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Karolina Kalata, BS
Sara Kohlbeck, PhD, MPH

Suicide among Wisconsinites increased 40% from 2000 to 2017, where teens and young adults were more likely to have thoughts of suicide than any other age group. The stress related to the COVID-19 pandemic may have exacerbated these poor mental health outcomes among youth. This study examines the association between neighborhood-level COVID-19 mortality and suicidal behavior among youth living in those zip codes. We hypothesize that, because of the social disruption and neighborhood-level stressors of the COVID-19 pandemic, zip codes in Milwaukee County that experienced disproportionately high rates of COVID-19 deaths will also demonstrate higher rates of suicidal behaviors among youth and young adults ages 11 to 24.

This study utilized suicide and COVID-19 death data from the Milwaukee County Medical Examiner’s Office. Suicidal behavior data (attempts, self-harm, ideation) were collected from local hospital emergency departments. Mental health data focused on individuals ages 11-24. All data was filtered for residents of Milwaukee County and looked at the time between March 1, 2020, and March 31, 2022. Data was de-identified and filtered to eliminate repeat visits. Zip codes were categorized by socioeconomic status using criteria from Health Compass Milwaukee. Statistical analysis, including bivariate linear regression and multivariate analysis of variance (ANOVA), examined the association between rates of suicidal behaviors and COVID mortality by zip code, controlling for SES and median age.

There were 1695 COVID-19 related deaths and 836 individuals with suicidal behaviors. The regression analysis revealed a statistically significant relationship between COVID-19 death rates within zip codes and suicide rates among youth (p=0.037) in Milwaukee County. This association suggests that zip code areas with higher COVID-19 mortality experienced increased suicide behavior rates among youth. The multivariate ANOVA test showed median age as a significant factor (p=0.0424).

Findings indicate a significant relationship between COVID-19 death rates and suicidal behaviors at the zip code level in Milwaukee County. This study highlights the pandemic’s profound impact on youth mental health and offers a framework for regional analysis to better identify areas where youth face the greatest challenges and improve targeted injury prevention strategies.

1. Analyze data on suicidal behavior among youth ages 11-24.

2. Compare suicide related outcomes to COVID-19 related outcomes by zip code and understand the association.

3. Examine how social disruption from the COVID-19 pandemic may have exacerbated mental health outcomes among youth.

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Sarah Frances, BS
James M. Noble, MD, MS

Concussion remains a serious public health problem in the United States, particularly in adolescents participating in contact sports. Except in limited circumstances, there are no requirements for systematically reporting sport-related concussion (SRC) in high schools reflected by limited infrastructure and support for reporting. Given these limitations, major gaps exist in understanding adolescent SRC epidemiology. Regional and even nationwide monitoring programs are of increasing interest, however the financial and practical implications of such programs are not well understood.

Local, regional, and state-wide high school SRC monitoring programs and nationwide research were identified to determine cost and other practical aspects, and potential barriers to implementation. Resources included 1) State Education department websites, 2) Compiled lists of state-level laws and implemented programs as available through the Centers for Disease Control and Prevention as well as the Brain Injury Association of New York State, and 3) other programs brought to our attention through professional networks. Costs were determined through 1) the above resources, 2) projections of athlete volume drawn from The National Federation of State High School Associations (NFHS), and 3) publicly available program- and state-level fiscal end-of-year documents detailing program expenses. Cost estimates included physicians, data managers, systems fees, and educational resources with varying athletic trainer support across models, ranging from none (presumed already in place) to new/dedicated lines. Means for fiscal support and flow of funds for support were also explored. We then created models for state- and athlete-level costs of implementing a program in New York State with 356,803 high school athletes.

Publicly available data were reviewed and semi-structured interviews were conducted with program coordinators at regional (a rural New York high school district), state (Hawaii Concussion Awareness Management Program (HCAMP) and North Texas Concussion Registry (ConTex) programs) and national (High School Reporting Information Online (RIO)) levels. Overall, there was variability in available infrastructure which ranged from a volunteer-based local enterprise to a state-funded mandatory program. Some programs were supported by state law enhanced by traffic violation surcharges, while others were supported through philanthropic or volunteer efforts. State-level cost estimates ranged from $7.9M to $33.1M, with per-athlete costs of $22.24 (ConTex) to $92.78 (Hawaii). Logistical challenges, including medical personnel and data infrastructure, appeared manageable at scale in each model.

High school SRC monitoring programs are generally financially feasible and often cheaper than routine costs associated with sports participation, such as uniforms and standard equipment. These models provide guidance for possible implementation of state- and federal-programs. Large, inclusive programs are necessary to identify critically understudied aspects of SRC including health disparities as relates to SRC detection, reporting, and recovery in diverse populations.

1. Attendees will be able to recognize the current public health burden of sport-related concussions and their unclear epidemiology within American high schools, with a focus on New York State.
2. Attendees will be able to analyze the current concussion monitoring programs in place in the United States and acknowledge the barriers to implementing similar models.
3. Attendees will be able to draw conclusions from the findings to a wider model for national and global concussion monitoring interventions to address potential unmet health disparities.

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Lauren Brewer, MD
Dana Gans, MD
Michele Nichols, MD
William King, DrPH
Kathy Monroe, MD, MSQI
Will Rushton, MD

Our hospital is seeing a number of pediatric patients test positive for methamphetamine on screening urine drug screen (SUDS). Child services become involved when child exposure to methamphetamine is suspected due to its illicit, dangerous nature. SUDS is an immunoassay prone to false positive results from poor antibody specificity. Comprehensive urine drug screen (CUDS) utilizes gas chromatography mass spectrometry and is more reliable but takes weeks to result. Our goal is to identify clinical correlates to risk stratify true ingestion while awaiting CUDS confirmation. Methamphetamine is metabolized into amphetamine and inactive compounds excreted into urine. True methamphetamine positive tests should be amphetamine positive as well. Presenting symptoms consistent with a sympathomimetic toxidrome may increase clinical suspicion for ingestion. Certain lab abnormalities are suspected in methamphetamine ingestions such as elevated creatine kinase (CK), hyperlactatemia, hyperglycemia, and hypokalemia.

This 5 year (2018-2023) retrospective cohort study compares clinical factors of pediatric patients who tested methamphetamine positive on urine drug test at a tertiary medical center. Inclusion criteria required methamphetamine positive SUDS and those without CUDS collection were excluded. Primary outcomes included amphetamine co-positivity, vital sign abnormalities, and hypokalemia. Secondary outcomes included CK elevation, hyperlactatemia, hyperglycemia, and clinical suspicion for ingestion. Age was divided into two groups, 0-5 years (age category 1) and 6-18 years (age category 2). Clinical values compared via logistic regression and utilized corrected Chi square test and T-test of means with Satterthwaite adjustment.

205 patients tested methamphetamine positive on SUDS. Only 52 subsequently had a CUDS obtained. 54% were male and 46% were female. 63% were in age category 1 and 37% in age category 2. 40% were less than 24-months-old. 23% tested in 2023, which was the year with the most cases. 62% of methamphetamine positive SUDS were confirmed with a positive methamphetamine CUDS and 60% were positive for both methamphetamine and amphetamine. This makes 97% of methamphetamine positive CUDS also amphetamine positive. 81% methamphetamine positive CUDS did have amphetamine positive on initial SUDS (Chi-square=25.7, P< 0.005). Age category 1 found to have statistically significant tachycardia when methamphetamine ingestion confirmed with mean heart rate 166 versus 133 when negative (T=-3.3, P=0.003). Age category 2 had clinically significant tachycardia with mean heart rate 104 when methamphetamine positive versus 84 when negative (T=-1.8, P=0.105). 58% age category 1 presented with fussiness, aggression, and agitation. Hypokalemia, CK elevation, hyperlactatemia, and hyperglycemia not statistically significant.

Tachycardia, a marker of sympathomimetic toxicity, was associated with methamphetamine resulting as true positive in ages 0-5 years. A positive amphetamine result on SUDS was also associated with methamphetamine resulting as a true positive, as suspected as amphetamine is a metabolite of methamphetamine. Clinical suspicion for methamphetamine ingestion should increase in patients ages 0-5 years presenting with unexplained fussiness, aggression, and agitation.

1. The presence of aggression, agitation, and fussiness is strongly correlated with methamphetamine ingestion and should increase clinical suspicion.
2. Methamphetamine ingestion correlates with tachycardia.
3. True methamphetamine ingestions should also test positive for its metabolite, amphetamine, on urine drug screen.

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Eve Losman, MD, MHSA
Douglas Wiebe, PhD
Taylor Hautala, MPH
Jill Solomon, MPH
Nichole Burnside, MBA

Despite a reduction nationwide in new opioid prescriptions since 2012, opioid overprescribing, as well as opioid misuse and overdose, remain significant U.S. public health issues. This issue extends to pediatric populations, with approximately 4 million pediatric opioid prescriptions in 2019, 45.6% of which were considered high-risk. This underscores the importance of safe prescribing practices, particularly in settings where youth frequently receive care, such as pediatric clinics and dental offices. It is well-documented that overprescribing of opioids has markedly contributed to the opioid epidemic; more recently, overdose deaths increasingly involve stimulants and benzodiazepines, signaling the need to address polysubstance use as part of our response to the opioid epidemic. In 2019, there was a deficit in just-in-time educational resources/tools; in response, the “Safer Prescribing Toolkit” was created to offer comprehensive, evidence-based guidelines and practical tools for healthcare providers and their patients pertaining to opioids, and more recently, stimulants and benzodiazepines.

In 2018-2019, a needs assessment of Michigan primary care providers was conducted, identifying knowledge/skills gaps. Based on the results, a comprehensive review of publicly available opioid prescribing resources and a systematic literature review to identify up-to-date recommendations were conducted in key areas. Provider and patient-focused educational content and resources were curated from existing sources or newly developed. Resources were reviewed by expert researchers/clinicians for accuracy and by practicing clinicians for usability and relevance. Training series covering topics related to safe prescribing were organized to complement the online toolkit. These efforts were funded by the Michigan Department of Health and Human Services. Periodic updates with new topics, including new sections on benzodiazepines and stimulants, have expanded the toolkit’s content.

Toolkit resources are categorized across three commonly prescribed substance types: opioids, stimulants, and benzodiazepines. Several sub-categories exist within each section, including but not limited to: background resources (i.e., managing acute/chronic pain, managing anxiety/insomnia, reducing stigma), just-in-time tools (clinical decision flowcharts, screening and assessment tools), tapering/deprescribing, opioid use disorders (screening, referral, naloxone, medication for opioid use disorder), and prescribing laws (PDMPs, legal resources). In addition, there are resources and tailored information on/for special issues and populations, including adolescents, teachers and coaches, LGBTQ+, pregnant women, older adults, and more. Since its 2019 launch and subsequent updates, the toolkit pages have had over 228,000 views, suggesting high engagement with the content.

Development/dissemination of a just-in-time online toolkit to guide safe prescribing of these controlled substances, evidence-based pain and anxiety management, and substance use disorder treatment/linkage to care has potential for broad public health and clinical impact in addressing the opioid overdose epidemic. Future work on this toolkit includes responding to feedback from physicians to make the toolkit easier to navigate.

1. Understand the ongoing challenges and complexities of the opioid epidemic in the United States, including polysubstance use, and the increasing involvement of stimulants and benzodiazepines in opioid-related deaths.
2. Recognize the importance of evidence-based tools and training in promoting safer prescribing practices for all patients from childhood to older adulthood.
3. Understand the key components of the Safer Prescribing Toolkit, including its development process, target audience, and primary objectives.

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Brenna Radigan
Symone Ferguson
DeShanta Richardson

The Florida CADR System is charged with conducting case reviews on all incidents of child deaths investigated by the Florida Department of Children and Families with the purpose of achieving a greater understanding of the factors contributing to preventable child death and to address these factors through the development of effective prevention efforts. The CADR System utilized data to inform the development of prevention initiatives to specifically address the primary factors contributing to the leading causes of preventable child death as demonstrated through the CADR case review process including, sleep-related infant death, drowning, and inflicted trauma.

Through the CADR case review process, an examination of at least 688 child death incidents occurring in 2019-2021, demonstrated sleep-related infant death and drowning as the two leading causes of preventable child death of cases examined by the Florida CADR System. Data analysis of surrounding circumstances of sleep-related infant death and drowning highlight contributing factors which is utilized to inform the development of effective prevention efforts.

CADR data demonstrates the majority of sleep-related infant deaths in Florida are among infants 1-4 months of age, most frequently occurring in an unsafe sleep environment such as an adult bed, and the infant is most often found on their stomach when discovered unresponsive. Additionally, CADR data demonstrates that the majority of child drowning deaths occur in children 1-4 years of age and occur during non-swim time activities or when the child was not expected to be in or near the water. These critical factors along with other data derived from the CADR system were used in the design, development, and implementation of two data-informed prevention initiatives: Sleep Baby Safely and Keep Kids Safe From Drowning. Further examination of CADR data indicates geographical areas of the state with higher-than-state-average occurrence of sleep-related infant death and child drowning, allowing the CADR system to focus efforts in critical areas of the state to make the greatest initial impact, with an overarching goal of implementing the developed prevention efforts statewide.

In 2019, the CADR System implemented Sleep Baby Safely in Duval County, Florida as a pilot project. The examination of needed resources, support, and demonstrated outcomes of this pilot project promoted the expansion of Sleep Baby Safely to include eight additional counites in the state with higher-than-state-average incidents of sleep-related infant death. In 2022, the Florida legislature approved funds to support the expansion of this project as well as the Keep Kids Safe From Drowning prevention effort by allocating $2.8 million to these efforts. Both prevention initiatives have been implemented through the coordinated efforts of Local CADR Committee members and stakeholders, with continued examination of data collected through the CADR case review process for further evaluation of efficacy and to further support prevention initiative efforts.

1. Attendees of this presentation will outline methods utilized in the development of data-informed prevention initiatives, Sleep Baby Safely and Keep Kids Safe From Drowning.
2. Attendees will be able to demonstrate how data-informed prevention initiatives can address primary factors contributing to preventable child death and identify available and/or needed data sources.
3. This presentation will encourage attendees to examine existing data-informed prevention initiatives and evaluate gaps which may be addressed through further prevention initiative development.

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Amber Kroeker, MPH, CPST
Emily Dicksa, MaT, BSPH, CPST

Injury is the leading cause of death for children. Children who experience one traumatic injury are at increased risk to experience another. Education and environmental modification is a critical component to injury prevention interventions. Historically, our hospital used our Safety Center as a site for injury prevention education at time of hospital admission for trauma. However, our Safety Center was located a five + minute walk from the Children’s Hospital and had very limited hours. The Safety Center housed one injury prevention health educator limiting availability to our trauma patients if the health educator was already engaged with another family. This new program sought to ease barriers to education post traumatic injury.

Our team worked to transition tailored injury prevention education from a Safety Center setting to a bedside setting. Injury Prevention Health Educators screen daily in the hospital Electronic Health Records (EHR) for any patient admitted with an unintentional injury including submersion injuries and ingestion injuries (poisonings, magnets). Once patients are identified, age-based injury prevention packets were assembled and delivered to family’s bedside. Safety product relevant to the injury is also offered to family. For example, if a child is admitted with a bicycle injury we offer a new helmet. A window fall injury may be offered window stops or guards. Presence of firearms in the home may result in distribution of gun locks. Education and product may extend beyond the child admitted if there are other children in the home.

We lack historical data for the number of trauma patients that came to the Safety Center for education. Anecdotally, we estimate that number to be around 4 families per month. Bedside trauma rounding was piloted in late 2018. Trauma Rounding numbers were: 2018: 22 Trauma Rounds 2019: 99 Trauma Rounds 2020: 131 Trauma Rounds 2021: 242 Trauma Rounds 2022: 439 Trauma Rounds 2023: 334 Trauma Rounds

Removing barriers to education in the form of bringing education to bedside resulted in significant increase in injury prevention education.

1. How to identify and remove access to resources for patients
2. How to craft a sensitive harm reduction intervention at bedside
3. How to transition from a resource intensive program (safety center) to a less resource intensive yet more beneficial program

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Kristy Brinker Brouwer, MS, CPST
Morgan Freshney, BS
Isabella Weingartz, BS
Nicole Matthews Papelain, BSN, RN, CPST
Jonathan Sheu, MD
Patrick Atkinson, PhD

Hip spica casts are commonly used for children aged 6 months to 5 years as an effective treatment for femur fractures and developmental hip dysplasia. While the spica cast is advantageous due to its non-invasive and conservative methodology, it can render transportation difficult. Past crash testing studies have shown that the child restraint shape and cast design significantly influence the positioning of the restrained child. One major drawback of these investigations was that all testing was performed on the same, simulated vehicle seat, as required by FMVSS 213. It was unknown how children fitted with hip spica seats would be positioned in actual vehicles. This was due to the design of 213 vehicle seat which allows unrestricted access from all directions. In contrast, access to seating positions in actual vehicles are constrained by adjacent features such as doors, nearby seats, and rear glass in the case of typical cars and pickup trucks. The current study was designed to investigate if children treated with a hip spica cast can be properly restrained in different child restraints in a range of typical vehicles.

Common vehicles representing a range of interior architectures were studied: 2-row truck, minivan, SUV, and compact car. Two crash test dummies (1 and 3 year-old) were used as child surrogates. Two child restraints (Merritt Wallenberg, Diono Radian R100) were investigated for the rear-facing and forward-facing configurations. An additional restraint (Ride Safer vest with or without the BubbleBum booster) was also studied for the forward facing 3 year-old. Casts typically utilized to treat bilateral hip dysplasia and femur fractures were applied to the dummies during which the positioning of the dummies body and lower extremities were maintained with a hip spica casting table. A third “walking” hip spica femur fracture cast was also created. A test matrix was created that attempted to properly restrain the two children in the different vehicles, in the different child restraints, while fit with each of the 3 hip spica casts.

The forward-facing 3 year-old was safely restrained in nearly all test configurations. All hip dysplasia casts were safely restrained while 67% of femur fracture and walking casts were safely restrained. In contrast, the rear-facing 1 year-old was only safely restrained in the hip dysplasia cast, femur fracture cast, and walking cast at a frequency of 87.5%, 12.5%, and 37.5%, respectively. The minivan was associated with greatest number safely restrained configurations.

The current study documents that certain combinations of vehicle, child restraint design, rear- or forward-facing direction, and spica cast type influence the safe restraint of a child. Of note, the hip dysplasia cast can be restrained safely in nearly all cases, regardless of the variation in independent test parameters. In contrast, the cast typically used to femur fracture cannot be safely restrained in all cases, with forward-facing yielding more success than rear-facing.

1. There are differences between the hip dysplasia and femur fracture spica casts.
2. Common reasons for improper restraint include head-neck-spine misalignment and reduced pulmonary function.
3. The minivan was associated with greatest number safely restrained configurations.