Thursday, March 23, 2023
Injuries are a leading cause of death both in the United States and globally. More than 50 million Americans experienced a medically treated injury in 2000, resulting in a lifetime cost of $406 billion, with males at greater risk.[1] Injuries are defined as physical damage that occurs due to a transfer of energy or the absence of essentials such as oxygen or heat. The types of energy include kinetic (motion), electrical, chemical, thermal, or radiation.[2] Categories of injuries include those done with harmful intent or intentional injuries (violence) and those done without harmful intent or unintentional injuries.[2]
Unintentional injuries are the leading of death for children in the United States. In 2003, the Centers for Disease Prevention and Control (CDC) reported 10,216 deaths of children between the ages of 0 to 18 years due to unintentional injuries.[3] However, deaths are merely the tip of the iceberg. There were 8,403,181 nonfatal unintentional injuries to children of the same age group in 2005.[4]
A wealth of information related to the incidence and prevalence of unintentional injuries in children was provided at the American Public Health Association annual meeting. Strategies for developing prevention programs and activities are highlighted, and a number of innovative approaches described.
Children's unintentional injury deaths vary according to age and developmental characteristics. For example, research shows that every minute and a half an infant is seen in a emergency department for an unintentional injury with injuries varying according to the child's developmental stage.[5] A 2001-2004 national study showed that traumatic brain injury was highest in 3-month-old infants and lowest in 12-month-old infants.[5]
Males are often at greater risk, as are minorities and poor children, although this is not the case for all injuries. For children between the ages of 1 and 4 years, the leading cause of unintentional injury death is motor vehicle crash, followed by drowning.[6] For children aged 5-9 years, the leading cause of unintentional injury death is also motor vehicle crashes, followed by fire/burns and drowning.[6] For those aged 10-14 years, motor vehicle crashes significantly lead the other causes of unintentional injury deaths, with nearly 60% of deaths due to motor vehicle crashes, followed by drowning, other land transport accidents, and fires/burns.[6] This too is the case for 15- to 19-year-olds, where nearly 77% of unintentional injury deaths are due to motor vehicle crashes, followed by poisoning and drowning.[6] The increased number of deaths of adolescents from motor vehicle crashes reflects, among many things, the transition of teens from passengers to drivers.
However, for nonfatal injuries, the picture is different. In 2005, the leading cause of nonfatal injuries for children between the ages of 1 and 4 years was unintentional falls (42.6%).[7] This was also true for ages 5-9 years (36.2%) and 10-14 years (26.1%).[7] However, for ages 15-19 years, the leading cause of nonfatal injuries was unintentional struck by/against (18.2%), followed by unintentional falls (14.9%).[7]
As children grow and develop, so do their risks for injury. Children will gradually encounter more and more injury risks as they are at the same time developing better perceptual and cognitive abilities to evaluate these risks and the motor skills to hopefully avoid them.[8] Keeping the environment free from hazards and caregiver supervision are crucial at this time.[8] As children continue to age, they soon become more independent and take on more responsibility for their own actions and decision-making.[8] Although risk-taking during this time is normal, excessive risky behavior and exposure to high-risk environments can be particularly dangerous.[8]
From infancy through early adolescence, the family is the primary influence for safety.[8] Also important during childhood are peers and community action.[8] Moving through adolescence, peers and social norms and values have greater influence.[8]
Motor Vehicle Injuries. The Centers for Disease Prevention and Control reports that of children ages 0-14 years killed in motor vehicle crashes in 2004, half were unrestrained and 1 of 4 involved a driver who had been drinking alcohol.[9] Restraint use (child safety seat, booster seat, or seatbelt) often depends on the driver's restraint use, especially when the driver is a parent.
Unfortunately, studies have repeatedly shown that most children who ride in safety seats are not correctly secured. A recent study showed that key factors that lead to misuse/nonuse among Hispanic parents include inability to afford seats, no tradition of using them in their native country, language barriers, vehicle overcrowding, and lack of knowledge about proper installation and use.[10]
As children get older, the risk for motor vehicle crash increases. Recent national estimates of unintentional pedal cyclist injuries treated in US hospital emergency departments resulting from an encounter with a motor vehicle showed that children, aged 10-14 years, had the highest injury rate, approximately 80% of those injured were male, and a common body part affected was the head, with the majority sustaining traumatic brain injury.[11]
Teenage drivers are the highest group for motor vehicle crashes when assessing miles traveled, number of licensed drivers, and per population.[12] Males are at particular risk as are teen passengers, pedestrians, and bicyclists.[12] Recent recognition of the high crash rates of newly licensed drivers has led to changes in licensing policies and a model known as graduated driver licensing (GDL). Through GDL, exposure to driving risk is managed by keeping new drivers out of high-risk situations (ie, driving at night, driving with teen passengers) until they have reached particular milestones such as a certain age, hours of supervised driving practice, etc.[12]
However, the characteristics of GDL programs vary from state to state.[12] Baker and colleagues reported that the more comprehensive GDL programs achieve reductions of approximately 25% in injury crashes of 16-year-old drivers.[13] If all states in the country adopted comprehensive GDL programs, it is predicted that about 24,000 injury crashes each year might be prevented.[13] In addition, prevention strategies for motor vehicle injuries need to continue to focus on restraint use, placing children in the back seat, and adults serving as positive role models for children by always wearing their seatbelts and obeying traffic safety laws.[12]
Drowning. It has been reported that for every child age 14 years and younger who dies from drowning, 5 receive emergency department care for nonfatal submersion injuries.[14] These submersions can cause brain damage.[14] The groups at risk for drowning include males, children, and blacks.[14] While children younger than 1 year of age often drown in bathtubs, buckets, or toilets, children between the ages of 1 and 4 years drown most often in residential swimming pools.[14] Alcohol use has been cited to be involved with 25% to 50% of adolescent drownings associated with water recreation.[14]
Boating is a particularly serious risk.[14] Most individuals who die in boating incidents are not wearing personal flotation devices, die due to drowning, and alcohol plays an important role.[14] Personal watercrafts also pose significant injury risks.[14] Preventive strategies for drowning including constant supervision of children around water, using a barrier-like fence to separate pools and other bodies of water from children, emptying water containers, beginning formal swimming lessons for children after they reach the age of 4 years, wearing life vests at all times when boating, following all water safety rules (including no alcohol use), and having adults, through their injury prevention behaviors, serve as positive role models for children.[14,15]
Fires/Burns. The majority of fire deaths occur in the home and most victims die from smoke or toxic gases and not from the burns.[16] Smoking has been cited to be the leading cause of fire-related deaths and cooking is the leading cause of residential fires.[16] Groups at greatest risk include children 4 years of age and younger, older adults, blacks, and Native Americans, poor Americans, rural Americans, and individuals living in manufactured homes or substandard housing.[16] Scald burns are also important because they are the leading cause of nonfatal fire injury.[17] Major fire/burn prevention strategies for children include never leaving children alone around open flames, stoves, or candles; keeping flammable products away from children; having a family fire escape plan and practicing it; installing smoke detectors on every level of the home and in every sleeping area; testing the alarms once a month; replacing batteries at least twice a year and the alarms every 10 years; keeping the hot water heater at no higher than 120 degrees Fahrenheit; keeping pot handles turned backward while cooking; keeping children out of the kitchen when cooking as much as possible; keeping flammables away from heat sources such as stoves, heaters, and fireplaces; installing fire sprinklers in your home; never smoking in bed or letting a cigarette smolder; and not keeping portable space heaters near flammable materials.[17,18]
Poisonings. The American Association of Poison Control Centers reports that there were more than 2 million poisoning exposures in 2000, 52.7% of which occurred among children younger than 6 years of age.[19] Almost all exposures occur in the home.[19] The most common exposures for children are ingestion of household products such as cosmetics and personal care products, cleaning substances, pain relievers, foreign bodies, and plants.[19] Adolescents are at real risk for poisonings, both intentional and unintentional.[19] Half of poisonings among teens are classified as suicide attempts.[19] Children aged 1-5 years are more likely to have elevated lead levels if they are poor, of non-Hispanic black race, or live in older housing.[19]
Poisoning safety tips include knowing the national Poison Center Control number (1-800-222-1222), reading all labels and finding out which products or plants are poisonous, locking up poisons and keeping medicines out of the reach of children, not taking medicine in front of children, never calling medicine "candy," never leaving potentially poisonous household products unattended, throwing away old medicines and cleaning products, using child-resistant packaging with medications, using carbon monoxide detectors, and checking the home for lead-based paint or lead in products.[20,21]
Falls. There is an increased risk for falls among children younger than age 5 years, although falls are a risk for all ages.[22] The physical environment is particularly important when it comes to falls, whether it be stairways and windows, clutter, etc. Many serious falls among children occur on playgrounds and during sports and recreational activities. However, falls in the youngest children happen more often in the home environment, on stairs, furniture, and out of windows.[22] Baby walkers are particularly risky for young children, and although the number of injuries related to this product has decreased greatly over the years, children are still injured from this product at an unacceptably high rate.[22]
Many playground injuries have also been attributed to falls. A study conducted in 2 inner-city areas in Indianapolis showed that 1 in every 20 neighborhood children sustained an injury requiring emergency care each year. Falls from playground and other related equipment helped contribute, along with pedestrian and cycling and sports activities to nearly 15% of the injuries.[23]
Some prevention tips for preventing falls include keeping chairs, cribs, and other furniture away from windows; avoiding the use of baby walkers; never leaving children alone on furniture where they may fall; strapping children into high chairs, swings, strollers, etc; removing clutter from floors and stairways; using handrails and safety gates at the top and bottom of stairs; using window guards; and making sure playgrounds have safe equipment and surface covering that is rubber, wood, mulch, or sand.[24]
The Haddon Matrix is a widely used tool for generating a range of injury prevention strategies. The matrix has 4 components that are examined over phases of time. The components include host, agent of injury (energy and its vehicle), the physical environment, and the sociocultural environment. Time factors include pre-event, event, and post-event.[25] If a motor vehicle crash is considered, pre-event is before the motor vehicle crash, event is during the vehicle crash, and post-event is following the crash.
One works through the Haddon Matrix by identifying the host, agent, and environmental factors that determine whether the event (in the case of pre-event) or injuries, along with their particular level of severity, occur during the different points in time. By understanding these factors, appropriate intervention strategies can then be developed. Haddon Countermeasures can also help guide intervention efforts.[25] These 10 measures can be used with a variety of injuries, and focus more on environmental or passive changes than on behavioral changes.[25]
Although the Haddon Matrix and Countermeasures are useful for developing strategies, they provide little guidance about actual planning and evaluation. In contrast, the public health approach, which includes surveillance, risk factor identification, intervention evaluation, and intervention implementation,[25] is primarily focused on planning and evaluation. A combination of approaches using both the Haddon Matrix and the public health approach should provide the greatest chance of success for a prevention strategy.
Injury prevention professionals have long supported that concept that successful interventions include education, legislation, and engineering/environmental changes. An example of this combination is child safety seat use. Much success has occurred due to extensive education, passage of legislation requiring child safety seat in all 50 states, and engineering changes so that seats are now more easily installed, especially with the new systems that do not require a seatbelt.
As interventions are developed, there is a real need for partnerships to be forged between professionals and community members. Partners in program development, implementation, and evaluation may include healthcare providers, educators, injury prevention professionals, parents, coalition members, school representatives, church representatives, engineers, legislators, media, and so on.
Future directions in the field of children's injury prevention involves a number of strategies, including the incorporation of better-tested and more sophisticated educational, legislative, and environmental intervention strategies. An integral component is the continued building of community partnerships, with the inclusion of parents in outreach efforts. A recent study showed that theory-driven, stage-tailored communication may very well enhance parent's exposure to injury prevention communication materials.[26] Also, it was found that computer technology and tailored messages can be effectively used through kiosks to deliver injury prevention messages in pediatric emergency departments that serve low-income, low-literacy families.[27] Mothers have often been targeted for injury prevention research and outreach; however, fathers should also be included and supported.[28]
Although all types of children's unintentional injuries need to be closely monitored, the rate of all-terrain vehicle (ATV)-related injuries continues to increase. Data from a level 1 pediatric trauma center in Dallas showed the incidence of children admitted for ATV-related injuries increased from 0.9% of admissions in 2000 to 2.4% of admissions in 2005 -- representing a 322% increase.[29] The median age for these injuries was 8.6 years and 82% of the children were not wearing protective gear at the time of the injury.[29] Another study showed that children who had been treated for an ATV injury had a very high rate of recidivism of ATV use.[30]
The ATV issue is a prime example of how there is a need for more creative and innovative strategies to combat injuries. Great strides have been made in children's injury prevention and there is much to be proud of. However, the morbidity and mortality related to injuries are still unacceptably high and new solutions are needed. These may include a greater focus on behavioral or environmental changes, or most likely, a combination of both. By working together and building on what has been learned in the past, healthcare professionals can and will make a difference.
