discuss management strategies. This article summarizes the recommendations of the consensus panel for physicians. The recommendations for nurses will be published separately. Definition and Scope of the ProblemEarly identification of DVA is the first step in optimizing patient care. The consensus panel described DVA as a clinical condition in which multiple attempts and/or special interventions are anticipated or required to achieve and maintain peripheral venous access. Special interventions are defined as the use of any technique or hospital resource with the potential to improve peripheral IV insertion success rates. These include traditional methods of enhancing the visibility and palpability of peripheral veins (eg, warming the catheter site to induce vasodilation) [10][11][12] ; advanced visualization technologies such as ultrasound, transillumination, and nearinfrared lighting 2,[13][14][15] ; and enlisting designated IV specialists and/or hospital staff with extensive experience in starting pediatric IVs.16 Some children may need more invasive interventions such as intraosseous (IO) infusion, a peripherally inserted central catheter, or a central venous catheter (CVC) to achieve parenteral access.There is a dearth of clinical evidence on the incidence of DVA in pediatric patients. Studies of IV insertion success rates indicate that 5% to 33% of children require more than 2 needle sticks to achieve IV access. [1][2][3][4] Even when interventions such as transillumination and ultrasound are used, up to 15% of children still require more than 2 attempts to establish venous access.2 A recent prospective analysis of 593 insertion attempts in centers with pediatric hospitalist services showed that successful placement E stablishing peripheral intravenous (IV) access in pediatric patients can be challenging. Clinical studies show that only 53% to 76% of children are successfully cannulated on the first attempt.1-4 Multiple failed attempts are painful and upsetting for the child and distressing for family members and caregivers, 5-9 yet there are no guidelines or consensus statements on the recognition and management of this problem.In January 2008, a panel of physicians and nurses specializing in emergency medicine, anesthesia, critical care, and hospital medicine convened to discuss peripheral difficult venous access (DVA) in children. Daniel Rauch, MD, FAAP, and Laura L. Kuensting, MSN(R), RN, CPNP, cochaired the roundtable discussion, which was made possible by a grant from Baxter Healthcare, Inc. The main objectives of the meeting were to estimate the frequency of DVA in pediatric patients; describe its clinical and emotional impact on the patient, the patient's family, and clinicians; develop terminology that accurately describes the condition; review the factors that help identify children with DVA; and

Childhood obesity is a major public health problem in the United States and is associated with numerous comorbidities. The relationship of obesity to risk of traumatic injury and recovery has been described, although not in depth. In adults with burns, obesity has been linked to negative impact on functional outcomes as well as increased mortality. Less is known about the impact of obesity on children with burns. The primary objective of this study was to determine the effect of obesity on length of hospital stay (LOS) among admitted pediatric burn patients. A secondary objective was to compare the difference in burn characteristics between obese and nonobese burn patients. To explore these questions, a retrospective cohort study of patients aged 0 to 18 years admitted to a children's hospital burn unit between February 1, 2000, and September 30, 2006 was performed. For the purposes of this study, obesity was defined as weight-for-length (<2 years of age) or body mass index (> or =2 years of age) > or =95th percentile for age and gender. Patients who had concomitant, nonburn injuries were not included in the study. LOS was measured in days, and an initial univariate analysis examined the association of clinical and demographic factors with LOS. To adjust for confounding, those factors that were found to be significantly associated with LOS were entered into a stepwise linear regression. A total of 528 patients were included in the study group, 17.4% of whom were obese. Obese patients were more likely to suffer a burn of a high-risk anatomic area (72.8% vs 60.8%). Median LOS for obese patients was significantly higher than nonobese (9.3 vs 7.1 days, P < .05). In the adjusted model, factors significantly associated with LOS included total body surface area burned, percent full thickness burn, Medicaid insurance status, and obesity. After controlling for these factors, obese children had a 6.5% longer LOS than nonobese children. This interesting finding raises the question of which factors are responsible for the increased length of stay for obese children hospitalized with burns. Investigating factors such as rate of complications, slower healing, or greater functional impairment may shed light on this finding.

IPV among female adolescents presenting to a pediatric emergency department is high. Certain risk-taking behaviors are correlated with adolescent dating violence. Four specific questions, if asked in this setting, can capture teens at risk.