Injury Control

Abstract

After completing this article, readers should be able to: Although there have been major reductions in the number of children and adolescents dying from injuries in the United States over the last 2 decades, trauma remains the most important cause of serious morbidity and mortality in the pediatric age group beyond infancy. Pediatricians play a central role in reducing the toll from injuries, a role that stretches beyond their office and into the community. In this article, we review the current magnitude of the problem and discuss prevention for some of the most important injuries to children and adolescents.The injury control model is based on the concept that the overall burden of trauma can be reduced through the primary prevention of injuries, optimal acute care of the injured patient, and rehabilitation to regain as much preinjury functioning as possible. The focus of this review is primary prevention, but the other components of injury control are within the purview of pediatricians and should not be ignored (Fig. 1).The injury control community has shifted away from use of the term “accident” to use of the term “injury.” More than just a semantic difference, this represents a shift in thinking from the idea that “accidents” are, for the most part, random, unpredictable, and nonpreventable events to the approach that “injuries” are preventable and to some degree predictable. It also focuses attention on the damage to the individual and the methods of controlling this damage through primary prevention, acute care, and rehabilitation. In addition, this conceptual shift allows similar approaches to control of intentional injuries (ie, assaults and self-inflicted injuries) and unintentional injuries (ie, “accidents”) that employ the same tools.In 1998, more than 18,000 children and adolescents in the United States died from injuries (Table 1). Two thirds of these injuries were unintentional, with motor vehicle injuries accounting for the single greatest cause of death. The cause of injury death varies with age. Drowning and fire and burn injuries exact the greatest toll in younger children; intentional injuries are primarily a problem in older adolescents. Motor vehicle occupant injuries are a leading cause of trauma death at all ages, but the number of deaths increases dramatically in the later teen years as adolescents become drivers and ride with other teen drivers.Although death is the most serious outcome from trauma, there are an estimated 18 injury hospitalizations and 200 injury-related emergency department (ED) visits for each child injury death. Among children younger than 21 years of age, there are more than 500,000 hospital admissions for injuries annually. More than 10 million injured children and adolescents are treated each year in hospital EDs. Falls represent the most common injury leading to ED care for children younger than age 15 years; being struck by or against something and motor vehicle injuries are the most common sources of ED trauma visits for teens ages 15 to 19 years.Prevention of motor vehicle injuries must be approached from a developmental perspective because the reasons for injury occurrence and the prevention strategies vary substantially across the pediatric age spectrum. Many of the strategies are well known and are not reviewed here; rather, we concentrate on newer problems and strategies.Pediatricians have been at the forefront of occupant protection for infants and toddlers. All 50 states have laws mandating the use of child restraint devices for infants traveling in motor vehicles; many state laws also cover toddlers and children up to 3 years of age. When children graduate from child car seats, they commonly are placed in adult seat belts or travel unrestrained. Only about one fifth of 4- and 5-year-old children are reported always to be restrained in a child-specific device. Some children place the shoulder belt of adult restraint systems behind them because it comes high across the neck or even the face. Others slouch forward in the seat to allow the knees to bend over the edge of the seat, which causes the lap belt to ride up on the abdomen instead of being anchored on the bony pelvis.There are clear hazards to young children using adult restraint systems. Seat belt-related injuries commonly consist of perforation and deserosalization injuries of the intestine and flexion-distraction injuries of the lumbar spine, with potential for cord damage (Fig. 2). In addition, there is an increased risk of head injuries from striking the interior parts of the car. These injuries are due to the lap belt riding up onto the abdomen instead of being anchored on the pelvis and lack of adequate restraint of the torso in a crash.Seat belt-related injuries can be prevented through the use of booster seats, which are perhaps better labeled “belt-positioning devices.” These relatively inexpensive seats raise the child up to allow proper use of the shoulder harness and provide an “artificial pelvis” to serve as the anchor points for the lap belt. Available data indicate that they can reduce the risk of injury substantially among children in the 4- to 8-year age group. Educational programs can increase use because most parents are unaware of the proper age for graduation of children to adult restraint systems (Table 2). A successful program in Seattle doubled booster seat use within 1 year. The impact of educational programs can be enhanced through legislation mandating use. Washington was the first state to pass such legislation, and other states, including Arkansas and California, have followed. Up-to-date information on choosing the correct car seats for children is available from the American Academy of Pediatrics (Table 3).Ample data indicate that the rear seat is safer than the front seat for both children and adults. One study of children younger than age 15 years found that the risk of serious or fatal injury in a crash was 27% lower for children in the rear seat compared with those sitting in the front seat. In addition, studies conducted by the National Highway Traffic Safety Administration and others indicate that airbags increase the risk of death for children younger than age 13 years who are seated in the front seat. Front airbags appear to offer little protection to children in a crash, but present a risk of serious or fatal injury from airbag deployment. The safest place for children clearly is in the rear seat, properly restrained for their age and size. Educational and legislative interventions to increase the number of children traveling in the rear have been successful.Motor vehicle crashes are the most common cause of injury death among teens in the United States. About 50% of teens who die in motor vehicle crashes are passengers; about 60% of those who die are riding with a teen driver. The risk of motor vehicle crashes is highest among teen drivers and higher among males than females. A 16-year-old teen driver is seven times more likely to crash per mile driven than is a 25- to 29-year-old driver. Research over the last decade has revealed a number of important risk factors for this increased likelihood to crash as well as some effective countermeasures.The number of passengers traveling with teen drivers appears to have a clear influence on the risk of crash. The risk of death among 17-year-old drivers is 50% greater driving with one passenger compared with driving alone; this risk is 2.6-fold higher with two passengers and threefold higher with three or more passengers. The risk is increased further if the passengers are younger than 30 years of age. Dangerous driving behaviors, such as speeding, swerving, running a red light, and drinking while driving, are more common if peers are in the car.Nighttime crashes account for more than one third of teen motor vehicle fatalities. Teens are five- to tenfold more likely to be in a fatal crash driving at night compared with driving during the day. The difficulty of driving at night combined with the inexperience of teen drivers is a deadly combination.Driving after drinking increases the risk of a crash at all ages, but especially for teens. Studies show that the threshold for impairment of driving skills is far below the 0.1 g/dL blood alcohol level commonly defined as intoxication. Recognizing this, all states have now adopted a “zero tolerance” policy for alcohol use among teen drivers. As a result of these and other policies, alcohol-involved fatal crashes among teens have decreased by 61% over the last 2 decades to a low of 21% of fatal crashes in 1998.One strategy for addressing the risks of teen driving is a program of graduated driver licensing (GDL). GDL is based on the premise that driving is a skill that must be practiced, and the time of practice for new drivers should occur under the safest possible conditions. In the past 4 years, 34 states and the District of Columbia have implemented GDL systems. To be effective, at least three stages in GDL are necessary: a beginner stage that has maximum restrictions to ensure safe learning, an intermediate stage that has restrictions on passengers and nighttime driving, and a final stage of unrestricted licensing. A teen moves through the stages only when skills have been demonstrated without citations or crashes and there has been sufficient time for practice. Recent studies from North Carolina and Michigan indicate that fatal crashes among 16-year-old drivers declined by 57% and 25%, respectively, following the institution of GDL. Not surprisingly, GDL laws are widely supported by most parents.High school driver education is a rite of passage for most teens in the United States. A recent evaluation of high school driver education, however, found no good evidence that teens who complete these courses have fewer crashes or violations than those who do not. No differences were found in the short or long term. Additionally, there may be a hidden risk in these programs if state law allows teens who take driver education to be fully licensed at an earlier age. If more young drivers are on the road without a demonstrable increase in driver safety, the net effect may be an increase in motor vehicle deaths.Approximately 250,000 people are hospitalized each year in the United States for traumatic brain injury (TBI), and about 50,000 die. TBI accounts for 70% to 80% of trauma deaths in children, with a particularly high risk among adolescent males. Many survivors have lifelong disability. The most common cause of TBI among children is motor vehicle crashes. Strategies to reduce motor vehicle occupant injury, described previously, are crucial in the prevention of childhood TBI. However, recreational injuries are another important cause of TBI that are amenable to injury control efforts.Bicycles are ubiquitous in childhood; unfortunately, many children do not practice proper riding habits or wear bicycle helmets. Consequently, 30% of bicycle deaths occur in the 5- to 14-year-old age group. Although 90% of these deaths involve collision with a motor vehicle, most nonfatal head injuries are the result of a simple fall. More than 100,000 child cyclists suffer nonfatal head or facial injuries each year, with 20% sustaining a traumatic brain injury.Studies of helmet effectiveness reveal that helmets decrease the risk of bicycle-related TBI by 70% to 88%. They also appear to decrease the risk of injury to the mid- and upper face by 65%. Helmets are effective at all ages and appear to provide benefit whether the crash is a result of a fall or collision with a motor vehicle. The Consumer Product Safety Commission (CPSC) now sets standards for all helmets sold in the United States. Safe helmets can be purchased for less than $20. Community-based programs have been effective in increasing the use of helmets by children. These programs are most effective when they involve multiple venues for the message, when physicians are involved, and when legislation requires children to be helmeted.Parents play a key role in bicycle safety for children. Studies by various groups indicate that most children wear helmets if their parents or accompanying adults are helmeted; fewer than one third of children are helmeted if the accompanying adult fails to wear a helmet. Inculcating the need for wearing a helmet from the first time children ride is the best way to ensure helmet use throughout childhood. Just as young children should not cross streets by themselves, parents need to choose safe areas for young children to bicycle that are away from traffic. Most severe bicycle injuries occur in bicycle-motor vehicle collisions. Parents should limit riding by adolescents who refuse to wear helmets.Head injuries are common in other sports, including skiing, snowboarding, horseback riding, and skateboarding. Although case-control studies have not examined helmet effectiveness for these sports, as they have for bicycling, the overwhelming evidence from studies of bicycle helmets and the availability of helmets for these other sports at a reasonable price strongly argue for their use.Nearly all fire and burn-related deaths to children and adolescents in the United States are due to residential fires. Most of these deaths occur at the scene and are due to smoke inhalation. Those at greatest risk are children younger than age 5 years and the elderly. Counseling to prevent residential fires might include advice to quit smoking (or to keep matches and smoking materials securely stored) and to maintain and use space heaters or other electrical devices properly. Unfortunately, the benefit of such counseling is unproven.Smoke detectors are designed as early warning devices to alert residents that a fire has started so they can vacate the premises and call the fire department. Smoke detectors appear to decrease the risk of fatality in a house fire by 60% to 70%. The prevalence of smoke detectors in the United States varies from 79% in Hawaii to 99% in Maryland. Homes that are most likely to require protection (older dwellings in deprived areas) are least likely to have working smoke detectors.One barrier to smoke detector effectiveness is homeowners taking out the batteries because of frequent false alarms. Among smoke detectors that failed to alarm in a house fire, 59% had been disconnected from their power source, most commonly because of nuisance alarms. One approach to reducing false alarms is to employ photoelectric rather than ionization smoke detectors. Photoelectric detectors have a far lower false alarm rate and are more sensitive to smoldering fires. Unfortunately, most smoke detectors in current use are ionization detectors, in part because they are about half the price.Counseling in physician offices may increase smoke detector ownership and use. Pediatricians can remind families to replace detector batteries every 6 months and to consider obtaining photoelectric detectors if nuisance alarms are a problem. A more practical approach may be to ask public health nurses or other home health visitors to provide information about proper smoke detector installation and use, along with access to low-cost safety equipment. Families also can be encouraged to develop and practice a fire escape plan for their home.Scald injuries are the most common burns in children younger than 4 years of age. Children may be burned when they pull hot liquids onto themselves from a stove, counter, or table. Children have thinner skin than adults and suffer deeper injuries when exposed to the same amount of thermal energy. In addition, a given volume of hot liquid burns a larger proportion of a child’s skin surface than an adult’s. Families can be reminded to use the rear burner on the stovetop, to turn pot handles away from exploring hands, and to keep hot liquids at least 10 in from the table’s edge.Tap water scalds can occur while bathing or washing with inadequate supervision. Although parents always should supervise bathing, simple adjustments to the water heater may be a more effective countermeasure to prevent these scald injuries. Tap water at 160°F (40.7°C) can produce a full-thickness scald burn in less than 1 second. At 120°F (48.4°C), many minutes of exposure are required to produce the same degree of injury. Although many new water heaters are factory-set to maintain a lower water temperature, most families are not served by new water heaters. Parents should be encouraged to test the temperature of their hot water, adjust the water heater as required, and retest the temperature. 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