eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Rotavirus

David D Nguyen, MD, FACEP, Attending Physician, Methodist Willowbrook Hospital, Houston, Texas
Sally Henin Awad, MD, FACEP, Medical Director, Forensic Nursing Program, Memorial Hermann Hospital System; Brent R King, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Texas Health Science Center at Houston; Chair, Department of Emergency Medicine, Memorial Hermann Hospital, Lyndon B Johnson General Hospital

Updated: Jun 1, 2009

Introduction

Background

Rotavirus is one of several viruses known to cause gastroenteritis. The rotavirus genome consists of 11 segments of double-stranded RNA enclosed in a double-shelled capsid. It is classified in the Reoviridae family. Rotavirus is a self-limited infection. Fluid stool losses may be dramatic, and death from dehydration is not uncommon, particularly in developing countries.

Transmission electron micrograph of intact rotavirus particles, double-shelled. Image courtesy of Centers for Disease Control and Prevention and Dr. Erskine Palmer.

Rotavirus infection most commonly strikes during the winter months (December through May), but it occurs year round in developing countries. In the United States every year, rotavirus first appears in the Southwest and spreads to the Northeast.¹ Almost every child 5 years and younger at some point will be infected with rotavirus in both developed countries and developing countries.

Pathophysiology

Rotavirus, like other viruses that cause enteritis, primarily infects the cells of the small intestinal villi, especially those cells near the tips of the villi. Because these particular cells have a role in the digestion of carbohydrates and in the intestinal absorption of fluid and electrolytes, rotavirus infections lead to malabsorption by impaired hydrolysis of carbohydrates and excessive fluid loss from the intestine. A secretory component of the diarrhea with increased motility can further exacerbate the illness. This increased motility appears to be secondary to virus-induced functional changes at the villus epithelium.

The pathologic changes to the intestinal lining may not correlate well with the clinical manifestations of the illness. In normal hosts, infections rarely occur in another organ system, although extraintestinal infections have been seen in immunocompromised hosts.²

The virus is shed in high titers in the stool starting before the onset of symptoms and persists for up to 10 days after symptom appearance.

Frequency

United States

Before the introduction of the rotavirus vaccines, this virus was estimated to cause 2.7 million diarrheal illnesses each year, with 55,000-70,000 of these requiring hospitalization annually.^3,4 In the 1990s and early 2000s, 410,000 office visits and 205,000-272,000 emergency department annual visits were attributed to rotavirus, and this resulted in yearly direct and indirect costs of the illness to be approximately $1 billion.³

International

Worldwide incidence of rotavirus is estimated to cause more than 125 million cases of diarrhea annually. Rotavirus is the foremost cause of childhood dehydrating gastroenteritis worldwide.

Mortality/Morbidity

• Before the introduction of the newer rotavirus vaccines, rotavirus was estimated to cause 20-60 deaths annually in the United States in children younger than 5 years.^3,5
• Approximately 527,000 deaths in children younger than 5 years are seen worldwide due to rotavirus.⁶ Virtually all these deaths occur as a result of hypovolemia.
• Significant morbidity is rare in the United States, but dehydration and shock can result in ischemic injury to the kidneys or the central nervous system.
• Children who become severely dehydrated may develop deep venous thromboses or cerebral venous thromboses.

Race

Race is not a factor in rotavirus infection, but one study did show that there was a reduced risk of hospitalization in infants born from Asian mothers in Washington State.⁷ Socioeconomic class also plays an important role as this disease is more prevalent among children with Medicaid insurance.⁷

Sex

Rotavirus affects males and females equally, although males with viral gastroenteritis have been associated with an increased risk of hospitalization compared with females.⁷

Age

Rotavirus can cause illness in adults and children. However, adults are often asymptomatic or less severely affected.

• Adults, if affected, usually have a few days of nausea, anorexia, and cramping pain.⁸ Diarrhea is a less significant symptom in adults than in children.
• Young children aged 4-24 months, particularly those in group daycare settings, are at increased risk for acquiring rotavirus.
• Low birth weight and prematurity as well as the paucity of breastfeeding have been associated with hospitalization from rotavirus.⁹

Clinical

History

• Often, a history of exposure to other children with diarrhea is reported.
• Symptoms usually begin within 2 days of exposure and include the following:
  • Anorexia
  • Low-grade fever
  • Watery, bloodless diarrhea
  • Vomiting
  • Abdominal cramps
• Stool output can be copious during the diarrheal phase of the illness, and dehydration is a common presenting complaint.

Physical

The physical examination findings for rotavirus infection are often unremarkable except for signs of dehydration.

• The most common finding is hyperactive bowel sounds.
• Rectal examination may stimulate the production of watery, heme-negative stools.
• Tachycardia can be disproportionate to the temperature.
• Sunken eyes and/or anterior fontanelle may be present.
• Dry or sticky-appearing mucosa may be present.
• Rough skin or diarrhea-induced diaper dermatitis may occur. 
• Depressed sensorium may be seen.
• Significantly decreased urine output is an important sign. However, it may be hard to identify this in diapered infants because the massive watery stool output makes it difficult to determine the amount of urine output.
• Weight loss can also occur.

Causes

The most significant risk factor for rotavirus infection appears to be participation in group daycare, presumably because the virus is spread through fecal-oral contact by the children themselves and by the daycare workers who are responsible for diapering. Also, fomites serve as important vectors for viral transmission.

Differential Diagnoses

Other Problems to Be Considered

Food poisoning
Cholera
Salmonella

Workup

Laboratory Studies

• Rotavirus may be identified by several means (ie, enzyme immunoassay being the most common, latex agglutination, electron microscopy, culture).³ However, in most cases, identification of the virus is important for public health or infection control purposes.³ In general, use of such testing is less useful in the ED and can take significant time (days to weeks) for results to return.

This electron micrograph reveals a number of RNA rotavirus virions, and a number of unknown, 29nm virion particles. Image courtesy of Centers for Disease Control and Prevention.

• Electrolyte levels should be measured with severe dehydration, alterations in mental status, associated seizures, or oral replenishment with excessive water or salt.  
• Bedside glucose levels should be measured in very young infants and in any age child with associated lethargy.

Treatment

Prehospital Care

• Prehospital care of affected infants should be directed toward ensuring a secure airway, breathing, identification of circulatory compromise, and maintenance of adequate circulation. Field personnel may not be able to achieve access in the child with a contracted circulatory volume.
  • Infants who appear significantly dehydrated ideally should have 20 mL/kg isotonic sodium chloride solution or Ringer lactate solution administered en route to the hospital.
  • Patients who are less severely affected need only monitored transport.
  • The destination ED should be an ED approved for pediatrics (EDAP) or a pediatric critical care center (PCCC).

Emergency Department Care

• After ensuring proper airway and breathing and assessing circulation, identification and treatment of dehydrated infants is the main objective. In many cases, appropriate rehydration may be accomplished using established oral rehydration protocols. Lethargic children require a fingerstick glucose level immediately either by EMS or in the ED.
  • For severely dehydrated children, vascular access (often via an IO line) is required.
  • Administer 20 mL/kg boluses until volume is restored. A total requirement of 60-80 mL/kg is not uncommon.
  • If more than 40 mL/kg is necessary, consider electrolytes, BUN, and creatinine levels.
• Maintenance of hydration is the key issue for children who are not dehydrated. Selection of an appropriate fluid is crucial.
  • Infants who receive hyperosmolar fluids (eg, commercial soft drinks, sports drinks, gelatin) and those who are fed high salt-content solutions (eg, commercial soup, boiled milk) are at risk for significant hypernatremia.
  • Ideal maintenance beverages for dehydrated infants with viral enteritis are commercial infant solutions such as Pedialyte and Rice-Lyte. These beverages contain a small amount (usually 2-3%) of glucose and the correct balance of sodium and potassium.
    • Rehydrating infants with these beverages may be particularly difficult within the first 2 days of the illness because vomiting frequently occurs.
    • If the infant is vomiting, administer small, frequent feedings.
  • Once vomiting has resolved, the baby may be given a standard soy-based infant formula. This formula provides adequate energy intake for intestinal healing.
  • Supplemental feedings of oral maintenance solutions may be administered if fluid losses are excessive.
  • Avoid sports drinks and other hyperosmolar beverages for the reasons previously stated. Similarly, excessive free-water intake may predispose the infant to hyponatremia.
  • Antiemetics may be considered for children older than 6 months to control emesis.

Medication

A rotavirus vaccine (RotaShield) was released for general use in 1998-1999. Despite promising initial results, RotaShield was withdrawn from the market in 1999 because of a causal relationship between the vaccine and several cases of intussusception. The risk was observed 3-14 days following administration of the first dose of the RotaShield vaccine in infants older than 3 months.

Clinical trials are currently ongoing for production of a new vaccine without significant adverse effects. Promising oral vaccines that have been shown to be efficacious in preventing rotavirus diarrhea and in reducing the severity of the disease are still being studied.

In February 2006, the United States Food and Drug Administration (FDA) approved one of the aforementioned oral vaccines known as RotaTeq. RotaTeq administration has been recommended for children as 3 separate oral doses at ages 2, 4, and 6 months.^3,15 In April 2008, the FDA approved Rotarix, another oral vaccine, for prevention of rotavirus gastroenteritis. Rotarix administration is currently recommended as 2 separate doses to patients at ages 2 and 4 months.^3,15 Rotarix was efficacious in a large study showing that it protected patients against severe rotavirus gastroenteritis as well as decreasing the rate of severe diarrhea or gastroenteritis of any cause.¹⁶

The minimum recommended age for the first dose of either RotaTeq or Rotarix vaccine is 6 weeks while the maximum age for the first dose of each is 14 weeks and 6 days.^3,15 The minimum time recommended between each dose of either vaccine is 4 weeks, and the maximum age for the final vaccine dose is 8 months and 0 days.^3,15 No maximum time between doses is specified by the Advisory Committee on Immunization Practices (ACIP).³

Either rotavirus vaccine can be given before, simultaneously, or after patient receipt of any blood product including those with antibodies.³ In addition, a study involving 484 infants between the ages of 6-12 weeks were randomized to receive either Rotarix concurrently with their 2-, 4-, and 6-month vaccines or Rotarix separately at ages 3 and 5 months.¹⁷ The 2-, 4-, and 6-month vaccines were Haemophilus influenzae type b conjugate vaccine, 7-valent pneumococcal conjugate vaccine, and combined diphtheria-tetanus-acellular pertussis-hepatitis B-poliovirus vaccine. Serum antibodies were drawn one month after the third dose of the above vaccines, and it was determined that the antibody response was similar to all of the antigens in both study groups.¹⁷

[#rotavirusvaccination]ACIP and the American Academy of Pediatrics (AAP) recommend that completion of the vaccination be completed by the same product.^3,15 However, if it is unknown which product was initially administered, the patient's vaccination series should still be completed with whichever vaccine is available.^3,15 ACIP and AAP do not directly state a preference for either RotaTeq or Rotarix.^3,15 Due to the use of different clinical scales defining severe rotavirus gastroenteritis in the trials of RotaTeq and Rotarix, a direct comparison of effectiveness currently cannot be made between the two vaccines.^15,18

Other vaccines may eventually be released in the United States, although a definitive date has not yet been set. In addition, side effects, such as intussusception, will be closely monitored for RotaTeq and any other future rotavirus vaccines. Between February 3, 2006, to January 31, 2007, 28 cases of intussusception after RotaTeq administration have been reported to the US Food and Drug Administration (FDA).¹⁹ However, this number does not exceed the basal expected number of cases of intussusception in the general population. The cases have developed after the first, second, or third dose of RotaTeq. Fortunately, no deaths were reported, but 16 of the 28 case patients required hospitalization and surgery, while the other 12 patients were treated with a contrast or air enema.

A study involving more than 63,000 patients who received Rotarix versus placebo at ages 2 and 4 months showed a decreased risk of intussusception for those patients receiving Rotarix.¹⁶ The intussusception data were determined over a 31-day observation period (inpatient or outpatient) after each dose of the Rotarix vaccine, and this also included a 100-day surveillance period for all serious adverse events.¹⁶ Although more patients who received Rotarix were observed to have seizures or pneumonia-related deaths, this link has not been directly established to Rotarix.^16,4 In addition, the FDA is requiring the Rotarix manufacturer to report data on postmarketing safety that involves more than 40,000 patients.⁴

In June 2007, the FDA also revised the RotaTeq Adverse Reactions and Post-Marketing sections of the label to include Kawasaki disease, as 6 cases of Kawasaki disease were reported in the phase 3 clinical trial of RotaTeq.²⁰ Five of the cases occurred in patients who received RotaTeq, while the other case was reported in a patient who received the placebo. Kawasaki disease has also been reported with Rotarix administration. In clinical trials, 17 cases of Kawasaki disease have been reported in those who received Rotarix, while 9 cases were reported in patients who received a placebo.³

Although more research is necessary, nitazoxanide was shown to reduce rotavirus diarrhea and gastroenteritis in a small study of 38 patients between the ages of 5 months to 7 years.²¹ Time to resolution of illness was 31 hours for the group who received nitazoxanide compared with 75 hours for the placebo group. Nitazoxanide is currently approved by the FDA for treatment of diarrhea in children and adults with diarrhea from Giardia or Cryptosporidium.

Vaccines

Elicit active immunization to increase resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Rotavirus vaccine (RotaTeq, Rotarix)

Currently, 2 orally administered live-virus vaccines are marketed in the United States. Each is indicated to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants.
RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a 3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A serotypes. Also contains attachment protein P1A (genotype P[8]).
Rotarix protects against rotavirus gastroenteritis caused by G1, G3, G4, and G9 strains and is administered as a 2-dose series in infants between ages 6 and 24 wk.
Clinical trials found that each vaccine prevented 74-78% of all rotavirus gastroenteritis cases, nearly all severe rotavirus gastroenteritis cases, and nearly all hospitalizations due to rotavirus.

Dosing

Adult

Not indicated

Pediatric

<6 weeks: Not established
RotaTeq
2 mL PO as a single dose at age 2 months, followed by 2 additional doses at ages 4 and 6 months; do not administer after age 8 months
Rotarix
1 mL PO as a single dose at age 2 months, administer a second dose at age 4 months; do not administer after age 8 months

Interactions

Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, high-dose corticosteroids) may decrease immune response; immunodeficiency states including HIV must be weighed clinically to determine risk versus benefit of vaccination; patients with significant acute gastroenteritis or moderate-to-severe acute illnesses should not receive the vaccine until their symptoms have improved

Contraindications

Documented hypersensitivity or severe allergy to prior rotavirus vaccine or to a vaccine component; patients with anaphylactic or severe allergy to latex should not receive Rotarix since the oral applicator contains latex (RotaTeq is latex-free); patients at risk of developing latex allergy (eg, those with spina bifida or bladder exstrophy) may receive either vaccine, although RotaTeq is preferred

Precautions

Pregnancy

Precautions

Common adverse effects include diarrhea, vomiting, otitis media, inflamed nasal passages, and bronchospasm; refrigerate and protect from light; handle and discard empty tube according to biological waste procedures; previously marketed rotavirus vaccine (RotaShield) was associated with intussusception, but RotaTeq did not show an increased risk compared with placebo in clinical trials (monitor for signs of intestinal blockage) and Rotarix did not show an increase in intussusception in 31,673 infants compared with 31,552 infants who received placebo; risk versus benefit of patients who have had prior intussusception must be clinically determined as current vaccines do not show direct correlation with increased intussusception; do not mix in same syringe with other vaccines or solutions

Follow-up

Further Inpatient Care

• Inpatient care is usually not needed for rotavirus infection unless the child is dehydrated, cannot tolerate oral liquids, has a poor social network, or appears toxic.

Further Outpatient Care

• Follow-up with the patient's primary physician is recommended to ensure patient improvement. The caretaker should also be instructed on clinical warning signs and the need to seek further care if the patient's symptoms worsen.
• Breastfeeding can continue regularly before and after the patient receives the rotavirus vaccine.¹⁵

Inpatient & Outpatient Medications

• Antiemetics have been used with some success in prevention of vomiting for gastroenteritis.¹³  Risk versus benefit of the medications must be determined by the treating clinician.

Transfer

• Transfer may be indicated for the dehydrated child who requires admission to a pediatric inpatient or ICU bed.

Deterrence/Prevention

• Rotavirus is contagious. Parents who have more than one young child or who help care for several small children should be cautioned about good hand-washing technique. Children who are asymptomatic should not play with children who are symptomatic during the diarrheal phase of the illness.
• Daycare centers should keep symptomatic children together and separated from those who are not symptomatic. Ideally, the staff should be segregated as well, so that some staff members care for only the symptomatic children, and some staff members care for the others. Fomites should also be disinfected, as viral spread from these objects has also been demonstrated.²²
• Health care workers can be vectors for this illness. Extra vigilance with regard to hand washing, stethoscope cleaning, and housekeeping is warranted during rotavirus outbreaks.

Complications

• The most important complication of rotavirus infection is dehydration.
• Multisystem organ failure is possible when dehydration leads to shock and even death.

Prognosis

• The prognosis for rotavirus infection is excellent as long as adequate hydration is maintained.
• Most children recover within a week of symptom onset.
• Rotavirus enteritis has virtually no important long-term sequelae.
• Reinfection is a common phenomenon.

Patient Education

• Parents should be taught the signs and symptoms associated with dehydration and should be instructed to seek care immediately upon noticing any of these signs or symptoms in a child.
• Parents must know which fluids should and should not be given and how to administer these fluids to young children who are vomiting.
• Parents should be informed about early refeeding with a soy-based infant formula and a bland, general diet, which may include lactose-free milk for toddlers.
• Diarrhea can last for 5-7 days.

Miscellaneous

Medicolegal Pitfalls

• Discharge instructions should include the signs of dehydration and clear instructions to return if any of these signs are noticed. Instructions also should warn against use of very osmolar or very salty fluids for the maintenance of hydration. On the other hand, excessive use of free water may be detrimental as well.
• Inadequate volume resuscitation with associated organ failure may result in shock and possibly death.

Multimedia

Media file 1: Transmission electron micrograph of rotavirus. Image courtesy of Centers for Disease Control and Prevention.

Media file 2: Transmission electron micrograph of intact rotavirus particles, double-shelled. Image courtesy of Centers for Disease Control and Prevention and Dr. Erskine Palmer.

Media file 3: This electron micrograph reveals a number of RNA rotavirus virions, and a number of unknown, 29nm virion particles. Image courtesy of Centers for Disease Control and Prevention.

References

1. Turcios RM, Curns AT, Holman RC, et al. Temporal and geographic trends of rotavirus activity in the United States, 1997-2004. Pediatr Infect Dis J. May 2006;25(5):451-4. [Medline].

2. Gilger MA, Matson DO, Conner ME, Rosenblatt HM, Finegold MJ, Estes MK. Extraintestinal rotavirus infections in children with immunodeficiency. J Pediatr. Jun 1992;120(6):912-7. [Medline].

3. Cortese MM, Parashar UD. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Feb 6 2009;58:1-25. [Medline]. [Full Text].

4. FDA Approves New Vaccine to Prevent Gastroenteritis Caused by Rotavirus. US Food and Drug Administration; April 3, 2008. [Full Text].

5. Fischer TK, Viboud C, Parashar U, et al. Hospitalizations and deaths from diarrhea and rotavirus among children <5 years of age in the United States, 1993-2003. J Infect Dis. Apr 15 2007;195(8):1117-25. [Medline].

6. Rotavirus surveillance--worldwide, 2001-2008. MMWR Morb Mortal Wkly Rep. Nov 21 2008;57(46):1255-7. [Medline]. [Full Text].

7. Newman RD, Grupp-Phelan J, Shay DK, Davis RL. Perinatal risk factors for infant hospitalization with viral gastroenteritis. Pediatrics. Jan 1999;103(1):E3. [Medline].

8. Anderson EJ, Weber SG. Rotavirus infection in adults. Lancet Infect Dis. Feb 2004;4(2):91-9. [Medline].

9. Dennehy PH, Cortese MM, Begue RE, et al. A case-control study to determine risk factors for hospitalization for rotavirus gastroenteritis in U.S. children. Pediatr Infect Dis J. Dec 2006;25(12):1123-31. [Medline].

10. Cezard JP, Bellaiche M, Viala J, Hugot JP. [Medication in infectious acute diarrhea in children]. Arch Pediatr. Oct 2007;14 Suppl 3:S169-75. [Medline].

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12. Fleisher GR. Infectious disease emergencies. In: Fleisher GR, Ludwig S, Silverman BK, eds. Synopsis of Pediatric Emergency Medicine. 4^th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002:298-325.

13. Roslund G, Hepps TS, McQuillen KK. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med. Jul 2008;52(1):22-29.e6. [Medline].

14. Turck D. [Prevention and treatment of acute diarrhea in infants]. Arch Pediatr. Nov 2007;14(11):1375-8. [Medline].

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16. [Best Evidence] Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [Medline].

17. Dennehy PH, Bertrand HR, Silas PE, Damaso S, Friedland LR, Abu-Elyazeed R. Coadministration of RIX4414 oral human rotavirus vaccine does not impact the immune response to antigens contained in routine infant vaccines in the United States. Pediatrics. Nov 2008;122(5):e1062-6. [Medline].

18. Givon-Lavi N, Greenberg D, Dagan R. Comparison between two severity scoring scales commonly used in the evaluation of rotavirus gastroenteritis in children. Vaccine. Oct 29 2008;26(46):5798-801. [Medline].

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20. Information Pertaining to Labeling Revision for RotaTeq. US Food and Drug Administration; June 15, 2007. [Full Text].

21. Rossignol JF, Abu-Zekry M, Hussein A, Santoro MG. Effect of nitazoxanide for treatment of severe rotavirus diarrhoea: randomised double-blind placebo-controlled trial. Lancet. Jul 8 2006;368(9530):124-9. [Medline].

22. Rogers M, Weinstock DM, Eagan J, Kiehn T, Armstrong D, Sepkowitz KA. Rotavirus outbreak on a pediatric oncology floor: possible association with toys. Am J Infect Control. Oct 2000;28(5):378-80. [Medline].

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30. Santosham M, Foster S, Reid R, et al. Role of soy-based, lactose-free formula during treatment of acute diarrhea. Pediatrics. Aug 1985;76(2):292-8. [Medline].

31. [Best Evidence] Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med. Jan 5 2006;354(1):23-33. [Medline].

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Keywords

rotavirus, rotavirus infection, rotavirus symptoms, rotavirus treatment, rotavirus vaccine, gastroenteritis, contagious virus, infection in children, enteritis, viral infection, diarrheal illness, childhood dehydrating gastroenteritis, severe dehydration, dehydration, fluid loss, diarrhea, Reoviridae, hypovolemia, viral enteritis, rotavirus outbreak, rotavirus genome

Contributor Information and Disclosures

Author

David D Nguyen, MD, FACEP, Attending Physician, Methodist Willowbrook Hospital, Houston, Texas
David D Nguyen, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Harris County Medical Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Sally Henin Awad, MD, FACEP, Medical Director, Forensic Nursing Program, Memorial Hermann Hospital System
Sally Henin Awad, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Writers Association, American Professional Society on the Abuse of Children, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Brent R King, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Texas Health Science Center at Houston; Chair, Department of Emergency Medicine, Memorial Hermann Hospital, Lyndon B Johnson General Hospital
Brent R King, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American College of Physician Executives, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

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