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Dana Eyerly, MD
Alicia Webb, MD
William King, Dr. PH
Michele Nichols, MD
Kathy Monroe, MD, MSQI

Drowning is a leading cause of injury death in children ages 1-4 years. However, few studies report on the descriptive epidemiology of childhood drowning changes during the COVID epidemic. Our objective was to describe the epidemiology of state reported child drownings in the pre, peri and post COVID periods. One of our research hypotheses was that Alabama’s statewide stay-at-home order (during COVID) resulted in a significant decrease in the numbers of drownings reported compared to other years.

Death records were obtained from the Alabama Department of Public Health for drownings during the years 2016-2021, for children ages 0-17 years old in Alabama. We labeled three time periods: 2016-2019 as pre-COVID, 2020 as peri-COVID and 2021 as the post-COVID period. Numbers of drownings and other key demographics were compared between the three study periods. State reported drownings were provided as an Excel file. Basic descriptive analyses were performed using Excel and Epi Info Version 7.1, (CDC). Year to year comparisons in the numbers of drownings were evaluated statically using the Poisson test of counts. Median age differences by location of drowning were compared using the Kruskal Wallis ANOVA and Dunn’s post hoc multiple comparison tests.

There were a total of 104 drowning fatalities reported, with 84 drownings in the pre-COVID era, 6 in peri-COVID and 14 post-COVID. The peri-COVID year had significantly lower numbers of reported drownings (p=0.003) compared to all other years. Median age was found to be higher among “Open Water/ Pond” drowning victims compared to those drowning in “Bath Tub” (p<0.0001) and “Pool, Hot Tub, Spa” (p=0.001). Pre-COVID, 52% of drownings were in children ages 1-4 years old, while there were not any drownings in children ages 1-4 years peri-COVID. 60% of drownings occurred in open water for the peri-COVID era as opposed to 33% pre-COVID and 38% post-COVID.

Pre-COVID, pools were the setting for the most drownings in children ages 0-17 years old in the state of Alabama. We theorize that social gathering restrictions peri-COIVD led to less pool parties at homes and the closing of public pools, decreasing potential drowning settings. Rate of drownings began increasing again in the post-COVID era, likely due to the openings of public pools and social gatherings. It is unusual that the drownings of children ages 1-4 years were so significant pre-COVID, but much less of a statement in the other two periods. This again may be because the closure of pools and less social gatherings around pools, reducing the number of toddlers who cannot swim around water.

1) Recognize that there were significant changes in the rate of fatal drownings for children during COVID
2) Compare the differences in drowning demographics, such as race, age, gender, location among the three COVID eras studied
3) Understand how stay-at-home may have played a role in drowning rates during COVID

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Colin Eaton, BS
Brittny Flynn, BS
Jasmine Curry, MD
Ben Hoffman, MD

Unintentional injuries remain the leading cause of death for children aged 1-18 years old, and drowning remains a major cause of preventable mortality. Data from the CDC demonstrates that Oregon children die from drowning at a higher rate than the national average, and significantly more than children and youth in the neighboring states of Washington (42% higher rate) and California (72% higher rate). Objective existing data sources lack the epidemiologic and demographic information necessary to inform drowning prevention efforts. We utilized media reports of child drowning events to provide that critical information.

We identified all drowning deaths for children and youth 0-17 years of age from the Oregon Bureau of Vital Statistics for the years 2006-2020. We then performed internet searches, using publicly available media reports, obituaries, and other items regarding each death to categorize each death by age, location, and type of water.

There were 171 unintentional pediatric drowning victims identified during the period examined. 134 (78%) had publicly available information that allowed us to characterize epidemiologic factors. Most pediatric drowning deaths occurred in natural water on public lands (61%overall, 85% for ages 4-17). Males drowned at a higher rate than females, approximately 3:1. The highest overall drowning rates occurred in children aged 0-4 years old, consistent with national trends. While most occurred on private property, almost half were associated with natural water and not swimming pools. Children of color drown at almost twice the rate of non-Hispanic white children (RR 1.927) in natural water on public lands. Between 6% and 20% of drownings may have been prevented with PFD use.

We employed media and other publicly available resources to identify key demographic and epidemiologic factors associated with drowning for children ages 0-17 in Oregon. Natural water, on both private and public land, poses the greatest risk, and children of color bear a higher burden of drowning mortality. Efforts to prevent drowning in Oregon must focus on ensuring access to multiple layers of protection, including water competence training and PFD use, and must incorporate community-based approaches to addressing equity and disparity. These findings will be used to inform community and policy initiatives to decrease drowning rates. Further research and epidemiologic tools should be used to help identify and address the disparities among drownings in children of color and other minority groups.

1. Oregon children suffer from higher rates of drowning as compared to neighboring states, particularly children of color are at disproportionately increased risk.
2. The majority of drownings occur in natural water on public lands, part of which could have been prevented with the use of a personal flotation device.
3. This data should be used to guide future policy initiatives to ensure the safety of children engaging in water activities.

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Cassandia Poteau, MS, CPST, CHES
Barbara DiGirolamo, M.Ed., CPSTI
Deirdre Walsh, BA

Hospital-based child passenger safety (CPS) technicians are an excellent source of information and can provide child safety seats (CSS) to those in need. However, their availability may be limited due to competing demands. With the increasing community demands on technicians, the CPS Nurse Champion program was created to provide education and training to nurses to increase their knowledge and level of skill in handling car seat consults. We classify this group of staff nurses interested in obtaining CPS education and training and/or who have completed their training as "CPS Champions". They are present to provide information and seats when the CPS technicians are unavailable.

Members of the Injury Prevention (IPP) and Surgical Nursing Programs created the Child Passenger Safety Nurse Champion Program to achieve CPS competency for nurses. The course is comprised of a lecture component and a hands-on component. Participants rotated through three different one-hour breakout sessions: 1) Traditional car seats 2) Infant car seat and Dream ride car beds 3) Modified EZ-On vest. Instructors evaluated whether or not the nurses met the core competency standards for each seat/bed. Participants completed a program evaluation at the end of the course. It is important to note that the CPS Nurse Champion program and the Infant Tolerance Screening are two different forms of nursing education.

Following the implementation of the CPS Nurse Champion program, there was an increase in nurses requesting car seats for their patients without consultation from hospital-based CPS technicians. There was little change between 2019 (total request of 166) and 2020 (total request of 167) due to the COVID-19 pandemic. In a post-COVID era, the request for car seats by nurses has risen each year, with 2022 seeing the highest request at 413.

The creation of the CPS nurse champion program is an essential education portion for nurses working in the field of pediatrics. Child passenger safety is a crucial piece to consider when caring for a child at a pediatric hospital as care and safety should always be the top priority. Since CPS technicians are not available 24/7, it is ideal to have nurses trained in CPS education, so families can receive assistance when a CPS technician is not available. The nurses can rely on their knowledge and skills to help families get the proper car seat for their children. However, nurses are still able to connect with CPS technicians if they encounter a child that may need a specialty restraint.

1. There has been an increase in car seat distribution during the hospital’s off hours.
2. Child passenger safety technicians have experienced a reduction in pages of non-complex patients needing car seats.
3. Child passenger safety champions continue to contact hospital-based CPS techs for assistance with complex patients.

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Dina Burstein, MD, MPH
Robert Sege, MD, PhD
Joachim Hero, PhD

Children’s brain growth and cognitive development is influenced by adverse and positive experiences. The original adverse childhood experiences (ACEs) study was published more than two decades ago, therefore there is a need to update the original formulation. This study was undertaken to explore the evidence for categories of ACEs not included in the original study, and for positive childhood experiences (PCEs) that promote optimal development and mitigate the adverse outcomes associated with ACEs. We report the results of a scoping review of the literature on original ACEs, possible expanded ACEs (ExACEs), PCEs and their effects on health outcomes. This scoping review describes the available literature with the goal of identifying gaps and preparing for systematic literature reviews.

We conducted a systematic scoping review according to PRISMA standards: bibliographic review across multiple databases, screening of titles and abstracts to eliminate irrelevant articles, full text screening to identify relevant articles, data abstraction, analysis and reporting. Scoping reviews do not include an assessment of data quality. This study included only English language reports of studies conducted in the United States that reported associations between exposures and outcomes published in 2014 or later. Studies of people from other countries and prevalence studies were excluded.

Over 23,000 articles were screened; 4,048 original ACEs, 6,617 ExACEs, and 8,919 PCEs. Only systematic reviews were considered for the original ACEs. Nineteen studies were included, and these reported 33 associations with abuse, 11 with family factors, and 7 with neglect. Few studies looked at physical health outcomes. Fifty-one original reports related to ExACEs were included. Exposures included bullying, discrimination, exposure to violence, and harsh parenting. Mental health outcomes were most commonly reported for ACEs and ExACEs.

A total of 220 original articles concerning PCEs were included. Analytic categories were based on the HOPE (Healthy Outcomes from Positive Experience) framework, categorized as relating to environment, relationships, and social engagement. The largest volume of literature related to caregiver relationships, school environment, and opportunities for community and spiritual engagement. Much of the data was derived from a small number of surveys. PCEs were inconsistently defined.

Since 2014, many studies published in peer-reviewed journal articles have examined the roles of adverse experiences, beyond the original ACEs, and positive childhood experience. Relatively few studies investigated associations between childhood experiences and physical health outcomes. Further systematic reviews are needed to better understand the health effects of the original ACEs, to explore the inclusion of discrimination, harsh parenting, and violence exposure as ExACEs, and PCEs on their own and co-occurring with ACEs.

1. Understanding of the quantity and focus of literature investigating health effects of original ACEs, ExACEs and PCEs.
2. Identify gaps in current body of research.
3. Identify potential ExACEs.

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Kristyn Jeffries, MD, MPH
Sara Sanders, MD
Brittany Slagle, DO
Charalene Fisher, MD
Dustin Williford, MD
Jacob Filipek, MD
Maxwell Taylor, MD
Rachel Ekdahl, MD
Rebecca Cantu, MD, MPH

Nearly 5000 snake bite injuries are reported to United States (U.S.) poison centers annually, with 30% of those injured being younger than 19 years of age. With limited quantities of antivenin available nationally, it is important that these resources be preferentially allocated to areas with higher incidence of snake bite injuries. The purpose of this study was to describe the incidence, patient characteristics and outcomes of pediatric hospitalizations related to snake bites in the U.S.

This retrospective cross-sectional study used the Pediatric Hospital Information System (PHIS) database to identify children 0-21 years old with hospital encounters for snake bites from January 1, 2016 through December 31, 2022. Data elements collected included sex, race and ethnicity, intensive care unit (ICU) charge flag, urbanicity, U.S. region, disposition, severity of illness, length of stay, and antivenin administration. U.S. regions were categorized based on the United States Census Bureau Regions and Divisions. Frequencies and Chi-Square analysis were used to characterize the populations.

There were 2,663 pediatric encounters for snake bites included in the study population, with patients primarily being male (61%), living in a Southern state (82%) and with a median age of 9.3 years (IQR: 5.5-13.1). Almost 82% of the patients were hospitalized for their injuries and 52% received antivenin at the children's hospital. Admitted children were significantly younger (p<0.0003) and more likely to live in non-urban zip codes (p<0.01), despite the majority of the study population having urban zip codes (72%). Rural children were also more likely to receive antivenin (p<0.01) than urban children.

There is significant variation in pediatric snake bites by U.S. region and rurality. Barriers to access to healthcare and antivenin may have led to more severe illness and subsequent hospitalization for injured rural children. Our findings could be helpful in directing allocations of antivenin and education about pediatric snake bite management to hospitals in areas with higher volumes of pediatric snake bites.

1. There was variation in patient characteristics and outcomes of pediatric hospitalizations related to snake bites in the United States.
2. A majority of children were hospitalized for their injuries and lived in Southern states.
3. Rural children were more likely to be admitted and receive antivenin.

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Megan Sinik, BS
Benjamin Linden, BS
Kristel Wetjen, RN, MSN
Pam Hoogerwerf, BA
Junlin Liao, PhD
Charles Jennissen, MD

Youth have become leading voices of concern as the epidemic of firearm deaths and injuries in the United States continues and worsens. The objective of our study’s was to investigate rural adolescent’s personal experiences with firearm-related violence, and their attitudes towards firearms and gun violence prevention strategies.

At the 2021 National FFA (formerly Future Farmers of America) Convention & Expo, a convenience sample of attendees were administered an anonymous survey at the University of Iowa Stead Family Children’s Hospital injury prevention booth. The survey explored their personal experiences with firearm-associated deaths and injuries, and their attitudes regarding firearm-related issues and safety measures. After data were compiled, descriptive (frequencies), bivariate (chi-square, Fisher’s exact test) and multivariable logistic regression analyses were performed using Stata 15.1 (StataCorp, College Station, Texas).

3,206 adolescents that were 13-18 years old participated in the survey with nearly half (45%) reporting they lived on a farm or ranch, 34% living in the country but not on a farm and 21% from a town. About 10% of participants had personally seen someone threatened with a firearm. Nearly half (46%) stated they knew someone who had been killed or injured by gunfire. Most agreed that a firearm safety course (75%) and background checks (74%) should be mandatory before purchasing a firearm (including sales and gifts between private citizens). One-half agreed that there should be laws requiring safe storage (both locked and unloaded) of firearms in homes, 18% disagreed. Nearly two-fifths (38%) agreed that parents should ask families where their children visit whether they have firearms stored unlocked. Overall, 31% agreed there should be a national database of all privately owned firearms, 35% disagreed. Only 21% agreed healthcare providers should ask parents about firearm storage in the home, 58% disagreed. Overall, those from farms were less likely to agree with firearm safety measures. Over three-quarters agreed a firearm in the home made it safer with nearly half (48%) strongly agreeing.

A majority of adolescent participants supported some firearm safety measures including required training and background checks. However, they do not agree with a number of other measures, some that are major components of firearm injury prevention efforts of organizations like the American Academy of Pediatrics. We did find that many rural youth’s lives had been affected by the threat of firearm violence and by firearm-related deaths and injuries. Our study did not investigate the effects of firearm violence on participants’ mental health and wellbeing, but future studies addressing this question seem highly justified. Rural firearm injury prevention programs should explore the basis for present attitudes and how they might be best modified to improve safety practices.

1. To understand the degree of exposure rural youth have to firearm-related violence and its resultant injuries and deaths.
2. To be able to state some of the general attitudes youth have about firearm issues.
3. To be able to list at least three factors that might influence youth’s attitudes regarding firearms.

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Altamish Daredia, MD
Eric Jorge, MD
Elizabeth Baker, PhD
Gabriela Oates, PhD
Kathy Monroe, MD, MSQI

Between 2012 and 2014, on average 1300 children under the age of 18 died each year because of a firearm related injury in the United States. Studies have shown that socioeconomic differences influence many health-related issues, including the overall number of firearm related injuries; however, the specific ways in which they affect pediatric firearm injuries is less well known. The Area Deprivation Index (ADI) is an objective measure used to stratify the level of socioeconomic disadvantage based on zip codes. This study aimed to divide locations into groups based on ADI and assess the intentionality of firearm injuries based on ADI in both rural and urban settings. The data shown here will help guide public health experts and pediatricians in targeting firearm injury prevention based on location.

A retrospective chart review of firearm related wounds was conducted in children ages 0-19 who presented over a twenty-year period (2000-2019) to our institution (pediatric quaternary care center and the sole pediatric level one trauma center in the state of Alabama), as well as the local county medical examiner’s office. More than twenty variables, including zip code, associated ADI score, associated Rural-Urban Commuting Area (RUCA) code, intentionality, and outcomes, were collected using pre-determined criteria and analyzed. After accounting for the demographic characteristics of the patients, a multivariable logistic regression was used to assess for associations between socioenvironmental measures (socioeconomic and rurality) and the intentionality of the shooting.

Those who experienced an intentional shooting had a higher mortality rate compared to those who experienced an unintentional shooting (52.65% vs 12.34%). Those who resided in urban areas have three times the odds of experiencing an intentional shooting (OR: 3.04, 95%CI: 1.55-5.96). Additionally, older children, females, and non-Hispanic Black children were more likely to experience an intentional shooting. Although individuals who lived in urban areas were overall more likely to experience an intentional shooting, it depended on the ADI. In areas with lower ADI, intentionality of the shooting did not vary by urban status. However, in areas with higher ADI, those who resided in urban areas were more likely to experience an intentional shooting.

There is a statistically significant increase in odds of an intentional shooting in an urban area as compared to a rural area, but only in low resource (high ADI) areas. More research is needed in this area of pediatric healthcare disparities, as well as ways that this knowledge can be used for more focused and targeted firearm injury prevention tactics.

1. Understand the basic trends in pediatric firearm injuries in the state of Alabama.
2. Learn which areas (based on SES and rurality) are more at risk for intentional vs. unintentional firearm injuries.
3. Identify how specific firearm injury prevention tactics can be applied to areas that are more at risk for intentional vs unintentional injuries.