Saving Kids Worldwide

One of the leading causes of death worldwide is injury to children, especially between 1-14 years of age. Most people are unaware that injury should be considered a disease. There is so much awareness of the benefits of immunization to prevent childhood disease but injury continues unabated. Action to prevent injury and death will save the lives of children and reduce the disability that results.

Worldwide, the challenge is the “burden of injury” which creates a significant economic and social impact upon the family, community and society. The effect upon the family is significant: absence of the child from school, loss of employment by the parent, reduction in income for the family who must care for the child and isolation of the family from the community. After a child steps upon a landmine or plays with unexploded ordinance, the mobility of the child is eliminated after an amputation of an extremity. In many cultures the family is shunned by the community. The “burden” affects the entire community that is responsible to provide a safe environment for the child. Surgeons can prevent death, improve the quality of life and provide a chance for rehabilitation following disability from injury.

Nevertheless, about 10% of the injuries to children worldwide challenge the best surgeons and health care systems. We rely upon a team of people to help save children once they are injured. It takes a system that includes response at the point of injury, acute treatment and a commitment to rehabilitation, to prevent the death of the child and restore them to health. The initial response time has impact upon the outcome. It is imperative that we prepare the first responder and the Emergency Medical System to save the life of the child and to provide transfer to an appropriate level of trauma care.

Sudden events that result in injuries, such as earthquakes, riots or political conflicts, create a challenge for all levels of the system. It takes a long time before you have a response by emergency services, so the bystander and local team need to be able to initiate emergency care while providing transfer to a facility for acute treatment. In the United States, only 10% of injured children have access to a verified pediatric trauma center, so that means 90% receive acute care in general hospital facilities.

The big question is “how do we take care of these kids no matter where they are in the world?” After 10 years of war in Iraq and Afghanistan, the approach to care for the injured child changed. This knowledge and experience affects the system of care and the approach to treatment that makes a difference to children. Better prevention, acute care and rehabilitation will improve the quality of life for the community.

A community has the opportunity to learn from the global experience with injury or to share them with colleagues throughout the world. The convenience and accessibility of using web-based technology can share life-saving ideas quickly. We now can provide access to new surgical techniques and to accelerate practical application in a matter of weeks, instead of years. As an example, The Childress Institute for Pediatric Trauma creates web symposia to provide cutting-edge practice to medical professionals in 33 countries over the past two years.

The timely transfer of pediatric trauma care knowledge is saving the lives of injured children worldwide. The challenge to provide contemporary trauma care to the worldwide community is worthy of our efforts. 

- MartinR. Eichelberger, M.D., Professor of Surgery and of Pediatrics at George Washington University, Children’s National Medical Center in Washington D.C.

Long-term Goals for Kids by Dr. Meredith

The National Institutes of Health (NIH) is an agency within the Department of Health and Human Services and is the principal biomedical research arm of the Federal Government. The NIH is comprised of 27 institutes and centers focused on various health issues facing Americans. The institute that is focused on children’s health issues is the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

It is a very good thing, in my opinion, that the NICHD formed the Pediatric Trauma and Critical Illness Branch (PTCIB) in 2012. It demonstrates a recognition that, in our nation, one of the most serious public health problems for children is injury, and that injury in children requires and merits some focus by our nation's most important federally-funded research support structure. I'm very gratified to see that Valerie Maholmes has been appointed as the chief of this division. She has a lifetime of commitment to children, to children's health issues, children's injury issues. I believe she will exhibit great leadership for this branch.

In late April, Dr. Maholmes convened a strategic planning group that met in Bethesda to
clarify what its mission should be going forward and to advise the new branch on how it can best accomplish its mission.  It was a group of fantastically bright and dedicated people interested in the well-being of children, particularly children’s injury issues.  Over the course of two days in multiple brainstorming sessions, the group identified a set of issues and developed a set of recommendations that I think will serve as a great architecture to both define and begin the process of executing the strategic plan for children's injuries within the branch.

Personally, I believe that all of the parties in our country, who are interested in improving the care for children's injuries and changing outcomes for the most common cause of death and disability of our children, need to get behind this effort at the NIH. Furthermore, we need to approach this journey with a long-term view.

At its core, pediatric injury is a huge health problem in our country and we need to assist, support and foster this branch with a vision toward its long-term success.  Long-term success means it would be a highly-funded source for research information and for convening and deliberating on all research issues that relate to pediatric injuries for our country; a national resource.

It will take years for that vision to be realized; years of research productivity; years of matriculation through the NIH institutes; years of well-meaning grassroots efforts by those of us who are in trauma centers and pediatrician's offices, and families and churches and synagogues that are interested in making sure that we do something about the plague of death that trauma represents amongst our children.

It's going to be worth the long-term ride and if we all try to assure the investments that are made are not aimed at short-term studies, short-term turnarounds, short-term goals but, instead, are aimed at long-term, big vision, strategic efforts, I believe this branch will turn out to be something great.

- Dr. J. Wayne Meredith, Wake Forest Baptist Medical Center, Chair of the Department of Surgery and Medical Advisor to the Childress Institute for Pediatric Trauma

NICHD Pediatric Trauma and Critical Illness Branch

The Eunice Kennedy Shriver National Institute of ChildHealth and Human Development (NICHD) was established by President John F. Kennedy n 1962 to better understand processes of human development and how they affect health from preconception through adulthood. Over the course of its 50 year history, the NICHD has continued to advance scientific knowledge to further its mission to help children have the chance to achieve their full potential for healthy and productive lives, free from injury, disease or disability. 

I joined the NICHD family to contribute to this important mission. Initially my work focused on efforts to understand the impact of exposure to various types of violence on children’s development.  

Some of the research we support helps us understand the traumatic experience of child maltreatment and how it affects children not only in terms of the associated injuries, but also how it affects a child’s ability to make friends, perform well in school and establish productive relationships later in life. We also support prevention and intervention research efforts that address global violence, trauma and injury.

Through a visioning process, the NICHD listened to the community of researchers, practitioners and advocates to identify additional priorities that we could undertake over the next 10 years. An outcome of this process was that a new Branch was needed to focus specifically on critically ill and injured children.

In 2012, the Pediatric Trauma and Critical Illness Branch was established and I was named Chief in late 2013. The goal of the Branch is to look at the continuum of influences on child health outcomes. So, we not only focus on the prevention of childhood injury and trauma, but we also study processes that help critically ill and vulnerable children reach their highest potential in life.

To accomplish this goal, we plan to hold a series of meetings to help us identify important priorities that we will address over the next 3- 5 years. We have already held a scientific meeting on such important issues as abusive head trauma. We are very excited about a conference we held in April that shed light on the special health care needs of children in military families.    

Most importantly, we will collaborate with our colleagues and partners to call attention to help us achieve the NICHD mission to have children live free of disease or disability and lead productive lives. 

- Dr. Valerie Maholmes, Chief of NICHD Pediatric Trauma and Critical Illness Branch

Blast Injury by Dr. Eichelberger

*Please note that some links may lead to graphic information not suitable for all audiences.

The Fourth of July inspires celebration - sometimes fireworks, bonfires and other fun activities can lead to serious injuries. This can be even scarier when children are involved. While thinking about "bombs bursting in air" and all of the week's news from war-torn countries, we turn our attention to an issue that is prevalent around the world, and unfortunately hit close to home last year in Boston.

Injury is the number one killer of kids in America and kills many worldwide. Unfortunately, over the last 10 years, children around the world are not just being injured by vehicles or gunfire or falls, but they are actually sustaining injury from explosion, a blast injury. This injury is rare in the United States, but the episode at the Boston Marathon bombings reveals that a new mechanism of injury can occur.  

The explosion creates a pressure wave that results in a blast injury. The most common and dangerous devices are land mines, unexploded devices or “improvised” explosive devices (IEDs), otherwise known as a roadside bomb. In a war-torn country, many of the bombs don’t explode upon impact. These devices have blue, yellow and red tags and children play with the tags, sometimes pulling the pin that detonates the device. These kids become victims of an explosion that result in a unique injury. 

In countries that are experiencing a civil war, such as Colombia, India, Chile, Iraq and Afghanistan, there are millions of “active” land mines. Even when enemies are not fighting, these devices are buried waiting to go off. Innocent children are out there walking and playing where it's easy for them to step upon a land mine.  

Historically, war creates the opportunity to learn new medical techniques and approaches to treatment of the injured patient, which is applicable to the adult patient and to children. When American and other military medical personnel are in these areas, they treat the children as well as the soldiers. Their experience and treatment techniques learned in the field are extremely valuable in saving children around the world. This process is going on right now! For example, in trauma centers we are changing the way we resuscitate pediatric patients with a new concept known as damage control resuscitation. We realize that when a child develops severe shock due to a critical injury, they do much better when we reduce the amount of crystalloid fluid typically given to these kids and instead, immediately treat hemorrhage with infusion of blood products. This approach is more focused upon the importance of coagulation of circulating blood to the survival of the child. Quickly sharing this information saves lives - Sami is an example.

Most American civilian surgeons know little about the effects of a blast from an explosion. Military surgeons who have treated a significant number of children with a blast injury are able to transfer the knowledge to their civilian colleagues to improve the capacity to care for children. A blast pattern is something that most surgeons in the U.S. will never see until there is a devastating emergency. That is one of the reasons we developed the web-based, Childress Pediatric Trauma Symposium and held three of them in the last two years. Our hope is to share knowledge and experiences with our colleagues around the world in time to save lives.

The Boston Marathon bombing is a critical example of why we need to know how to treat a child following a blast injury. If we can share techniques developed to treat children, we can save the lives of children worldwide.

Martin R.Eichelberger, M.D., Professor of Surgery and of Pediatrics, George Washington University, Children’s NationalMedical Center, Washington D.C.