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Amelia T. Collings, MD
Christina Georgeades, MD
Manzur Farazi, PhD
Mary E. Fallat, MD, FACS, FAAP
Peter C. Minneci, MD, MHSc, FACS, FAAP
K. Elizabeth Speck, MD, MS, FACS
Kyle Van Arendonk, MD, PhD, FACS
Katherine J. Deans, MD, MHSc, FACS, FAAP
Richard A. Falcone Jr., MD, MPH, MMM, FACS, FAAP
David S. Foley, MD, FACS, FAAP
Jason D. Fraser, MD, FACS, FAAP
Samir Gadepalli, MD, FACS, FAAP
Martin S. Keller, MD
Meera Kotagal, MD, MPH, FACS, FAAP
Matthew P. Landman, MD, FACS, FAAP
Charles M. Leys, MD, FACS
Troy A. Markel, MD, FACS, FAAP
Nathan Rubalcava, MD
Shawn D. St. Peter, MD, FACS, FAAP
Thomas T. Sato, MD, FACS, FAAP
Katherine T. Flynn-O’Brien, MD, MPH, FACS, FAAP

The COVID-19 pandemic disrupted social, political, and economic life across the world, shining a lens on the vulnerability of many communities. The objective of this study was to investigate the pediatric trauma experience of vulnerable populations, including those of minority race and lower socioeconomic status, during the COVID-19 pandemic.

A US-based multi-institutional, retrospective study was conducted evaluating patients <18 years old with traumatic injuries. “Historical” controls from an averaged period of March-September 2016-2019 were compared to patients injured after the implementation of regional stay-at-home orders through September 2020 (“COVID” cohort). The US census tract-based Social Vulnerability Index (SVI) is a measure of a community’s ability to function during a disaster. Minority race was defined as non-white. Differences in injury type, intent, and mechanism were explored based on race and SVI.

A total of 47,385 pediatric trauma patients met study inclusion. Overall pediatric trauma volume increased during the COVID cohort compared to the Historical cohort (Historical 5,891 patients vs. COVID 7,068 patients). During COVID, children of minority race experienced a significant increase in intentional injuries (COVID 17.7% vs. Historical 14.5%, p=0.02), while their white counterparts had no significant change (COVID 4.5% vs. Historical 5.4%, p = 0.06). Likewise, firearm-related injuries doubled in minority children (COVID 163 patients [10.0%] vs. Historical 80 patients [5.7%], p<0.001), but did not change in white children (p = 0.23). Children from the most vulnerable neighborhoods, as defined by the highest SVI quartile, had an 84% increase in penetrating injuries (p< 0.01), however there was no statistically significant change in penetrating injuries in the least vulnerable, or lowest SVI quartile, neighborhoods (p = 0.34). More specifically, during COVID, children from the most vulnerable neighborhoods also suffered an increase in firearm-related injuries (COVID 11.1% vs. Historical 6.1%, p=0.001) while children from the least vulnerable neighborhoods had no change (COVID 0.44% vs. Historical 0.66%, p = 0.60).

Injured children of minority race and higher SVI experienced a disproportionate increase in violence during the COVID-19 pandemic in the United States compared to white children and children from neighborhoods with lower SVI. The pandemic appeared to widen existing disparities. Addressing these disparities is essential to mitigate the impact of future pandemic effects on violent injury in minority children and vulnerable communities.

1. During COVID, children of minority race experienced a significant increase in intentional injuries, however there was no change among white children.
2. During COVID, firearm-related injuries doubled in minority children but did not change in white children.
3. During COVID, children from the most vulnerable neighborhoods had an increase in penetrating injuries, while there was no statistically significant change in penetrating injuries in the least vulnerable neighborhoods .

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Melissa Blumberg, MD
Wendy J. Pomerantz, MD, MS
Michael A. Gittelman, MD

During the COVID-19 pandemic, families increasingly turned to outdoor activities to socially distance. Recreational equipment sales rose significantly during this time. It is not clear how these changes impacted pediatric injuries. The objective of this study was to investigate changes in the incidence of pediatric emergency department (PED) visits related to outdoor recreational activities during the COVID-19 pandemic versus the preceding 5 years.

This was a single center, retrospective chart review study conducted at a large free standing children’s hospital with a level 1 trauma center. Data were obtained from the PED electronic medical records. Children 5-14 years old with a PED visit from March 23-September 1 in years 2015-2020 with an ICD-10 code for injury associated with recreation and the use of common outdoor recreational equipment (playgrounds, bicycles, ATVs/motorbikes, skateboards/scooters/roller skates/blades, trampolines, and watercraft) were included. Pandemic year, 2020, was compared with the average of pre-pandemic years (2015-2019). Data collected included patient demographics, injury, and disposition. Descriptive statistics were used characterize the population. Chi squared analysis and ANOVA were used to determine relationships between groups.

There were 29044 total injury visits during the study months of which 4712 (16.2%) were due to an included recreational injury. There was a higher proportion of visits related to recreational injury during COVID (8.2%) compared to before (4.9%). Of all study patients, 2771 (58.8%) were male, 3614 (76.6%) were white, 762 (16.2%) were black, 229 (4.9%) were Hispanic, 2668 (56.6%) had private insurance and 627 (13.3%) were admitted to the hospital. Before and during COVID, there were no differences in sex, ethnicity, or ED disposition. During COVID, there was a higher percentage of white patients and patients with commercial insurance injured. There was a significantly lower deprivation index of patients injured in recreation during COVID compared to the mean before COVID. The types of recreational equipment used were significantly different pre- and during COVID with more injuries due to bicycles, ATV/motorbike, wheeled vehicles and fewer due to playground equipment and watercraft during COVID. More injuries occurred in the home compared to at schools and daycares during COVID.

The COVID-19 pandemic has impacted pediatric recreational injuries. The increase in bicycle, ATV/motorbike, and non-motorized wheeled vehicle injuries is consistent with documented sale trends. Closure of parks and limited travel during this time likely contributed to the decrease in playground and water equipment injuries. The cost and access to recreational equipment may explain in higher injury rates in patients with commercial insurance and lower deprivation index during COVID. Further research is needed to determine future prevention efforts to curtail recreational injuries during a pandemic.

1.Demonstrate changes in the proportion and types of ED visits related to recreational injury before and during the pandemic. 2. Discuss the demographics of recreational injury during the pandemic. 3. Review socioeconomic factors that may affect injury patterns

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Tanya Charyk Stewart, MSc
Purnima Unni, MPH
Holly R. Hanson, MD, MS
Jason Gilliland, PhD
Andrew Clark, PhD
Douglas D. Fraser, MD, PhD

Declaring COVID-19 a pandemic on March 11, 2021 changed the world. Public health directives to stay at home, socially distance, and lockdown by restricting access to businesses, schools, and recreation facilities, fundamentally changed our exposure to injury risk factors, resulting patterns of injury, and conducting injury prevention (IP). The objective of this study was to determine the impact the COVID-19 pandemic on injury and its prevention at trauma centers in Canada and the United States.

A survey was created and pre-tested on the REDCap platform. Survey domains were: 1) IP initiatives; 2) injury data; 3) staffing and funding; 5) IP pandemic pivots; 6) facilitators and barriers; 7) training; and 8) demographics. The online survey was distributed through trauma/IP associations: Pediatric Trauma Society, Trauma Association of Canada, and Injury Free Coalition for Kids. An initial survey invitation and two email reminders were distributed to members. Descriptive statistics were calculated on responses.

A total of 59 responses were received from pediatric (43%), adult (12%), and combined (34%) trauma centers, from 22 states and 4 provinces. Most respondents were female (71%), in an IP Specialist role (68%), averaging 10.5 years IP experience. The majority (89%) of programs targeted age groups from birth to 15 years old. Nearly one-third reported IP to be less of an institutional priority with 18% of centers having funding changes [median -17% (-41, 8.5)], resulting in staffing changes at 37% of centers (36% redeployments and 15% terminations). IP efforts decreased at 63% trauma centers during the pandemic, particularly with in-person programs, including community events (-87%) and school-based programs (-83%). Overall, 85% of respondents reviewed injury data to keep current with changing injury epidemiology. The top reported increased mechanisms were mainly intentional: GSW (78%), abuse (73%), assaults (70%), and self-inflicted (70%). Leading increased unintentional injuries were home (65%), ATV (64%), and cycling (56%) injuries. Leading pivots and innovations were presenting (75%) or participating (73%) in IP education virtually, posting on social media (61%), adding technology (31%), and combining COVID-IP messaging (17%). Virtual programming was the leading training requested (77%). Top barriers to pivoting were redeployment of partners (46%) and staff (31%), as well as lack of technology (39%) in the target population. Facilitators were technology at trauma center (76%), support of trauma program (66%), and having IP funding maintained (58%).

Nearly two-thirds of trauma centers decreased IP efforts during the pandemic due to staffing and funding reductions. The leading increased injury mechanisms were intentional, so further intentional and violence prevention is needed, along with support for mental health. While trauma centers successfully pivoted by using technology and going virtual, access issues in the target population were a barrier resulting in health inequities. This needs addressing to be able to prevent injuries for all subpopulations equally.

1. Describe the impact of the COVID-19 pandemic on injury prevention staffing, funding and programming at trauma centers in Canada and the United States.
2. Quantify changes in injury epidemiology and injury prevention efforts during the COVID-19 pandemic.
3. Identify facilitators and barriers to pivoting injury prevention efforts due to the pandemic, as well as training opportunities for injury prevention practitioners.

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Malvi Mehta, BS
Michelle Ruda, MD
Sandra McKay, MD
Zoabe Hafeez, MD

During the shelter-in-place period of the COVID-19 pandemic, there was a perceived increase in emergency department (ED) visits and hospitalizations among the pediatric population in Houston. Using local data comparing ED visits before and during the pandemic, the frequencies of 5 different injury mechanisms were geographically mapped around the Houston area. After localizing certain injury mechanisms to specific regions of Houston via zip codes, a community-based injury prevention program was implemented with the goal of preventing pediatric mortality at a regional level. In January 2022, we were awarded a grant by the Texas Pediatric Society (TPS) to fund 4 types of injury prevention materials for community distribution.

The main injury mechanisms from ED data included burns, falls, motor vehicle/pedestrian injuries, firearm related injuries, and child abuse/neglect. Injury mechanisms were identified and separated by ICD-10 codes. Pre-pandemic data was from the January to September 2019 timeframe, while the pandemic data was collected from the same time period in 2020. After mapping the frequencies of different types of pediatric injuries based on zip code data, the top 3-5 zip codes with the highest number of injuries were identified in each injury mechanism category. Using grant funding, injury prevention materials were ordered for 4 injury categories. Water thermometers were ordered for burn prevention, baby gates for fall prevention, car seats for motor vehicle accidents, and firearm safety locks for prevention of accidental firearm injuries. In the top 3-5 zip codes for each injury category, several pediatrician’s practices were contacted in efforts to send them the relevant injury prevention materials for community distribution. Participating physicians were sent a pre and post survey to assess comfort level in addressing injury prevention topics as well as track the number of patients given materials during well child visits.

This community intervention project is ongoing; however, at this time 2 pediatrician’s practices have begun to participate in burn prevention and fall prevention by accepting materials to distribute to patients. With grant funding we were able to order 20 water thermometers, 10 baby gates, 10 firearm safety locks, and 5 car seats. Currently, primary care physicians are still being sought out for participation in firearm and motor vehicle injury prevention in the targeted zip codes for those injury types. Pre and post survey results are still in the process of being collected as well.

The goal of this project is to geographically target different types of injuries based on local ED data and implement community-based injury prevention via pediatrician’s practices. With the help of a grant, vulnerable populations of patients were identified in particular zip codes to receive relevant injury prevention materials from their primary care physicians. Although limitations of this project have proved to include lack of response from PCP offices and limited follow up with surveys, this could be overcome by contacting more offices in the targeted zip codes.

1. Discuss the utility of mapping in injury prevention efforts.
2. Outline a plan for targeting vulnerable patient populations at a community level within the scope of a large city.
3. Demonstrate how to identify specific injury mechanisms and advocate for prevention at a local level.

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Brent M. Troy, MD, MPH, FAAP
Kiesha Fraser Doh, MD
Allison Linden, MD, MPH
Yijin Xiang, MPH
Maneesha Agarwal, MD, FAAP

Unintentional injuries, including traumatic-brain-injuries (TBI), are the leading cause of pediatric morbidity and mortality in the United States. Helmet use in activities, such as bicycling, scootering, snow sports, skating, horseback riding, and all-terrain-vehicles (ATVs) riding, can reduce TBI incidence and severity. Epidemiology surrounding TBI and helmet use is ever-evolving, and changes may have been further accelerated by the COVID-19 pandemic that altered family lifestyles including access to resources, finances, family activities, and supervision of children; however, this has not been studied in-depth.

Utilizing the trauma registries from 2 large, metropolitan pediatric hospitals within a single healthcare system during 2018-2020, we retrospectively compared patients presenting with injuries sustained during activities where helmet use is recommended (AWHUR). AWHUR included mechanisms such as bicycling, ATVs, horseback riding, dirt-biking, skateboarding, skating, and snow sports. Inclusion criteria were patients aged 0 to 18 years old who met national trauma registry criteria and were injured while participating in AWHUR. Abstracted data included demographics, insurance status, activity type, helmet use, presence of head injury, and extent of head injury, including neurosurgical consultation. Data was analyzed for a 9.5-month period each year to compare the same period pre-COVID and in concordance with the statewide declared closure of schools and recreational facilities during the pandemic.

A total of 1093 patients presented with injuries from AWHUR over 3 years. AWHUR injuries increased annually from 263 patients in 2018 to 492 in 2020. The most frequently implicated mechanisms included bicycles (35.9%), ATVs (20.3%), skateboards (11.6%), scooters (8.3%), and dirt-bikes (7.4%). There was an increase in unhelmeted patients from 111 (58.7%) in 2018 to 258 (64.8%) in 2020. A significant increase in neurosurgical consultation was found from 17 (6.5%) patients in 2018 to 87 (17.7%) patients in 2020 (p=0.021). The proportion of patients who presented with head injuries and without wearing a helmet increased pre-pandemic to during the pandemic. Additionally, there was a notable increase in the percentage of patients with Medicaid presenting from AWHUR injuries during the pandemic from 104 (39.5%) in 2018 to 252 (51.2%) in 2020 (p< 0.001).

This study found an increase in patients presenting with injuries sustained whilst engaged in AWHUR in relation to the COVID pandemic. Concerningly, there was a trend towards decreased helmet utilization, increased associated head injuries, and increased neurosurgical consultations. There remains a critical need to improve helmet usage in AWHUR through helmet campaigns, due to the increase in the number of AWHUR injuries and decreased helmet usage during the pandemic. Further analysis is needed into the communities impacted by AWHUR related head injuries, from the pandemic, with focus on the increase in patients with Medicaid.

1. We found an increase in pedaitric AWHUR injuries during the pandemic as compared to previous years.
2. There has been a significant increase in neurosurgical consultation for pediatric AWHUR head injuries during the COVID-19 pandemic as compared to previous years.
3. A notable increase was seen in patients with Medicaid presenting with AWHUR injuries during the pandemic and the majority of them were not wearing a helmet.