Outcomes after injury prevention counselling in a paediatric office setting: a 25-year review

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life.

METHODS

We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2 centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors.

RESULTS

A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.

CONCLUSIONS

In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.

Assessment of the Smoke Free Families Tobacco Screening, Counseling, and Referral Program in Pediatric Primary Care Practices

OBJECTIVE

The Smoke Free Families (SFF) program trained pediatric providers to use an SFF tool during well-child visits (WCVs) of infants ≤12 months to "Ask" caregivers about tobacco use, "Advise" smokers to quit, and "Refer" smokers to cessation services (AAR). The primary objectives were to assess the prevalence and changes in caregiver tobacco use after being screened and counseled by providers using the SFF tool. A secondary objective was to examine providers' AAR behavior facilitated by using the SFF tool.

METHODS

Pediatric practices participated in 1 of 3 6-9-month SFF program waves. Over the 3 waves, all initial SFF tools completed on caregivers during their infant's WCV were evaluated for the caregiver and household tobacco use and providers' AAR rates. An infant's first and next WCV was matched to determine changes in caregiver tobacco product use.

RESULTS

In total, the SFF tool was completed at 19,976 WCVs; 2081 (18.8%) infants were exposed to tobacco smoke. A total of 834 (74.1%) caregivers who smoked received counseling: 786 (69.9%) were advised to quit, 700 (62.2%) were given cessation resources, and 198 (17.6%) were referred to the Quitline. In total, 230 (27.6%) of caregivers who smoked had a second visit; 58 (25.2%) self-reported that they quit using tobacco. Among cigarette users (n = 183), 89 (48.6%) reported that they used fewer cigarettes or quit at their infants' second WCV.

CONCLUSIONS

Systematic use of the SFF AAR tool during infants' WCVs could improve the health of caregivers and children, resulting in decreases in tobacco-related morbidity.

Secure windows for child safety: a retrospective study of window falls in children, aiming to raise prevention awareness

PURPOSE

The aim of the study is to enhance understanding, raise awareness and inform prevention programmes regarding potential factors that lead to severe paediatric injuries caused by unintentional falls from windows.

METHODS

This is a retrospective review from a major Trauma Centre, covering the majority of North West England and North Wales and included children under the age of 16 that had sustained falls from windows and were hospitalised between April 2015 and June 2020.

RESULTS

Overall, 825 patients' records have been reviewed, 39% of which exhibited neurosurgical injuries (322 admissions). The most common cause of injury was falls (42%), out of which 19% was identified as falls from windows which was eventually the core focus of this review (25 patients). The records showed that 72% of the falls were not witnessed by another individual, suggesting that children were being left unattended. Average GCS recorded at presentation was 11.2 and 56% of cases were identified as severe major traumas. With a mean stay of 2.2 days in ICU, 1.6 days in HDU and 6 days in the neurosurgical clinic, average treatment costs per patient were £4,493, £651 and £4,156 respectively. Finally, 52% of patients were identified to require long-term physiotherapy/occupational therapy due to permanent disabilities, 20% long-term antiepileptic treatment for seizures and 44% long-term psychological services input.

CONCLUSION

This study presents our experience at a major tertiary trauma centre in the UK over a 5-year period, from a paediatric neurosurgical injuries perspective due to fall from windows. We aim to raise awareness and highlight the importance of establishing prevention programmes which would hopefully decrease the incidence of paediatric window falls.

Availability of death review of children using death certificates and forensic autopsy results

The Model Project for Child Death Review (CDR) was initiated in Japan, but parental consent is required for detailed investigations. We proposed an alternative method to review child deaths using death certificates and forensic autopsy results when parental consent is not provided. We extracted and reviewed death certificates for the deceased younger than 18 years from among all certificates submitted in Shiga Prefecture between 2015 and 2017. In addition, we analyzed autopsy records in cases that underwent forensic autopsy. The prevalence of each cause of death was compared among age groups. The situation and circumstances of unnatural deaths were analyzed in detail. Of 131 certificates, unnatural deaths accounted for 29.7 %. The prevalence of each cause of death significantly differed among age groups. Malignant disease and suicide were most common in school-aged children and congenital disease was most common in infants. Suicide was the leading cause of unnatural death, followed by suffocation, which was most common in infants. Situations where suffocation was reported included co-sleeping with the mother and breastfeeding. Despite parental consent not being obtained, the trends of regional child deaths and the circumstances of accidental deaths were clarified by the present method. However, the results of detailed investigation were lacking. This study provided basic information for implementing detailed methods and procedures for CDR at the governmental level. To perform optimal CDR, legislation for collecting detailed information without parental consent is required.

Drowning prevention counselling by paediatricians to educate caregivers on water safety

AIM

Drowning is the leading cause of unintentional injury death for children 1-4 years of age in the USA. Texas, a southeastern state, is disproportionately burdened by paediatric drowning. The aim of this project was to increase drowning prevention counselling provided during well-child visits to families with children aged 0-10 years.

METHODS

We developed and implemented a water safety counselling programme for paediatricians to impart to families during well child, urgent care and ED visits for 0-10 year age group. Physicians completed and self-reported demographic, pre- and post-intervention, counselling rate and project evaluation surveys, while caregivers completed post-intervention surveys only. Both physicians and caregivers were surveyed on evidence-based drowning prevention strategies (four-sided fencing of pools, touch supervision, life jackets and swim/cardio-pulmonary resuscitation classes).

RESULTS

Thirty-three physicians and 1934 caregivers participated in the project. Physicians demonstrated statistically significant improvement in discussing drowning prevention with patients (3.5 vs. 4 on Likert scale; P = 0.002) in 2018 versus 2019. The counselling frequency in primary care settings increased from 54% to 70% from year 1 to 2. 100% of physicians correctly identified the best drowning prevention strategy and 80.6% of caregivers reported learning new water safety information in 2019 versus 68.8% in 2018 (P value < 0.001).

CONCLUSIONS

This water safety education programme demonstrated increased drowning prevention counselling during well-child visits. The counselling was effective as demonstrated by increased caregiver acquisition of new water safety information. Paediatricians had adequate drowning prevention knowledge; an efficient counselling strategy helped them impart this knowledge to their patients.

Trends in Abusive and Nonabusive Injury Hospitalizations in Young Children in Texas, 2004-2018

Hospitalization data provide context to understanding abusive and non-abusive injuries and how these hospitalizations change over time. The purpose of this study was to utilize Texas inpatient hospitalization data to assess age-related differences among infants (<12 months of age) and toddlers (12-59 months of age) in injury trends and patterns of injury among abusive and non-abusive hospitalization encounters over a 15-year time period. For both age groups, pediatric hospitalizations for non-abusive injuries decreased significantly over time; however, hospitalizations for abusive injuries did not. Compared to non-abusive injury hospitalizations, abusive injury hospitalizations were statistically more likely to involve more body regions and were associated with fractures, internal organ injuries, and superficial wounds. Abusive injury hospitalizations had longer lengths of stay and resulted in higher illness severity scores. Toddler injury hospitalizations were associated with most of the body regions, with the exception of traumatic brain injury for which the odds of hospitalization were higher for infants. This study confirms the persistence of abusive injury hospitalizations and the age-related susceptibility to certain injuries comparing infants and toddlers. The findings reflect the clinical documentation and decision making of pediatric practitioners in a large state over 15 years and inform the trends in identification of injuries which are most common and consistent by age and intent.

Pediatric Health Care Provider Perspectives on Injury Prevention Counseling in Acute and Primary Care Settings

The objective of this study was to characterize how pediatric primary care and emergency medicine health care providers and trainees engage in injury prevention counseling and assess perceptions toward injury prevention resources. We surveyed physicians, advanced practice providers, and trainees in the Emergency Department, Primary Care Network, and Pediatric Residency Program at Children's Hospital of Philadelphia from September to November 2019. Of the 578 eligible participants, 208 (36.0%) completed the survey. When asked to rank the suitability of alternative personnel for providing counseling, 63.0% of the participants selected an injury prevention specialist as best suited. Seventy-six percent of the providers considered a tablet or mobile device used before a patient encounter to be a helpful resource. Variability existed in provider comfort, knowledge, and frequency of counseling by injury topic. Free-text responses cited time as a barrier to counseling. Opportunities exist to improve the provision of injury education through the utilization of novel resources and personnel.

Pilot of primary care physician discussion and resource allocation after screening for unintentional injuries and social determinants of health

Background

Standardized screening tools used by pediatric providers can help determine a child’s injury and social risks. This study determined if an office-based quality improvement program could increase targeted anticipatory guidance and community resource distribution to families.

Methods

Practices recruited from the Ohio Chapter, American Academy of Pediatrics’ database self-selected to participate in a quality improvement project. Two age-appropriate screening tools, corresponding talking points and local resources for birth–1 year and 1–5 year aged children were developed for unintentional injury and social health determinant topics. After a one-day learning session, practice teams implemented the tools into well-child care visits for children < 5 years of age. Two months of retrospective baseline data was collected for each participating clinician. During the 6-month collaborative, physicians randomly reviewed 5 screening tools monthly for each age category to identify injury and social risk discussions and to determine if resources were provided. Frequencies of counseling and resource distribution were calculated. Participating providers received Maintenance of Certification IV credit.

Results

Ten practices (18 providers) participated and 667 tools (n = 313, birth-1 year, n = 354, 1–5 year) were collected. For birth–1 year, the most common risky behaviors were related to unintentional injuries: no CPR training 164(52%), car seat not checked 149(48%) and home furniture not secured 117 (37%). For 1–5 year screens, unintentional injuries were also most common: no CPR training 222(63%), car seat not checked 203(57%) and access to choking hazards 198(56%). Families practiced riskier behaviors for unintentional injuries compared to social risks for both age groups (birth – 1 year, social 189/4801 (4%) vs. unintentional injury questions 999/6260 (16%) and 1–5 years, social 271/5451 (5%) vs unintentional injury questions 1140/6372 (18%). From baseline, discussions increased from 31% to 83% for birth – 1 year and 24% to 86% for 1–5 year families. Resource distribution increased by 63% for birth-1 year and 69% for 1–5 year families by pilot conclusion.

Conclusions

Using standardized screening tools in an office setting shows that families often practice unintentional injury risks more than having social concerns. After screening, appropriate resources can be provided to families to encourage behavior change.