Injury Prevention

By William B Stratbucker,MD

Injury is the leading cause of death and disability in children and adolescents. "Injury" is not synonymous with "accident." Unlike an accident, a childhood injury is an understandable, predictable, and preventable occurrence.

Pediatric injury prevention is one of the most important and challenging aspects of child health care. Young children inherently lack mature decision-making skills to protect themselves from injury, while some older children and adolescents engage in risky behaviors in attempts to rebel against adult advice. No child is immune to all dangers that pose a threat to his or her health and safety. Statistics show that preventable childhood injuries account for 44% of all deaths in individuals aged 1-19 years. Rates and statistics cited in this article are mainly from the American Academy of Pediatrics Policy Statements, Pediatrics journals, and the AAP publication Injury Prevention and Control for Children and Youth (Widome, 1997). Prevention of childhood injury-related deaths is the responsibility of many. Pediatricians, as guides during a patient's health maintenance checkup, should address injury prevention with parents and caregivers, as well as with the children themselves when appropriate. Parents need to take an active role in preventing childhood injury in and around the home and in the car. Schools and daycare providers are responsible for minimizing hazards and providing a safe environment. Product manufacturers are charged with making products safe for children and are held to safety standards and regulations. Communities and government bodies are responsible for enacting and enforcing child protection laws. Advocacy groups challenge the current state of injury prevention law and manufacturing practice to impact child safety. Citizens who witness violations of child safety laws should alert the appropriate authorities; in certain situations, citizens can be held responsible for not reporting a witnessed neglectful or abusive action. Finally, researchers constantly examine the current state of child safety and the prevailing statistics to identify areas of concern and apply methods to improve the science of injury prevention.

The 3 fundamental aspects of injury prevention science are epidemiology, biomechanics, and behavioral science.

• Epidemiology provides an understanding of the nonrandom distribution of injury risk among populations of children so that areas of concern can be identified and targeted interventions can be designed and implemented.
• Biomechanics provides an understanding of human vulnerability and resilience to limit energy transfer in a potentially injurious event. For example, biomechanics researchers and engineers have continually challenged and updated designs of infant car seats to provide protection in motor vehicle collisions.
• Behavioral science provides knowledge about effective and ineffective ways of altering the risk of injury by manipulating behaviors of children, adolescents, adults, and communities. For example, laws that require the use of seat belts in automobiles can be analyzed for effectiveness in curtailing childhood injury and death.

Injuries, unlike accidents, are understandable, predictable, and preventable.  

A fundamental concept of the science of epidemiology is the phase-factor matrix, introduced in 1972 by William Haddon. The matrix is a conceptual framework that identifies 3 stages of event-related modifiable risk factors within the science of epidemiology.

• Pre-event factors (eg, separating bicyclists from traffic)
• Event factors (eg, protection from head injuries with helmet use while bicycling)
• Postevent factors (eg, availability of emergency services and trauma center after an injury)

Haddon later examined these phases of time in how they relate to the host or victim, the agent (or vehicle), the physical environment, and the social environment. Taking all these elements into account and creating a matrix gives one a framework for how intervention can be applied within each cell of the matrix.

For instance, this matrix can be applied to firearm injuries. Pre-event aspects refer to the age of the child, the curiosity of the child about the weapon, and whether the weapon is out of reach of the child. Places to intervene during the pre-event can be analyzed within each element. The host, or child, can be taught never to play with firearms. The agent, or firearm, can have a trigger lock. In the physical environment, or child's home, the firearm can be locked away out of reach from the child. The social environment for this example can be one in which laws restrict the purchase of firearms.

The event would be the child firing the gun. The amount of harm and damage that would result from this event can be minimized by the host, or victim, wearing bulletproof clothing. The agent, or vector, can have bullets of a less dangerous caliber. The physical environment can include bulletproof glass to also minimize damage and harm from the event. As for the postevent, the extent of injury depends on the host's age and physical condition. The environmental factors involved with the postevent are availability of the Emergency Medical Services (EMS) systems and proximity of trauma centers and pediatric intensive care units.

The 3 forms of injury prevention interventions are as follows:

• Active intervention - An action taken on the part of the child or parent to prevent injury (eg, placing medications out of the child's reach)
• Passive intervention - No action required for the intervention to be successful (eg, packaging of medications in nonlethal amounts)
• Mixed intervention - Part active and part passive (eg, bike helmets inherently protect the cyclist's head, but they must be worn correctly)

Generally, the more effort required on the part of the child or parent, the less successful the intervention.

Racial considerations

American Indian and Alaskan Native children are at a higher risk of unintentional injury than children of other races in the United States. These 2 ethnic groups also have a higher rate of injury-related death. Approximately 700,000 children in the United States are either American Indian or Alaskan Natives. From 1992-1994, a total of 881 injury-related deaths occurred in these populations. This rate is equal to 52.3 per 100,000 compared with a rate of 28.3 per 100,000 children in all races in 1993. The rate of motor vehicle injury in American Indian and Alaskan Native children is 3 times higher than that in black and white children. The rate of motor vehicle injuries to pedestrians is 4 times higher, the rate of drowning is 2 times higher, and the rate of fire or burn injury is approximately 2.8 times higher.