home. Available at https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Handguns-in-the-Home.aspx. Accessed: May 27, 2016.
  8. American Academy of Pediatrics. Council on Injury, Violence, and Poison Prevention Executive Committee. AAP policy statement.  Firearm-related injuries affecting the pediatric population. November 2012; 130 (5)