Article, Neurology

Neurologic complaints in young children in the ED: when is cranial computed tomography helpful?

Unlabelled imageNeurologic complaints in young children “>American Journal of Emergency Medicine (2012) 30, 1507-1514

Original Contribution

Neurologic complaints in young children in the ED: when is cranial computed tomography helpful?

Tarannum M. Lateef MD, MPH a,b,?, Rebecca Kriss MD a,

Karen Carpenter MD a, Karin B. Nelson MD b,c

aInova Fairfax Hospital for Children, Falls Church, VA 22042, USA

bChildren’s National Medical Center and George Washington University School of Medicine, Washington, DC 20010, USA

cNational Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA

Received 1 November 2011; revised 12 December 2011; accepted 13 December 2011

Abstract

Main Objective: The objective of this study is to describe the use of emergent head computed tomography in young children and ask in which circumstances scans contributed to immediate management. Methods: We reviewed electronic records of children, aged 1 month through 6 years, who received a Head CT.at a large suburban emergency department between February 2008 and February 2009. Age, sex, chief complaint, history, physical examination, indication for and results of head CT, Red flags in history or physical examination, final disposition, and number of Head CT scans performed to date were recorded. Abnormalities on CT scans were classified as significant or incidental, and subsequent interventions were documented.

Results: Emergent head CTs were performed on 394 children. The most common indications were trauma, 65%; seizure, 11%; and headache, 6%. Computed tomographic abnormalities were found in 40% (154 children): 32 significant findings,104 incidental findings, and 22 preexisting abnormalities. Four children with significant findings required immediate intervention. They all had red flags in both history and physical examination, and 3 of 4 children had known preexisting pathology; 1 child had nonaccidental trauma. Only 1 child had a significantly abnormal CT with no identifiable red flags; this child was admitted for observation and was discharged within 24 hours. Approximately a third of children had no readily identifiable red flag for the CT scans that they received. Of note, 20% of the young children had received more than 1 head CT scan to date, and 6% had between 6 and 20 scans. Conclusions: Every child in this sample who required emergency intervention had red flags on history and physical examination. The 35% of CT scans performed in young children without red flags did not contribute usefully to their acute management.

(C) 2012

* Corresponding author. Departments of Neurology and Pediatrics, Children’s National Medical Center, George Washington University Medical School, Washington, DC 20010, USA. Tel.: +1 202 476 6230;

fax: +1 571 226 8346.

E-mail address: [email protected] (T.M. Lateef).

Introduction

computed tomographic scans of the brain greatly enhance our ability to examine brain anatomy and pathology in living subjects and thus evaluate the anatomical basis for certain abnormal neurologic signs and symptoms. The

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2011.12.018

availability and use of CT have greatly increased [1-3], but the true value of head CT in medical decision making in young children is not completely known.

Awareness is increasing that CT involves risks as well as benefits [4] and that the risk of Radiation-induced malignancy is maximal in young children [4-7]. brain tumors are in general the second leading cause of malignancy in childhood. Good clinical management, therefore, requires an informed balancing of risk and benefit in specific situations.

The CT scan is a fast and reliable means of diagnosing certain life-threatening conditions that require prompt inter- vention, notably Intracranial bleeding, tumors, and hydro- cephalus. Despite its strengths, CT is not the optimal imaging modality for many neurologic disorders, as it has limited utility in examining the posterior fossa, the most common locus of brain tumors in young children, and CT is less sensitive than magnetic resonance imaging (MRI) for identification of cortical dysplasia, acute ischemia, cerebrovascular abnormal- ities, and other subtle developmental anomalies. Computed tomographic scans for young children are often ordered in situations in which their benefit is dubious, such as with headaches [8] and minor head trauma [9-14] in normal well- appearing children as well as in developmental delay, new- onset seizures [15], Febrile seizures, and breakthrough seizures in children with known epilepsy [16].

One examination of the benefits derived from CT in Minor head injury in children found that almost half of the scans were uninformative [9]. Those authors defined situations in which CT results can aid in clinical care. Another recent study indicated that CT added little to clinical information and physical examination in adults with head injury [14].

Recent reports document a 5-fold increase in CT use between 1995 and 2008 for children who visited an emergency department (ED), most of them at non-pediatric-focused facilities [17]. However, little data exist on patterns of ordering a CT scan, and specific situations in which unnecessary, costly, and potentially harmful imaging can be avoided.

With a goal of improving quality of care, we investigated clinical indications prompting emergent head CT in young

Table 1 Selection of red flags for 3 major clinical indications prompting CT

children in a large suburban hospital and examined the circumstances in which scans did and did not influence immediate management. We focused on children younger than 6 years because of the significant lifetime attributable risk of death from cancer from CT in that age group [4].

Methods

We searched billing records at Inova Fairfax Hospital for Children (IFHC) pediatric ED, a large suburban level 1 trauma center, between February 26, 2008, and February 26, 2009, for children, aged 1 month to 6 years, who had a head CT scan. Age, sex, chief complaint, history of present illness, medical history, review of systems, and physical examination were recorded from ED PulseCheck (PICIS, Wakefield, MA), the electronic ED charting system. The number of scans per child within and before the study period was noted.

Based upon these data and the criteria indicated below, we categorized each child as having either no red flags or red flags in history, physical examination, or both. The list of red flags predicting Intracranial injury for trauma [9,10], seizures

[18],and headache [8,19-24] was derived from the evidence- based literature (Table 1). Minor head trauma has been defined as a history of a loss of consciousness (LOC) or posttraumatic amnesia and a Glasgow Coma Scale score greater than 12 [25,26].

The result of the head CT was recorded from GE Centricity IDX Imagecast (Fairfield, CT), an electronic medical report viewer, and was classified as normal, incidental, significant, or no change from a preexisting abnormality. A retrospective review of the number of head CT scans performed to date at our facility was done for each child. Children who also received an MRI, the time interval between the CT and MRI, and the result of the MRI were documented.

The free text doctors’ notes in PICIS were inspected for documentation of neurology or Neurosurgery consultation as well as any neurosurgical intervention. The child’s disposi- tion after the ED and final diagnosis were recorded.

Trauma

Seizure

Headache

History

Age b2 mo

Focal seizure and age b36 mo

Chronic progressive pattern

LOC

History of bleeding diathesis

Acute onset “worst headache”

Fall N3 ft

Malignancy

Headache/emesis upon waking

History of bleeding diathesis

Hydrocephalus

Dizziness

Trauma

Mental status change

Prolonged seizure N30 min

Suspected nonaccidental trauma

Physical examination

GCS b15

Prolonged postictal state

Focal neurologic deficit

Skull defect

Focal neurologic deficit

Signs of basilar Skull fracture

Ataxia

Signs of increased ICP

Focal neurologic deficit

A standardized abstraction database was created with all the fields outlined above and precise operational definitions of red flags were established before chart abstraction. If a variable, or mostly in this case, a red flag, was not mentioned on the chart, it was assumed to be absent. The main data abstractor for the study was a pediatric resident, who was extensively trained and supervised by a pediatric neurology attending physician. Several “practice runs” were done before actual data collection. Periodic meetings between the main abstractor and 2 pediatric neurologists were set up to resolve questions about data entry and classification and review coding rules. Cases were periodically sampled and reviewed by supervising attending to assess the reliability of the data collection.

61-71 months

9.6%

1-12 months

30.2%

37-60 months

21.8%

13-36 months

38.3%

Fig. 1 age distribution of young children receiving CT.

Table 2 Indications for head CT

Results

Over a 1-year period, 16 163 children aged 1 month to 6 years were seen in this ED. Two percent (394) of these encounters resulted in a head CT; 380 children had 1 scan during the study period, 11 had 2, 1 (hemophiliac) had 3, and

Category

Subcategory

Subtotal

Total, n (%)

Trauma

Accidental

230 (58%)

Head trauma with LOC or amnesia and GCS N12

26

Head injury, degree unknown

26

Major trauma, unknown head involvement

25

Fall without LOC, unknown head involvement

153

Trauma

Suspected nonaccidental

28 (7%)

Seizure

44 (11%)

Febrile seizure

8

afebrile seizure, h/o seizures

11

First afebrile seizure

25

Headache

22 (6%)

Altered mental status

17 (4%)

Lethargy

6

Behavioral change

11

Previous intracranial pathology

14 (4%)

CSF leakage

1

Hydrocephalus

1

Fracture

2

VP Shunt malfunction

10

Ataxia

9 (2%)

Syncope

3 (0.7 %)

Miscellaneous

27 (7.3%)

Macrocephaly, head bobbing and vomiting,

1 each (7)

persistent fever, papilledema, unequal pupils,

head banging, mastoiditis, motor delay

Scalp/forehead swelling, torticollis, abnormal

2 each (8)

movements, abnormal Cranial nerves

bulging fontanelle

3

Vomiting, no known trauma

8

CSF indicates cerebrospinal fluid.

Red flag(s)

Normal

Preexisting abnormality

Incidental finding

Significant finding

Total

None

100

4

35

1

140

In history

77

10

29

6

122

In examination

23

0

16

4

43

In history and examination

36

8

25

20

89

Total

236

22

104

32

394

2 (a hemophiliac and a child with von Willebrand disease) had 5 scans each. Most of the study population were younger than 3 years (Fig. 1), with a mean age of 28 months. Almost two-thirds (63%) were male.

Table 3 Status of red flags and CT findings

The most common indication for head CT was accidental trauma, observed in 58% (Table 2). An additional 7% had suspected nonaccidental trauma; 11%, seizures; and 6%, headache. Altered mental status and preexisting intracranial pathology each prompted 4% of the scans. The miscella- neous category included 3 patients with worrisome physical examination findings (head bobbing, unequal pupils, and papilledema) recognized by the primary care physician who had referred them to the ED for imaging. Of the 394 children,

100 (25%) had no red flags on history or physical examination and no abnormal findings on CT (Table 3), whereas in 1 child with no red flags, there were significant findings on CT. Of the 394 children scanned, 140 (35%) had no documented indication for their CTs.

Table 4 indicates the 3 major indications (accidental or nonaccidental trauma, seizure, or headache) prompting head CTs in the ED, abnormal Imaging results, presence of red flags, and final outcome. Only one of these children, a child with nonaccidental trauma, required emergent neurosurgi- cal intervention.

Trauma

A history of trauma prompted 65% of the head CTs. Of the 230 children with accidental trauma, 153 had a fall without LOC or known head injury, whereas 26 had head injury otherwise unspecified, and 25 had major trauma with unknown head involvement. All the children with suspected nonaccidental trauma, and two-thirds of the children with a history of accidental trauma had red flags prompting a CT. The most common abnormalities observed in children with accidental trauma were sinusitis (37/230) and soft tissue

Table 4 Major indications for head CT and the significance of findings

swelling or hematoma (23/230). Significant Skull fractures and/or intracranial bleeds were observed in 12 of 230 scans in this group; almost all these children were found to have a history of a fall and a physical examination finding of skull defect or significant soft tissue swelling of scalp or face.

significant abnormalities in head CT were more frequent in children with nonaccidental trauma: 9 children (32%) of

28 imaged had a fractured skull and/or intracranial hemorrhage; 1 had plagiocephaly; and the others were normal. One 8-month-old child with a history of trauma had Second-degree burns and suspected nonaccidental trauma; an epidural hematoma was discovered on CT that required immediate neurosurgical intervention.

Seizure

A history of seizure prompted 11% of CTs. More than half of these were for new-onset afebrile seizures. The other CTs in this group were performed on children experiencing a febrile seizure or with a known history of seizures. Most (65%) of children with seizures did not have a red flag for CT. Most (30/44) of the CT findings in this group were normal, whereas the others showed sinus disease or known preexisting anomalies. Only 1 child had a potentially significant finding on CT, a possible venous angioma; nonemergent follow-up imaging by MRI was recommended. None of these patients required emergent intervention.

Headache

Approximately a third (32%) of the 22 children with headache received a CT scan. None had a space-occupying lesion or required neurosurgical intervention. Findings on CT included 6 cases of chronic sinus disease, 2 arachnoid cysts, 1 stable ventriculoperitoneal (VP) shunt, and 1 possible cerebellar hypoplasia.

Indication for CT

n (%)

Significantly abnormal CTs, n (%)

Red flags for CT, n (%)

Neurosurgical intervention, n (%)

Trauma (accidental)

230

(58%)

14 (6%)

153 (66.5%)

0

Trauma (nonaccidental)

28

(7%)

9 (32%)

28 (100%)

1 (3.5%)

Seizure

44

(11%)

1 (.02%)

15 (35%)

0

Headache

22

(6%)

9 (32%)

7 (32%)

0

Radiographic results

n

%

Normal

235

59.6

Sinusitis

56

14.2

Miscellaneous

31

7.9

Soft tissue swelling/hematoma

25

6.3

Skull fracture

14

3.6

Hydrocephalus

9

2.3

Epidural hematoma

7

1.8

Arachnoid cyst

3

0.8

Chiari malformation

3

0.8

Subarachnoid hemorrhage

3

0.8

Large adenoids

3

0.8

Subdural hemorrhage

2

0.5

Ear opacification

1

0.3

Mastoiditis

1

0.3

Stroke

1

0.3

Total

394

100

Of the 4 children with headache who required emergent neurosurgical intervention or transfer to another facility for escalation of care, 2 had VP shunt pathology, 1 was status post recent craniotomy, and 1 had suspected nonaccidental trauma with both history and physical examination sugges- tive of child abuse.

Table 5 Results of CT scans performed

Overall, red flags were present in 253 (64%) of the 394 children in this sample. Table 3 displays the CT findings relative to the presence or absence of red flags. Only 1 child with a significantly abnormal head CT scan did not have an identifiable red flag on chart review. This was a 4-month-old boy reported to have fallen off a bed onto carpeting; the height of the fall was not documented but was assumed to be less than 3 ft. He had no history of LOC or neurologic deficits on examination. His physical examination showed “small erythematous marks over anterior/frontal area and left temporal area [with] no obvious hematoma.” There were also “few scattered erythematous marks on [his] back.” The head CT scan showed “small amount of subarachnoid hemorrhage over the left frontal convexity” with no fracture. He was admitted to the hospital for observation and discharged within 24 hours without surgical intervention. There was no documentation of concern for nonaccidental trauma.

Table 5 lists the results of the CT scans. Nearly 60% were normal. Incidental findings were present in 104 of scans with any abnormality; the most common finding was sinusitis.

One in 5 young children in this series had received more than 1 head CT scan to date, and 6% had between 6 and 20 scans. Children with 6 or more scans had a history of hypocoagulability or VP shunt.

Discussion

This study is the first to describe the clinical circum- stances, not limited to trauma, which prompted emergent

cranial CTs in young children in a large pediatric ED. The most common clinical indications for CT scanning were head trauma, seizures, and headache. We sought to identify situations in which head CT scans influenced immediate outcome. Most children with significant findings on head CT had red flags in history, physical examination, or both. In none of 394 young children who underwent head CT scans did CT findings in the absence of red flags indicate a need for emergent intervention.

Head trauma

Approximately half of children assessed for head trauma in North American EDs undergo CT examination [10]. Less than 10% of head CT scans in children with minor head trauma (GCS, N13) show Traumatic brain injuries, however, and injuries needing neurosurgical intervention are very uncommon in these children [10-12].

Several recent studies have sought Evidence-based approaches to decisions concerning balance of benefit of CT scanning vs risk of radiation-induced malignancy. In the most recent such study, Kuppermann et al [10] concluded that, in children whose GCS was less than 14, the benefit of CT examination exceeded the risk and that study excluded such children and also those who were asymptomatic. For children younger than 2 years old–who are more sensitive to radiation, less verbal, and more vulnerable to nonacci- dental trauma–with normal mental and behavioral status, no scalp hematoma except frontal, LOC for less than 5 seconds, no palpable skull fracture, and nonsevere mechanism of injury predicted absence of clinically important brain injury with a negative predictive value of 100% in this large sample. For older children, those factors plus absence of basilar skull fracture and of vomiting or Severe headache were almost as regularly associated with absence of significant brain injury.

Use of these evidence-based decision rules can signifi- cantly and safely reduce exposure of young children to radiation. Most children seeking care in EDs are evaluated in general hospitals without extensive pediatric experience [27], and in such hospitals, the application of the decision rules can be especially helpful.

Headache

Among the children who received CT scans in the ED in this study, 6% presented with headache as the chief complaint. The American Academy of Neurology practice parameter of 2002 addresses only children with recurrent headaches, does not discuss whether its recommendations are altered by the age of the child, and makes no specific recommendations about patients in the ED setting [24]. Studies investigating the cause of headaches presenting to pediatric EDs showed that most such visits are attributable to common nonominous conditions, such as upper respiratory illnesses or migraine [8,19-23].

In a previous study, we demonstrated that, for young children presenting to the ED with headache, normal neurologic examination findings, and benign history, CT scanning seldom leads to diagnosis or contributes to immediate treatment [8]. All previous studies, including those done with this young population, have shown that children with life-threatening conditions have demonstrable objective findings in the neurologic examination and red flags in the history. A previous analysis of data for more than 3000 children with brain tumors showed that 98% had 1 of 5 signs (papilledema, ataxia, hemiparesis, abnormal eye movements, or depressed reflexes) [28]. The value of a thorough neurologic examination cannot be overstated.

Seizures

Febrile seizures

In children aged 6 months to 4 years, by far, the most common seizure type is febrile seizures. The important task in the ED in managing such children is to recognize meningitis or Metabolic disorder including serious dehydra- tion. In the child who is conscious and free of focal neurologic signs after a febrile seizure, neuroimaging seldom contributes to acute management [29]. “Emergent CT is not indicated for patients with no known seizure risk factors, normal neurologic examination, no acute symptomatic cause other than fever, and reliable neurologic follow-up” [30].

New-onset afebrile seizures

In young children, the most common cause of seizure onset is cerebral dysgenesis or other fixed anatomical lesion not requiring urgent imaging. Such lesions are better studied by MRI, and indeed, CT can give false-negative evidence. An evidence-based review in ED patients found that 3% to 8% of children presenting with seizure had CT findings resulting in a change in acute management, chiefly cerebral hemorrhage, tumors, cysticercosis, or obstructive hydro- cephalus [31]. That review included subjects aged up to 21 years and did not include consideration of the history or physical examination. Lesions requiring acute intervention in children presenting with a first seizure are uncommon [32], but the current literature, including a study of neuroimaging in infants aged 1 to 24 months [33], does not separate young children with red flags on history of physical examination from those without warning signs.

A set of recommendations for evaluation of a first seizure concludes that, in children, “There is insufficient evidence to recommend for or against routine neuroimaging in children who present only with a single unprovoked seizure.” However, there is known risk of exposure of young children to radiation. Therefore, neuroimaging should be considered only for “children with a postictal focal neurologic deficit that does not resolve or in children who do not return to baseline neurologic function within several hours.” [34] In most young children without red flags, decisions about imaging can be deferred to an outpatient visit.

Recurrent afebrile seizures

Imaging may be indicated if there are new findings on history or physical examination or there is increasing difficulty in seizure control but is seldom required on an emergency basis.

Syncope

Syncope (fainting) is a sudden LOC and postural tone due to decrease in cerebral perfusion. By adolescence, a third to half of children experience at least 1 episode of syncope. Brief tonic extension and tonic jerks at the end of such episodes are compatible with the diagnosis of syncope and do not alter prognosis. Such “convulsive syncope” is common in young children, and failure to recognize it can lead to overdiagnosis of epilepsy [35,36]. The most common form of reflex syncope in young children is breath-holding spells. The yield of neuroimaging in young otherwise- asymptomatic subjects with syncope is low [37,38].

This study and others have demonstrated that the diagnostic yield of CT scans is low for children who present to the ED with neurologic complaints, nonworrying history, and normal neurologic examination. Furthermore, the risks associated with CT scanning are not negligible. The risk of cancer from exposure to ionizing radiation is much greater for pediatric patients [6,7,24] than for older persons, for 2 principal reasons. First, rapidly dividing and developing young tissue are more sensitive to radiation. Second, children have a longer lifetime ahead of them during which radiation- related cancers can develop. For a 5-year-old child who undergoes a single head CT scan, the lifetime risk of fatal cancer resulting from radiation exposure.has been estimated to be approximately 1 in 2500 [6]. There are also data to suggest that exposing the infant brain to doses of ionizing radiation equivalent to those from head CT can adversely affect intellectual potential in adulthood [39].

The cost of a noncontrast CT scan at our institution is approximately $1500. In a time of rapidly exploding health care costs, cost is another reason for not ordering this test without clear justification.

Although MRI scans are in many cases the preferred imaging modality for several neurologic complaints, such as new-onset seizures and chronic nonprogressive headaches, MRI is not available in late evening and overnight hours. In addition, sedation is frequently required when performing MRI studies on young children and necessitates additional medical personnel for such procedures. Increasing the availability of fast sequence magnetic resonance protocols, which currently exist only in some pediatric EDs, may substantially reduce the number of CT scans being done in many ED settings and replace them with the more informative and appropriate MRI scans.

Emergency department physicians confronting pediatric neurologic complaints often are trained in adult care, have no established clinical guidelines to direct them, and work in the presence of considerable parental anxiety. Examination of a young child by adult-trained physicians is challenging.

Therefore, it is not surprising that the Diagnostic approach is guided more by a fear of being “less than complete” than by evidence. A recent study by Larson et al [17] reported that non-pediatric-focused EDs made up 89.4% of ED visits associated with CT in children, and CT use increased from 316 133 examinations to 1 438 413 over the study period. The authors also commented that most of the radiologists who oversaw and interpreted these studies probably were not subspecialty-trained in pediatric radiology. All previous studies, and now ours in this youngest population, have shown that life-threatening conditions have demonstrable objective findings in the neurologic examination and, in most cases, also red flags in the history.

The neurologic examination in the ED must focus primarily on identifying acute, potentially life-threatening processes and secondarily on identifying disorders that require referral to and management by other specialists. Although the neurologic examination in both children and adults consists of the same 6 major components (ie, mental status, cranial nerve examination, motor examination, re- flexes, sensory examination, evaluation of coordination, and balance), there are some key differences that distinguish the pediatric evaluation from that of an adult. Because of difficulties in gaining the cooperation of the very young patient, a substantial part of the evaluation lies in obtaining a Detailed history from the parents. This is particularly relevant when trying to assess mental status and establish how different the child is from his/her neurologic baseline. Red flags in the mental status examination would include extreme irritability, inconsolability, increased sleepiness, or lethargy. Assessing the cranial nerves usually requires bright colorful objects that interest the child and allow for adequate fixation and tracking and assessment of whether nystagmus is present. Engaging the young child’s attention is crucial to successful completion of the mental status and cranial nerve examination. Similarly, asymmetries of strength or gait and ataxia are best observed by encouraging the young child to manipulate toys or gadgets, engage in physical play, and distract into moving around the examination space. Although challenging, it is usually possible to perform a rapid but adequate neurologic examination in the pediatric ED.

It is common in imaging studies and occurred in 104 of 394 children in this study, to encounter unanticipated and unsought findings that are irrelevant to the purpose of the scan. Such “incidentalomas” may trigger a “cascade effect”

[40] of investigations and interventions and, sometimes, complications of these. “The unintended consequences of screening by imaging can make a well person ill.” [41] It is particularly troubling when a complication of intervention arises in the workup of a child for whom the initial scan was of dubious necessity.

Parental demand is often cited as one of the key reasons driving the increase in CT scans. In several cases, patients are specifically sent to ED by their primary care physicians, leading to parental expectation that their child will receive a CT scan. Research, however, shows that most parents (5/6)

were unaware of the risks of radiation from CT. A brief educational handout can improve parental understanding of the increased risk of cancer related to pediatric CT without causing parents to refuse studies recommended by the referring physician [42].

Limitations of this study include its retrospective design and lack of complete follow-up monitoring. Analysis was limited to information in clinical records, and it is possible that not all pertinent history and examination findings were recorded. The electronic system of ED documentation was adopted just before study period, and this may have influence the quality of clinical details. We did not include children who had already received a head CT before arrival in our ED. The study did not include record review of children with neurologic complaints who did not undergo head CT. However, this study is a critical first step toward under- standing the circumstances in which emergent head CT scanning (a procedure of significant risk) occurs in young children and to identify when it may actually be useful and clinically indicated.

Conclusions

For the 35% of young children who presented to the pediatric ED with neurologic complaints but normal neurologic examination and benign history, CT scanning did not lead to diagnosis or contribute to immediate management. Computed tomographic scans were useful in the diagnostic evaluation of young children with red flags in history or physical examination, but CT scans did not improve immediate management of children without red flags. Parents and health care providers need to be fully informed of the risk of radiation, and there should be clear and specific clinical justification for the performance of CT scans in young children.

Acknowledgments

The authors thank Dr Maybelle Kou (Department of Emergency Medicine, IFHC) for her thoughtful review of the manuscript and insightful comments. We are grateful to Dr David Ascher (Chairman, Department of Pediatrics, IFHC) for his encouragement and support.

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