Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child' s and family' s reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction. Pediatrics 2012;130:e1391-e1405 BACKGROUND A systematic approach to pain management is required to ensure relief of pain and anxiety for children who enter into the emergency medical system, which includes all emergency medical services (EMS) agencies, interfacility critical care transport teams, and the emergency department (ED). 1 The administration of appropriate analgesia in children varies by age as well as by training of the ED team (which includes physicians, nurses, physician assistants, and nurse practitioners), however, and still lags behind analgesia provided for adults in similar situations. 2 Furthermore, neonates are at highest risk of receiving inadequate analgesia. 3,4 Encouragingly, improvements in the recognition and treatment of pain in children have led to changes in the approach to pain management for acutely ill and injured pediatric patients. 5 Studies have shown an increase in opiate use in children with fractures. [6][7][8] Recent advances in the approach and support for pediatric analgesia and sedation, as well as new products and devices, have improved the overall climate of the ED for patients and families in search of the "ouchless" ED. 5,9 Increased parental education regarding pain and sedation, physician comfort and desire to enhance patient satisfaction, and a quest to satisfy accreditation regulations have appropriately driven this effort. System-wide approaches for pain management awareness and strategies work best if they are woven into the fabric of the emergency medical system through education and protocol development. The purpose of this report was to provide information to optimize the comfort and minimize the distress of children and families as they are cared for in the emergency setting.

Enterovirus D68 (EV-D68), a member of the Picornaviridae family, was first identified in 1962 and is part of a group of small, nonenveloped RNA viruses. As a family, these viruses are among the most common causes of disease among humans. However, outbreaks of disease attributable to EV-D68 have been rarely reported in the previous 4 decades. Reports from a few localized outbreaks since 2008 describe severe lower respiratory tract infection in children. In the late summer of 2014, EV-D68 caused a geographically widespread outbreak of respiratory disease of unprecedented magnitude in the United States. The Centers for Disease Control and Prevention was first notified of increased respiratory viral activity by Children's Mercy Hospitals (CMH) in Kansas City, Missouri, and EV-D68 was identified in 50% of nasopharyngeal specimens initially tested. Between mid-August and December 18, 2014, confirmed cases of lower respiratory tract infection caused by EV-D68 were reported in 1,152 people in 49 states and the District of Columbia. A focused review of EV-D68 respiratory disease and clinical highlights from the 2014 U.S. outbreak are presented here.

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Relative to AAP recommendations, PEM fellowship directors underuse ORT, especially for moderately dehydrated children. Physician innovativeness does not influence ORT use. Further study of effectiveness, length of stay, staff requirements, and ORT acceptance in the emergency department setting, especially in children with moderate dehydration, may influence ORT use.

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Background: Avoiding unnecessary hospitalization has long been a goal of child health care providers. Managed care practice environments increasingly pressure the practicing pediatrician to avoid hospitalization. Objectives: To estimate the proportion of childhood dehydration hospitalizations eligible for care in alternative settings (eg, short-stay treatment and triage units, home nursing) and to assess the type and duration of services that might be required for alternative setting care of children with these illness episodes. Design: All dehydration hospitalizations for the 198 593 children (aged Ͼ1 month and Ͻ19 years) dwelling in Rochester, NY (Monroe County), between 1991 and 1995 were identified in county-wide hospital discharge computer files. Medical records were reviewed for a random sample of 380 of the hospitalizations. Children with major underlying conditions were excluded from analysis because of higher risk for deterioration, and greater complexity of medical care might render alternative settings inappropriate. Measures included a 4-item score estimating level of dehydration, serum bicarbonate level at presentation, and time to rehydration. Rehydration was defined as a drop in urinespecific gravity to 1.010 or less or reduction of fluid administration to the maintenance rate. Results: Altogether, 1121 dehydration hospitalizations occurred during the study period. Based on medical record review for a random sample of 380 of these 1121, major underlying problems were present in 27.4% (104) of hospitalizations sampled. Simple, acute gastroenteritis accounted for 75.4% (208) of 276 hospitalizations remaining in the sample. Levels of dehydration for these children were estimated as at least 5% for 51.0% (106) and at least 10% for 16.3% (34) of hospital admissions, and serum bicarbonate levels were 12 mmol/L or less for 26.0% (54). Time from hospital admission to rehydration was no greater than 12 hours for 79.3% (165) and no greater than 24 hours for 94.7% (197). However, hospital stay was generally substantially longer. The time hospitalized following rehydration represented 85.8% of the average inpatient stay. Hospital discharge was heavily concentrated in daytime hours, although the children achieved rehydration at all hours of the day. No deterioration occurred during hospitalizations studied. Conclusion: Nearly all children hospitalized for simple, acute gastroenteritis in Rochester might be eligible for care in alternative settings designed to provide hospitallevel care for short periods.