AJN's April cover photo of a child being cared for in the ICU at Fann Hospital in Dakar, Senegal, was chosen to highlight the risk of delirium in hospitalized children, a topic discussed in our feature article, "Recognizing Delirium in Hospitalized Children: A Systematic Review of the Evidence on Risk Factors and Characteristics." While delirium in hospitalized adults and older adults has been well documented, little is known about this phenomena in children. This systematic review by Holly and colleagues revealed several primary characteristics (agitation, disorientation, visual hallucinations, inattention, and sleep disturbances) and risk factors (male sex, preexisting anxiety, developmental delay, and being on mechanical ventilation), and noted symptoms similar to those seen in older adults. The authors also note that the acute care environment-especially intensive care-is a primary factor in contributing to delirium, and discuss practical measures for nurses and parents to help children process these frightening experiences.
I never liked working with severely ill children. The ED where I worked had a separate pediatric department, but severe trauma cases were brought to the adult area, as we were used to dealing with multiple trauma. I recall children seriously injured in car accidents and in falls from apartment windows, children choking from objects lodged in their throats, teenagers who attempted suicide, and kids with gunshot wounds. Those situations were stressful and the level of anxiety was high, much more so than with adult trauma. Those of us involved in the resuscitations often had to step away and "take a moment." Even worse was facing the parents of a child whose future was now uncertain. After these events, many of us were angry that what had happened to these children was often preventable.
Emergency situations are dramatic and the consequences are immediate, but what about the subtle and continuous hazards that threaten children's health? What about the conditions that lead up to the crisis events? Recent reports suggest that we need to pay more attention to children's well-being. An article in the January issue of Health Affairs (and summarized in this month's In the News) should make us all sit up and take notice. After comparing U.S. child health outcomes with those of 19 other developed, "wealthy" nations over a 50-year period, the authors found that while child mortality rates had declined in all countries, the United States had the highest overall child mortality rates from 1990 through 2010. The most significant differences between the United States and the other countries occurred in perinatal mortality and in injuries among children ages 15 to 19, notably from car accidents and firearms (U.S. children were "82 times more likely to die from gun homicide" than children in other wealthy nations). The authors note that the differences in mortality largely developed between the late 1960s and the 1980s, when educational outcomes declined and poverty in the United States increased, and there was less spending on child health and welfare programs. Yet here we are today, with proposed federal cutbacks to safety net programs for families.
Another article in this issue recounts the Great London Smog of 1952, which killed 12,000 people over five days and caused long-term health effects in young children: 20% of children born in London at that time developed childhood asthma. This environmental disaster led to the passage of the Clean Air Act in Britain four years later and to the enactment of the U.S. Clean Air Act in 1963. The author, Barbara J. Polivka, reports on the health advances attributed to this legislation, while noting that poor air quality is still an issue for 40% of Americans. Yet here we are today, as the Environmental Protection Agency, which "works to ensure that Americans have clean air, land and water," faces severe budget cuts and the elimination of funding for research on the effects of chemical exposures.
And recently, the American Academy of Pediatrics, recognizing that depression is a serious problem for adolescents (in 2016, almost 13% had a major depressive episode), recommended annual screening beginning at 12 years of age. Yet funding for programs that provide mental health services are among federal budget cuts as well as the cuts in some states. Is it any wonder that U.S. children fare worse than their international peers?