Childhood injury deaths: national analysis and geographic variations

Community features' varying insight into emergency department use for different childhood injuries

BACKGROUND

Community-level factors, including poverty level, minority population, and rurality are predictive of child injury rates. Community-based interventions targeting high-risk communities have been suggested for prevention and are reliant on understanding details of the community and prevalent types of injuries. The present study assessed injury rates based on characteristics of the community and for different types of injuries.

METHOD

A retrospective review of emergency department visits identified zip-code and injury type data for children 0-19. Injuries related to bicycles, falls, motor-vehicle traffic (MTV), and violence were examined. Poverty level, minority population, rural classification, and insured population were obtained at the zip-code level. Regression models examined the association between community features and injury rates for the four categories of injuries.

RESULTS

The results showed that the relationship between community features and injury rates was dependent on injury type. Rurality was associated with a lower rate for bicycle and falls, but a higher rate of MVT; higher insured population was associated with higher MVT and violence rates; higher minority population was associated with lower rates for falls and MTV; and higher population in poverty was associated with lower rate for MTV.

CONCLUSIONS

The findings indicate that injury rates not only cluster among community-level characteristics, but also the type of injury. Variation in community features and injury types offer insight into a holistic approach to child health.

PRACTICAL APPLICATIONS

In addition to other factors related to risk for injuries, health providers' knowledge of features of the local community and prevalent injuries in the environment may be helpful additions to programming geared toward lessening the burden of injuries on children and healthcare systems.

Pattern of childhood injury in a tertiary centre

INTRODUCTION

Childhood injury and death have been projected to be a disease of public health significance, however, the trend in many developing countries of which Nigeria is one is still unknown. We, therefore, examine the pattern of childhood traumatic injury in our institution.

MATERIALS AND METHODS

The information of patients aged 16 years and below who presented with trauma was extracted from the trauma registry of the emergency units of University College Hospital, Ibadan, from 2015 to 2020. Data were analysed using the SPSS version 20.

RESULTS

A total of 3146 children were managed for trauma in the accident and emergency departments of the hospital. Most of them were males (61.2%) and within the under-five age group (36.4%). The majority of the injuries were secondary to fall (41.8%). Male child was more likely to be involved in any mechanism of injury and children between 11 and 16 years were commonly involved in machine hand injury (80%). Following intervention in the accident and emergency department, 44.1% were discharged in the emergency units, 21.5% required admission into the specialist ward, 6.0% died, 5.0% discharged against medical advice and 2.6% were referred.

CONCLUSION

The burden of childhood injury is becoming significant thus demands more attention.

The impact of regionality and hospital status on mortality associated with non-accidental trauma

INTRODUCTION

Non-accidental trauma (NAT) affects 2 per 100,000 children annually in the US and may go unrecognized. The aim of this study to quantify the burden of NAT and to evaluate regional variations in mortality.

METHODS

The Kids Inpatient Database (2000-2012) was queried for pediatric patients presenting with a diagnosis of NAT. Data was obtained on demographic, clinical and hospital-level characteristics. Primary outcome measure was mortality. Multivariable logistic regression models for age, sex, race/ethnicity, insurance status, income quartile, hospital volume, region (Northeast, South, West and Midwest), teaching status, and injury severity scores.

RESULTS

NAT represented 1.92% (n = 15,999) of all trauma patients. Mortality rates were 3.98% for patients presenting with NAT. African American children had a higher likelihood of mortality compared to White children (OR[95%CI]:1.35[1.03-1.79]), however, this effect was not statistically significant for patients being treated at designated children's hospitals (OR[95%CI]:1.23(0.78-1.95) and urban facilities (OR[95%CI]:1.30[0.99-1.72]). Statistically significant regional variations in mortality, lost significance for patients treated at designated children's hospitals (p > 0.05).

CONCLUSION

NAT has devastating consequences and is associated with a high mortality rate. Treatment at designated children's hospitals results in the loss of variation in mortality, resulting in diminished disparities and improved outcomes. These findings align with current trends towards the "regionalization of pediatric health care" and reflects the value of regional transfer centers that are.

A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury

Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.

Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand: a cross-sectional study

OBJECTIVE

Rapid access to advanced emergency medical and trauma care has been shown to significantly reduce mortality and disability. This study aims to systematically examine geographical access to prehospital care provided by emergency medical services (EMS) and advanced-level hospital care, for the smallest geographical units used in New Zealand and explores national disparities in geographical access to these services.

DESIGN

Observational study involving geospatial analysis estimating population access to EMS and advanced-level hospital care.

SETTING

Population access to advanced-level hospital care via road and air EMS across New Zealand.

PARTICIPANTS

New Zealand population usually resident within geographical census meshblocks.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportion of the resident population with calculated EMS access to advanced-level hospital care within 60 min was examined by age, sex, ethnicity, level of deprivation and population density to identify disparities in geographical access.

RESULTS

An estimated 16% of the New Zealand population does not have timely EMS access to advanced-level hospital care via road or air. The 700 000 New Zealanders without timely access lived mostly in areas of low-moderate population density. Indigenous Māori, New Zealand European and older New Zealanders were less likely to have timely access.

CONCLUSIONS

These findings suggest that in New Zealand, geographically marginalised groups which tend to be rural and remote communities with disproportionately more indigenous Māori and older adults have poorer EMS access to advanced-level hospitals. Addressing these inequities in rapid access to medical care may lead to improvements in survival that have been documented for people who experience medical or surgical emergencies.

Perinatal Periods of Risk Analysis: Disentangling Race and Socioeconomic Status to Inform a Black Infant Mortality Community Action Initiative

Objectives The goal of this study is to use Perinatal Periods of Risk (PPOR) analysis to differentiate broad areas of risk (Maternal-Health/Prematurity, Maternal Care, Newborn Care, and Infant Health) associated with being Black from those associated with being poor. Methods Phase I PPOR compared two target populations (Black women/infants and poor women/infants) against a gold standard reference group (White, non-Hispanic women, aged 20+ years with 13+ years of education), then against each other. Phase II PPOR further partitioned excess risk into (1) Very-low-birthweight-risk and (2) Birthweight-specific-mortality-risk and identified individual-level risk factors. Results Phase I PPOR revealed Black excess mortality within the Maternal-Health/Prematurity category (67% of total excess mortality). Phase II PPOR revealed that Black excess mortality within this category was primarily due to premature deliveries of very-low-birthweight infants. In a unique extension of the PPOR methodology, a poverty-excess-PPOR was subtracted from the Black-excess-PPOR, and showed that Black women have substantial excess mortality above and beyond that associated with poverty. Subsequent analyses to identify Black-specific risks, controlling for poverty, found that vaginal bleeding, premature rupture of membranes, history of preterm delivery, and having no prenatal care significantly predicted preterm delivery. Conclusions This study demonstrated the utility of PPOR, a standardized risk assessment approach for focusing health promotion efforts. In the study community, PPOR identified that maternal preconception and prenatal factors contributed the greatest risk for Black infants due to prematurity and low birthweight. Higher socioeconomic status did little to mitigate this risk. These findings informed a community-wide plan that integrated evidence-based strategies for addressing systematic racial inequity with strategies for addressing systematic socioeconomic disadvantage.

Spatiotemporal approaches to analyzing pedestrian fatalities: the case of Cali, Colombia

OBJECTIVE

Injuries among pedestrians are a major public health concern in Colombian cities such as Cali. This is one of the first studies in Latin America to apply Bayesian maximum entropy (BME) methods to visualize and produce fine-scale, highly accurate estimates of citywide pedestrian fatalities. The purpose of this study is to determine the BME method that best estimates pedestrian mortality rates and reduces statistical noise. We further utilized BME methods to identify and differentiate spatial patterns and persistent versus transient pedestrian mortality hotspots.

METHODS

In this multiyear study, geocoded pedestrian mortality data from the Cali Injury Surveillance System (2008 to 2010) and census data were utilized to accurately visualize and estimate pedestrian fatalities. We investigated the effects of temporal and spatial scales, addressing issues arising from the rarity of pedestrian fatality events using 3 BME methods (simple kriging, Poisson kriging, and uniform model Bayesian maximum entropy). To reduce statistical noise while retaining a fine spatial and temporal scale, data were aggregated over 9-month incidence periods and censal sectors. Based on a cross-validation of BME methods, Poisson kriging was selected as the best BME method. Finally, the spatiotemporal and urban built environment characteristics of Cali pedestrian mortality hotspots were linked to intervention measures provided in Mead et al.'s (2014) pedestrian mortality review.

RESULTS

The BME space-time analysis in Cali resulted in maps displaying hotspots of high pedestrian fatalities extending over small areas with radii of 0.25 to 1.1 km and temporal durations of 1 month to 3 years. Mapping the spatiotemporal distribution of pedestrian mortality rates identified high-priority areas for prevention strategies. The BME results allow us to identify possible intervention strategies according to the persistence and built environment of the hotspot; for example, through enforcement or long-term environmental modifications.

CONCLUSIONS

BME methods provide useful information on the time and place of injuries and can inform policy strategies by isolating priority areas for interventions, contributing to intervention evaluation, and helping to generate hypotheses and identify the preventative strategies that may be suitable to those areas (e.g., street-level methods: pedestrian crossings, enforcement interventions; or citywide approaches: limiting vehicle speeds). This specific information is highly relevant for public health interventions because it provides the ability to target precise locations.

The cost-effectiveness of New York City's Safe Routes to School Program

OBJECTIVE

We evaluated the cost-effectiveness of a package of roadway modifications in New York City funded under the Safe Routes to School (SRTS) program.

METHODS

We used a Markov model to estimate long-term impacts of SRTS on injury reduction and the associated savings in medical costs, lifelong disability, and death. Model inputs included societal costs (in 2013 US dollars) and observed spatiotemporal changes in injury rates associated with New York City's implementation of SRTS relative to control intersections. Structural changes to roadways were assumed to last 50 years before further investment is required. Therefore, costs were discounted over 50 consecutive cohorts of modified roadway users under SRTS.

RESULTS

SRTS was associated with an overall net societal benefit of $230 million and 2055 quality-adjusted life years gained in New York City.

CONCLUSIONS

SRTS reduces injuries and saves money over the long run.

Clinical clues for head injuries amongst Malaysian infants: accidental or non-accidental?

Identifying the differences between infants with non-accidental head injuries (NAHI) and accidental head injuries (AHI) may help alert clinicians to recognize markers of abuse. A retrospective review of infants <1 year of age admitted to a tertiary referral centre in Malaysia over a two year period with a diagnosis of head injury or abnormal computed tomography head scans was conducted to identify the clinical features pointing towards a diagnosis of NAHI by comparing the socio-demographics, presenting complaints, clinical features and the extent of hospital investigations carried out. NAHI infants were more likely to be symptomatic, under a non-related caregiver's supervision, and presented with inconsistent or no known mechanism of injury. Subdural haemorrhages were more common in NAHI infants. The history, mechanism of injury, presenting signs and symptoms as well as the nature of the injuries sustained are all valuable clues as to whether a head injury sustained during infancy is likely to be accidental or not.

A 10-year epidemiologic review of homicide cases in children younger than 5 years in Fulton County, GA: 1996-2005

The primary purpose of this study was to present the epidemiologic review of homicide deaths certified by the Fulton County Medical Examiner's Office from January 1, 1996 through December 31, 2005 in children younger than 5 years. The secondary purpose of this study was to determine if the observed cases of homicide deaths among children younger than 5 years in Fulton County are significantly greater than expected when compared with those in the State of Georgia. For purposes of this study, only homicide deaths of Fulton County residents were included. The authors reviewed all homicide cases in children younger than 5 years: infancy (<1 year) and early childhood (1-4 years). χ values were calculated using Epi Info (version 3.4.1; Centers for Disease Control and Prevention, Atlanta, Ga) to determine differences in homicide among age group, race, and sex variables. In addition, a χ test at the α level of 0.05 was done to determine if the observed cases of homicide deaths among children younger than 5 years in Fulton County were significantly greater than expected when compared with those in the State of Georgia. There were 49 homicide cases in children younger than 5 years identified over this 10-year period. The yearly distribution of these 49 homicide deaths ranged from 1 death in 2003 to 9 deaths in 2004. Most of the patients were male (n=29, 59.2%) and black (n=44, 89.8%). Between infancy and early childhood cases, homicide victims were nearly equally divided between the 2 groups. However, χ values showed that decedents younger than 5 years are more likely to have died of homicide compared with decedents 5 years or older (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.29-2.35). Black decedents younger than 5 years are more likely to have died of homicide compared with other races (OR, 3.21; 95% CI, 1.21-9.28). Male and female decedents are equally at risk to have died of homicide (OR, 1.14; 95% CI, 0.61-2.11). The authors also determined that the total homicide risk for children younger than 5 years in Fulton County during the years 1996 to 2005, at the α level of 0.05, is 1.8 relative to the state. Brain injury was the primary cause of death in most cases (n=23, 46.9%). Although this study was unable to collect information on the victim's suspect/offender characteristics, it was noted that only 37% of the cases (n=18) went to trial. Most homicide investigations were under the Atlanta police jurisdiction (n=28, 57.1%). Results from this study may assist local and state government officials in recognizing the epidemiologic characteristics of children at risk to help them allocate limited resources efficiently and implement preventive measures to at-risk populations effectively.

Early identification of children at risk of unintentional injury: a sensation seeking scale for children 2-5 years of age

OBJECTIVE

Sensation seeking is a personality attribute associated with injury in school-age children, adolescents, and adults. This study aimed to develop and evaluate the psychometric properties of a questionnaire measure of sensation seeking for young children 2-5 years of age.

METHODS

Items tapping aspects of sensation seeking (Novelty Seeking, Behavioral Intensity, Thrill Seeking) were developed, content validation was completed by child development experts, and 72 parents then completed the Sensation Seeking Scale for Young Children (SSSYC) twice (3 months intervening) to establish internal and test-retest reliabilities. To assess criterion validity, scores were related to children's preferences for high versus low sensation seeking activities, their free play behavior in an indoor playroom, and to children's history of unintentional injuries.

RESULTS

Indices of internal reliability and test-retest reliability were good and questionnaire scores positively correlated with sensation seeking behaviors during free play, preferences for high versus low sensation seeking activities, and injury measures, providing support for criterion validity.

CONCLUSION

This initial evaluation of the SSSYC suggests that it is a psychometrically sound measure of sensation seeking. This scale may be useful for identifying high sensation seekers at young ages, providing the opportunity for early intervention to prevent unintentional injuries.

The burning issue of injury in Ireland: Part 1

Intentional and non intentional injury is a major global public health concern. Traditionally, injuries have been regarded as random, unavoidable 'accidents'. However, within the last few decades a better understanding of the nature of injuries has changed these old attitudes, and today both unintentional and intentional injuries are viewed as largely preventable events. Burn injuries are of special importance in the field of injury prevention. On average, 82 people die in Ireland each year from fire and burns. However, burn injuries have known causes and can be prevented and controlled. In order to prevent burn injuries it is important to understand the aetiology and epidemiology of burn injuries. The aim of this 3 part series of articles is to provide an overview of burn injury care where this first article focuses on current epidemiology, aetiology and burn injury prevention strategies.

Mortalities among children and adolescents in manipal, southern India

OBJECTIVE

To describe the epidemiology and trends of traumatic deaths among children and adolescents in Manipal, Southern India.

METHODS

Analysis of all trauma deaths in children and adolescents aged between 1 and 19 years, autopsied between January 1994 and December 2005. The study is based on autopsy records, information furnished by the police, and chemical analysis report.

RESULTS

There has been a substantial decline in the incidence of traumatic deaths among children and adolescents during 1994 to 2005. Road traffic injuries were responsible for maximum mortalities (38.4%), followed by those because of burns (24.9%) and poisoning (15.9%). Males comprised 59.6% of cases. Male-to-female ratio was 1.5:1. Males predominantly died of traffic injuries (45.2%), whereas females as a result of burns (37.4%). There was more than two-fold increase in injury-related mortalities from childhood to adolescence (1:2.3).

CONCLUSION

Among children and adolescents, traffic injuries and burns are responsible for maximum injury-related mortalities in males and females, respectively. More injury reducing measures are required for effective reduction in traumatic deaths.

Incidence and pattern of burn injuries among children with disabilities

BACKGROUND

Burn injuries are an important cause of severe morbidity and mortality among children. However, the epidemiology of burns among disabled children has received little attention.

METHODS

Burn injuries were identified for children aged less than 12 years using International Classification of Diseases, Ninth Revision, Clinical Modification codes in Ohio Medicaid claims data. Using FY2002 Ohio Medicaid claims data, incidences and relative risks of burn injuries for disabled and nondisabled children were calculated by age, gender, and race or ethnicity. Logistic regression was used to analyze risk factors for burn injuries.

RESULTS

There were 4,307 burn injuries identified in the FY2002 Ohio Medicaid claims database. The incidence of burn injuries for disabled children was significantly higher than for nondisabled children (103.00 per 10,000 vs. 77.41 per 10,000, respectively; p < 0.001). Children aged 1 or 2 years had the highest incidence of burn injuries, regardless of disability status. For disabled children, the incidence of burn injuries decreased after 2 years of age and leveled out at approximately 100 per 10,000 children after 3 years of age. However, for nondisabled children, the incidence of burn injuries decreased until 6 years of age, after which it leveled out at approximately 40 per 10,000 children. After controlling for potentially confounding factors, the risk of burn injuries was significantly higher for disabled than nondisabled children (odds ratio = 1.80; 95% confidence interval, 1.50-2.17).

CONCLUSIONS

Disabled children had a significantly higher incidence of burn injuries than nondisabled children did. The risk of burn injuries, even after controlling for demographic factors, was significantly higher for disabled children than nondisabled children.

Epidemiology and mechanisms of femur fractures in children

The most common pediatric orthopaedic injury requiring hospitalization is a femur fracture. This study aimed to identify the epidemiology and mechanisms of injury so that these injuries might be reduced through specifically targeted safety measures. Data for this study were culled from the 2000 Kids' Inpatient Database representing over 2.5 million pediatric hospital discharges. Of the nearly 10,000 femur fractures, 1076 (11%) occurred in children younger than 2 years; 2119 (21%) in children aged 2 to 5 years; 3237 (33%) in children aged 6 to 12 years; and 3528 (35%) in adolescents aged 13 to 18 years. The most (71%) occurred in male patients. Falls and motor vehicle collisions accounted for two thirds of those injuries, with the incidence of falls greater in the younger children and motor vehicle collisions more prevalent in older children. Fifteen percent of femoral fractures in children younger than 2 years were because of child abuse. Length of hospital stay, number of diagnoses and procedures, and hospital charges were greatest in the adolescent age group, likely because of high-energy trauma with resultant polytrauma. Hospital charges were more than 222 million dollars with the average charge over 2.5 times that in adolescents compared with infants/toddlers. Pediatric orthopaedists must continue to press for increased safety for our children, particularly adolescent motor vehicle safety. Abuse should be considered when a child younger than 2 years presents with a femoral fracture.

Trends in childhood injury mortality in Canada, 1979-2002

OBJECTIVE

To examine national trends in mortality rates for injuries among Canadian children younger than 15 years in 1979-2002.

METHODS

Data on injury deaths were obtained from the Canadian Vital Statistics system at Statistics Canada. Injuries were classified using the codes for external cause of injury and poisoning (E-codes) by intent and by mechanism. Mortality rates were age adjusted to the 1990 world standard population. Negative binomial regression was used to estimate the secular trends.

RESULTS

Annual mortality rates for total and unintentional injuries declined substantially (from 23.8 and 21.7 in 1979 to 7.2 and 5.8 in 2002, respectively), whereas suicide deaths among children aged 10-14 showed an increasing trend. All Canadian provinces and territories showed a decreasing trend in mortality rates of total injuries. Motor vehicle related injuries were the most common cause of injury deaths (accounted for an average of 36.4% of total injury deaths), followed by suffocation (14.3%), drowning (13.5%), and burning (11.1%); however, suffocation was the leading cause for infants. The number of potential years of life lost due to injury before age 75 decreased from 89 343 in 1979 to 27 948 in 2002 for children aged 0-14 years.

CONCLUSIONS

During the period 1979-2002, there were dramatic decreases in childhood mortality for total injuries and unintentional injuries as well as various degrees of reduction for all causes of injury except suffocation in children aged 10-14 years and drowning in infants. The reason for the reduction in injury mortality might be multifactoral.

Violent deaths in small children in northern Sweden

OBJECTIVES

To identify causes and trends of violent deaths among children younger than 4 years in a northern region.

STUDY DESIGN

Retrospective analysis of medico-legal autopsy and police data.

METHODS

Data from all 72 deaths from "external causes" 1977-2004, in children < 4 years from the northern half of Sweden were analysed.

RESULTS

The death rate was 7.1 per 100,000 children and year during the first half of the study period, and 5.2 during the second half. Vehicle- and drowning-related deaths were halved. Fifteen were struck by motor vehicles (in 8 cases by heavy vehicles), 14 car occupants were killed in car crashes, 12 were killed by intentional violence inflicted by an adult, and 9 each were killed by (i) carbon monoxide/smoke inhalation, (ii) asphyxiation, or (iii) drowning. The boy:girl ratio was 1:1 in all groups, except in the groups "drowning" and "run over by motor vehicle", where boys dominated.

CONCLUSIONS

Medical professionals have a difficult but important task in identifying and taking action against child abuse and in promoting child safety especially in the traffic and home environments.

Fatal crashes involving young unlicensed drivers in the U.S

INTRODUCTION

Young unlicensed drivers' involvement in fatal crashes is a recurrent problem in the United States.

METHODS

This descriptive study extracted cross-sectional data on fatal crashes from the Fatality Analysis Reporting System from 1998 to 2002. Young unlicensed driver fatal crashes are examined by age, gender, and region.

RESULTS

There were 2,452 young unlicensed driver fatal crashes representing 10.8% of all young drivers' fatal crashes. By age, 72.5% are over 15 years, males are involved in 74.5%, and southern and western states have a higher percent of young unlicensed driver fatal crashes.

CONCLUSIONS

Subgroups of young people based on their age, gender, and region are over-represented in fatal crashes as unlicensed drivers. Further studies are needed to investigate the context and factors of young unlicensed drivers, essential to tailor interventions.

IMPACT ON INDUSTRY

Young unlicensed drivers circumvent the established licensing process and pose a serious threat to themselves and other road users.

Temporal trends, gender, and geographic distributions in child and youth injury rates in Sweden

OBJECTIVE

Sweden has the lowest child injury mortality rate in the world, 5.2/100 000 for children under 15. This paper describes temporal trends in Sweden, as well as gender related and geographic differences.

DESIGN

The Swedish Cause-of-Death Register (1987-2001) and the Hospital Patient Register (1987-2002) were used to compare rates for the country as a whole and for discharges aged 0-20 by municipality, using the SEATS time series analysis program.

RESULTS

There was a decrease in the rate of fatal unintentional injuries from 7 to 4 per 100 000 for girls and from 16 to 10 per 100 000 for boys since 1987. The gap between girls and boys was reduced and boys now have almost the same mortality rate as girls for violence related deaths. Road and other unintentional injuries show a general decrease whereas the pattern for falls varies by age and sex. Self inflicted injuries increased for both sexes, but more for girls. Substantial differences in injury rates between municipalities were also found-up to six times for girls and eight times for boys.

CONCLUSION

Substantial declines in injury fatalities over time were found, but these were different for boys and girls. There remain substantial differences between municipalities. These data, published in a child injury atlas, have prompted substantial interest among media and the authorities.

Urban-rural variation in mortality and hospital admission rates for unintentional injury in Ireland

OBJECTIVE

To explore urban-rural differences in the mortality and hospital admission rates for unintentional injuries in the Republic of Ireland.

DESIGN

Standardised mortality ratios (SMRs) in residents of urban and non-city areas (called rural areas) from all causes of unintentional injury were calculated using Central Statistics Office mortality data from 1980-2000. Hospital admission data (Hospital In-Patient Enquiry) from 1993-2000 were used to calculate standardised hospital admission ratios (SARs) in urban and rural residents. Population data were obtained from the 1981, 1986, 1991, and 1996 censuses.

RESULTS

The rate of unintentional injury mortality was significantly higher in rural residents for all-cause unintentional injury mortality (SMR 103.0, 95% confidence interval 101 to 105), and specifically for deaths related to motor vehicle trauma (MVT), drowning, machinery, and firearms. There were significantly higher SMRs in urban residents for falls and poisoning. The rate of unintentional injury hospital admission was significantly higher in rural residents for all-cause unintentional injury (SAR 104.6, 95% confidence interval 104 to 105) and specifically for injuries from falls, MVT, being struck by or against an object, injuries in pedal cyclists, fire/burn injuries, and machinery injuries. SARs were significantly higher in residents of urban areas for poisoning and injuries in pedestrians.

CONCLUSIONS

There are urban-rural differences in mortality and admissions for injuries in Ireland. Possible reasons for the higher rural mortality rates are higher case fatality in MVT and rural exposure to hazardous farm machinery, firearms, and open areas of water. This information could assist in targeting prevention programmes under the proposed National Injury Prevention Strategy.

Medicolegal Childhood Deaths in Adana, Turkey

The objective of this study is to determine the characteristics of and changes in the medicolegal childhood deaths that occurred in the provincial center of Adana, and to contribute to the establishment of a database for the development of national and international policies. The study is a retrospective research examining the 1,110 cases in the age group 0 to 18, which were specified as medicolegal deaths in the provincial center of Adana-Turkey between the years 2000-2004. The cases were examined according to age, sex, causes of deaths, the origins and scenes of occurrence. Among all the deaths, 523 cases (47.2%) were seen in the age group of 0-6 years. Accidents account for 900 cases (81.1%), and blunt traumas (594 cases) represent the most common cause of deaths. The share of traffic accidents in total blunt traumas was found to be 441 cases (74.2%). And 270 (24.3%) of all medicolegal deaths occurred as a result of household accidents. The present study has also indicated that the home and surroundings represent the highest-risk areas. As a conclusion, setting up childhood injury prevention committees and providing training programs for parents will be effective for the prevention of childhood injuries and deaths.

Mortality of children in the Transkei region of South Africa

This study attempted to unfold, perhaps for the first time, the problem of childhood mortality resulting from trauma in the Eastern Cape Province of South Africa. This study was carried out in the Umtata and Ngqeleni magisterial districts, which have a combined population of about 400,000. Most people there have very few resources and have historically relied on money repatriated by migrant workers. In the Transkei region, unemployment is at a very high level: 48.5%. Assault on children is very common in this region, and this may result in death. The aim of this study was to establish the state of deaths resulting from pediatric trauma, and to formulate recommendations that could probably help prevent or reduce these deaths. The objective was to gather epidemiologic information on the victims of pediatric trauma. The study was designed as a descriptive study, using reviews of traumatic deaths in pediatric age groups during the period January 1993 to December 1999. This study was carried out on cases that were brought to the medicolegal laboratory at Umtata General Hospital, Umtata, in the Transkei region of the Eastern Cape Province, South Africa. There were 6181 autopsies conducted from 1993 to 1999. All the medicolegal autopsies were divided into two groups: pediatric (15 years of age or younger) and adult (older than 15 years). Of the autopsies, 89.4% (n = 5587) were in the adult group, and 10.6% (n = 594) were in the pediatric group. Of the pediatric deaths, 64% (n = 383) were related to trauma. The highest numbers were in the 11- to 15-year (n = 146, 38%) and the 6- to 10-year (n = 135, 34%) age groups. Of the children who died of trauma, 112 (28%) were aged 0 to 5 years. Unintentional injuries from motor vehicle accidents were the leading cause of death (59%), whereas intentional injuries (41%) were associated with murder. Nearly a quarter (22%) of pediatric traumatic deaths were due to penetrating injuries: stab (12%) and gunshot (10%) wounds. Most of the pediatric deaths occurred during the festive months of December, January, and April; the death toll during these months was three to four times higher than in the rest of the year. It was concluded that 64% of pediatric deaths in the Transkei region were the result of trauma. This represents 1 pediatric trauma death for every 10 adult trauma deaths. Forty-one percent of the child trauma deaths were due to intentional injuries, usually murder. It is recommended that the government set targets and put into place strategies for the reduction of pediatric deaths due to trauma. The different deaths so called "rule of reversal" could be considered as an indicator of social health.

Characteristics of injured children attending the emergency department: patients potentially in need of rehabilitation

OBJECTIVE

To provide an epidemiological overview of the characteristics of injured children and to compare hospitalized and nonhospitalized injured children to identify predictors of hospitalization and, with that, possible predictors of disablement.

DESIGN

Retrospective analysis of data obtained from a computerized trauma registration system and medical records.

SETTING

Department of Traumatology, University Hospital Groningen, the Netherlands.

SUBJECTS

Children (0-19 years) injured in 1996 and 1997 (n = 5,057).

RESULTS

The majority of children were injured in home and leisure accidents (53%) and sustained minor injuries. Only 55 (1%) children were severely injured (Injury Severity Score (ISS) > or = 16). Overall, 512 (10%) patients required hospitalization, 19 children were referred to a rehabilitation centre, and 24 children died due to their injuries. The majority of these patients were injured in traffic. Compared with the group of nonhospitalized patients, the group of hospitalized patients consisted of more males and traffic victims, were more severely injured and sustained more head/neck, spine, and thorax and abdomen injuries. Nonhospitalized patients incurred proportionally more upper and lower extremity injuries. The ISS, the body region of most severe injury, and injury cause (traffic accidents) were significant predictors of hospitalization.

CONCLUSIONS

Young traffic victims, severely injured children in terms of high ISS scores, and children with injuries affecting the head/neck/face or thorax/abdomen carry the highest risk of hospitalization.

How common is abuse in Greece? Studying cases with femoral fractures

AIMS

To examine the extent of undiagnosed child abuse in Greece by studying young children with femoral fractures, which may be associated with abuse.

METHODS

Fifty seven consecutive cases of children under 6 years of age with femoral fracture were identified from the Emergency Department Injury Surveillance System database. Controls were 4162 children with other orthopaedic injuries from the same database.

RESULTS

Whereas in the literature about one third of femoral injuries among young children are attributed to child abuse, no child in the studied series had been diagnosed or even investigated in this context. Nevertheless, the pattern of occurrence of femoral injuries was compatible with that of child abuse, in that patients were frequently very young boys of low socioeconomic status, and the accident had frequently occurred under poorly identified or implausible conditions at time periods when most family members were crowded at home.

CONCLUSIONS

Epidemiological risk factors for child abuse characterise femoral fractures in young children in Greece. It appears that child abuse is present in this country as in most other cultures. There is a clear need for refocusing medical personnel and hospital social services so that the problem is revealed, quantified, and appropriately dealt with.

Firearm availability and unintentional firearm deaths

BACKGROUND

Between 1979 and 1997, almost 30,000 Americans died from unintentional firearm injuries, half of whom were under 25 years of age and 4,600 of whom were less than 15 years old.

PURPOSE

To explore the association between state firearm levels and rates of unintentional firearm deaths by age group, accounting for several potential confounders.

METHODS

The study used a proxy for firearm availability and pooled cross-sectional time-series data on unintentional firearm deaths for the 50 United States from 1979 to 1997. Negative binomial models were used to estimate the association between firearm availability and unintentional firearm deaths.

RESULTS

A statistically significant and robust association exists between gun availability and unintentional firearm deaths for the US as a whole and within each age group. Multivariate analysis found that, compared to states with the lowest gun levels, states with the highest gun levels had, on average, 9 times the rate of unintentional firearm deaths. These results hold among men and women, for Whites and African Americans.

CONCLUSION

Of the almost 30,000 people who died in unintentional firearm deaths over the 19-year study period, a disproportionately high number died in states where guns are more prevalent. The results suggest that the increased risk of unintentional violent death among all age groups is not entirely explained by a state's level of poverty, urbanization, or regional location.

Injury related infant death: the impact of race and birth weight

OBJECTIVE

To examine the effect of race and birth weight independent of other sociodemographic factors on injury related infant death using national data.

SETTING

Infants born in the United States to mothers who were white (non-Hispanic), African American, Mexican American, and Native American.

METHODS

Linked infant birth and death data from the National Center for Health Statistics for 1989-91 were analyzed to calculate unadjusted and adjusted odds ratios for death due to homicide or unintentional injury within the first year of life. In addition to maternal race and birth weight, the risk of death was adjusted for maternal age, prenatal care, maternal education, paternal education, marital status, birth order, interval since last pregnancy, smoking during pregnancy, and alcohol intake during pregnancy.

RESULTS

Among 10.7 million births during 1989-91, 821 homicides and 2397 unintentional deaths were reported in infants. Relative to whites, African Americans were at highest risk for homicides (unadjusted and adjusted odds ratios = 3.6 (95% confidence interval = 3.1 to 4.2) and 1.6 (1.3 to 1.9), respectively) and Native Americans at highest risk for unintentional injuries (unadjusted and adjusted odds ratios = 3.8 (3.0 to 4.8) and 2.1 (1.7 to 2.6), respectively). After accounting for other sociodemographic factors, Mexican American infants appeared protected from injury (adjusted odds ratio = 0.7 (0.6 to 1.0) for homicides and 0.7 (0.6 to 0.8) for unintentional injuries). An inverse effect of birth weight was seen-as birth weight decreased, risk of homicides and unintentional injuries increased. After adjustment for the sociodemographic factors, very low birthweight babies were still at substantially increased risk of homicides with an odds ratio of 2.1 (1.4 to 3.1) and unintentional injuries with an odds ratio of 2.9 (2.4 to 3.7).

CONCLUSIONS

Using a large national data-set, the effect of race as a risk factor for fatal infant injuries was mostly explained by birth weight and other sociodemographic factors. Preventable risk factors need to be identified for African Americans and Native Americans, in particular. Birth weight is an important independent risk factor; very low birthweight babies should be monitored for both homicide and unintentional injury.

Solving a linear model of nonfatal risk behavior and injuries in school children

A calculating method and computer program have been developed for solving an overdetermined system of linear equations. It was applied for calculation of group risk exposure of school children (10-15 years) to nonfatal injuries in sport recreation and playing (SRP). Interviewed non-injured school children were separated into non-overlapping groups of risky behavior. Data on interviewed non-injured and non-interviewed injured children were put into a linear system of equations consisting of a 4 x 3 matrix scheme. Each equation represents children of the same age and sex and consists of the percentage of interviewed children grouped into high medium or low risk behavior and of the percentage of injured children. Four methods of calculating the matrix system were evaluated and the best implemented as a new developed computer program. The resulting linear group risk factors enable the prediction of behavior outcome. Data on interviewed injured children were compared with the results obtained. The validation procedure is proposed by testing the sensitivity and robustness of the method.

American Academy of Pediatrics: Falls from heights: windows, roofs, and balconies

Falls of all kinds represent an important cause of child injury and death. In the United States, approximately 140 deaths from falls occur annually in children younger than 15 years. Three million children require emergency department care for fall-related injuries. This policy statement examines the epidemiology of falls from heights and recommends preventive strategies for pediatricians and other child health care professionals. Such strategies involve parent counseling, community programs, building code changes, legislation, and environmental modification, such as the installation of window guards and balcony railings.

Relationship between socioeconomic factors and severe childhood injuries

The objective was to examine the relationship between injury rates and socioeconomic factors for children in Hamilton County, Ohio, using small-area analysis. The subjects were county residents less than 15 years old who were hospitalized or died of injuries between January 1, 1993, and December 31, 1995; they were identified through a population-based trauma registry. The census tract was the unit of analysis; the rate of injury per 100,000 population was the dependent variable. Risk factors included median income, level of education, percentage below the poverty level, percentage unemployment, percentage non-Caucasian, and percentage families headed by females. There were 2,437 children meeting the case definition; injuries per census tract ranged from 0 to 2,020.2 per 100,000 per year. Census tracts with higher injury rates had lower median incomes, more people with less than a high school education, more unemployment, more families headed by females, more people living below the poverty level, and more non-Caucasians than those with lower rates. In a regression model, percentage of people living below the poverty level, percentage of those who did not graduate from high school, and percentage unemployment were significant risk factors for injuries, P < .001. Since small-area analysis examines associations on an ecological level rather than an individual level, these studies should always be interpreted with caution because an association found at the level of the census tract may not apply at the individual level. Interventions to reduce injuries should target socioeconomically disadvantaged children living below the poverty level and those in areas with fewer high school graduates and more unemployment.

Multiple attribute entropy classification of school-age injuries

The data exploration task in epidemiology of school children injuries is aimed at defining specific risk groups that can be further analyzed for definition of prevention measures. These groups are selected by means of entropy classification of relevant data collected in the Koprivnica district, Croatia. The necessary pruning procedure for the entropy classification tree is proposed for: (a) entropy increase for uniformly populated classes, and (b) entropy decrease for the case of zeros in a class. The second reason for pruning is emphasized for multiple (> 3) attribute descriptions of injury events because the number of classes increases exponentially with the number of attributes. Four possible prevention groups have been found by entropy classification: (1) dislocation, sprain and strain injuries, mostly on legs of both age groups of boys (7-10 years, 11-14 years) in/around the house activities; (2) arm fractures of all boys in/around the house activities; (3) open wounds mostly of the head, in younger boys at school, and open wounds in younger boys in road traffic; and (4) contusions mostly on arms, of older girls at school and contusions in older boys in road traffic accidents. These groups comprise 57.2% of all considered cases.

A burn prevention program as a long-term investment: trends in burn injuries among Jews and Bedouin children in Israel

In order to broaden our long-term intervention efforts in elementary schools in Israel (underway since 1988) and to set priorities for further population-specific actions, we compared the pattern of burn injuries among two age groups (0-4; 5-14) of two ethnic groups of Jews and Bedouins admitted to a regional hospital between 1986 and 1995 (n = 1050). The findings indicated a significant downward trend, though somewhat nonlinear, in burn admissions among the older age groups. A relatively less favorable trend was observed for the younger age groups. Consistently across years, burn rates in the younger group of Bedouin children were the highest. For the 10-year period, a significant season by ethnic group variation in burn admissions was observed, with a peak in the spring and in the wintertime for the Jews and Bedouins, respectively. A significant trend of decrease, mostly among older children, in average lengths of hospital stay, was also evident. Yet, regardless of age group and across years, Bedouin children stayed longer in the hospital than Jewish children. The overall leading causes of injury (for 1992-1995) were hot liquids (69%), fire (17%), chemicals (9.5%) and contact (2%). In our view, there is a need to address at-risk populations through environmental, community and family-oriented interventions and to venture beyond the pathogenic factors to the investigation of the salutary factors of health under diverse life conditions.

Motor vehicle and roadway factors in pedestrian and bicyclist injuries: an examination based on emergency department data

Information on 2558 persons treated for injuries incurred while bicycling or walking was collected from eight hospital emergency departments over approximately a one-year time period. The emergency departments represented a mix of urban and suburban/rural sites in three states--California, New York, and North Carolina. The data were collected on special survey forms and included detailed information about the location of the injury event. Results show that, overall, 70% of the reported bicycle injury events and 64% of the reported pedestrian injury events did not involve a motor vehicle. In addition, 31% of the bicyclists and 53% of the pedestrians were injured in non-roadway locations such as sidewalks, parking lots, or off-road trails. Although pedestrians and bicyclists struck by motor vehicles in the roadway were generally the most seriously injured, they represented less than a third of the reported cases. Increased knowledge of non-roadway and non-motor vehicle pedestrian and bicyclist injury events can contribute to more effective program and countermeasure development to improve pedestrian and bicyclist safety.

Epidemiology and prevention of traffic injuries to urban children and adolescents

OBJECTIVES

To describe the incidence of severe traffic injuries before and after implementation of a comprehensive, hospital-initiated injury prevention program aimed at the prevention of traffic injuries to school-aged children in an urban community.

MATERIALS AND METHODS

Hospital discharge and death certificate data on severe pediatric injuries (ie, injuries resulting in hospital admission and/or death to persons age <17 years) in northern Manhattan over a 13-year period (1983-1995) were linked to census counts to compute incidence. Rate ratios with 95% CIs, both unadjusted and adjusted for annual trends, were calculated to test for a change in injury incidence after implementation of the Harlem Hospital Injury Prevention Program. This program was initiated in the fall of 1988 and continued throughout the study period. It included 1) school and community based traffic safety education implemented in classroom settings in a simulated traffic environment, Safety City, and via theatrical performances in community settings; 2) construction of new playgrounds as well as improvement of existing playgrounds and parks to provide expanded off-street play areas for children; 3) bicycle safety clinics and helmet distribution; and 4) a range of supervised recreational and artistic activities for children in the community.

PRIMARY RESULTS

Traffic injuries were a leading cause of severe childhood injury in this population, accounting for nearly 16% of the injuries, second only to falls (24%). During the preintervention period (1983-1988), severe traffic injuries occurred at a rate of 147.2/100 000 children <17 years per year. Slightly <2% of these injuries were fatal. Pedestrian injuries accounted for two thirds of all severe traffic injuries in the population. Among school-aged children, average annual rates (per 100 000) of severe injuries before the intervention were 127.2 for pedestrian, 37.4 for bicyclist, and 25.5 for motor vehicle occupant injuries. Peak incidence of pedestrian and bicyclist injuries occurred during the summer months and afternoon hours, whereas motor vehicle occupant injuries showed little seasonal variation and were more common during evening and night-time hours. Age-specific rates showed peak incidence of pedestrian injuries among 6- to 10-year-old children, of bicyclist injuries among 9- to 15-year-old children, and of motor vehicle occupant injuries among adolescents between the ages of 12 and 16 years. The peak age for all traffic injuries combined was 15 years, an age at which nearly 3 of every 1000 children each year in this population sustained a severe traffic injury. Among children hospitalized for traffic injuries during the preintervention period, 6.3% sustained major head trauma (including concussion with loss of consciousness for >/=1 hour, cerebral laceration and/or cerebral hemorrhage), and 36.9% sustained minor head trauma (skull fracture and/or concussion with no loss of consciousness >/=1 hour and no major head injury). The percentage of injured children with major and minor head trauma was higher among those injured in traffic than among those injured by all other means (43.2% vs 14.2%, respectively; chi2 = 336; degrees of freedom = 1). The percentages of children sustaining head trauma were 45.4% of those who were injured as pedestrians, 40.2% of those who were injured as bicyclists, and 38.9% of those who were injured as motor vehicle occupants. During the intervention period, the average incidence of traffic injuries among school aged children declined by 36% relative to the preintervention period (rate ratio:.64; 95% CI:.58,.72). After adjusting for annual trends in incidence, pedestrian injuries declined during the intervention period among school aged children by 45% (adjusted rate ratio:.55; 95% CI:.38,.79). No comparable reduction occurred in nontargeted injuries among school-aged children (adjusted rate ratio:.89; 95% CI:.72, 1.09) or in traffic injuries among younger children who

Fractures of the femoral shaft in children. Incidence, mechanisms, and sociodemographic risk factors

BACKGROUND

Fractures of the femoral shaft in children are caused by major musculoskeletal trauma and result in high direct and indirect medical costs. To date, the American literature has focused on treatment options and outcomes, but the epidemiology of these injuries has been generalized from Scandinavian studies reported in the 1970s and early 1980s. The goals of the current study were (1) to determine the age, gender, and race-specific rates and mechanisms of fractures of the femoral shaft in children in a large United-States-based population and (2) to identify associations between the rates of these fractures and multiple sociodemographic indicators. Such information is vital for preventive efforts.

METHODS

The Hospital Discharge Database of the Maryland Health Services Cost Review Commission for the years 1990 through 1996 was used to obtain demographic data on 1485 cases of acute fracture of the femoral shaft in patients who were less than eighteen years old, and data from the United States Bureau of the Census for the state of Maryland for the year 1990 were used to obtain denominator data. Reliable external-cause data were available from the 1995 and 1996 databases for 472 patients. Small-area analysis was performed at the zip-code level to determine associations between numerous sociodemographic indicators and the rate of femoral shaft fracture.

RESULTS

The annual rate of femoral shaft fracture in children was 19.15 per 100,000. With regard to age, there was a bimodal distribution, with peaks at two and seventeen years. Boys had higher rates of fracture than did girls at all ages, and blacks had higher rates than did whites. The primary mechanisms of fracture were age-dependent and included falls, for children less than six years old; motor vehicle-pedestrian accidents, for those six to nine years old; and motor-vehicle accidents, for teenagers. Firearm-related injuries accounted for 15 percent of the fractures among black adolescents. Adverse socioeconomic conditions were significantly associated with higher rates of fracture.

CONCLUSIONS

The rates and mechanisms of femoral shaft fractures in children depend on age, gender, and race. For children living in the United States today, the epidemiology of these fractures is different than that described in earlier, Scandinavian reports.

Outcome and cost of child abuse

OBJECTIVE

To compare the cases of child abuse (CA) with other admissions in a pediatric intensive care unit (PICU) for differences in patient-specific health care costs, severity of illness (SI) and mortality, and describe their outcome.

METHOD

A retrospective cohort study of all patients admitted to the PICU between January 1991 and August 1994. Discharge diagnosis, age, SI, mortality rate, length of stay, hospitalization charges ($Hosp), and mortality were retrieved.

RESULTS

There were 937 admissions; 13 were secondary to CA. Cases of CA represented 1.4% of admissions and 17% of deaths. CA patients had the highest SI (61%), $Hosp ($30,684), daily charges ($5,294) and mortality rates (53%) than any other group. In our patients, SI is a factor that affects charges. Even when compared to a cohort group with SI, child abuse patients had higher daily hospitalization charges (p < .05). The medical bills for the acute care of a CA patient averaged $35,641 per case. Even with these expenditures, 70% died and 60% of the survivors had severe residual morbidity.

CONCLUSION

These results confirm that interventional medical care in response to severe CA is very costly and the ultimate outcome is significantly worse than other diseases. Therefore, we believe it is imperative to allocate resources to prevention.

Which Prevention Strategies for Child Pedestrian Injuries? A Review of the Literature

In 1992, motor vehicle-related injury was the leading cause of injury-specific death in the United States for children aged zero to fourteen years. In the five to nine years age group, childhood pedestrian injury was exceeded only by motor vehicle occupant injuries as the leading cause of death. The prevention of these injuries is a multifactorial problem involving individual characteristics of the child, environmental design, and the mutual dependence between the child and his or her environment. This article considers the plethora of descriptive and analytical research and proposes suitable strategies to reduce the rate of child pedestrian injury.

Car transportation conditions of preschool children: use of children's car safety seats

The objective of this study was to evaluate children's car safety seat usage in a non-random study population of the Capital and surrounding area of Attica and a provincial region in Greece. One or both of the parents of 1556 children (aged 0-4 years) were interviewed. A questionnaire covering car safety seat usage by area of residence, age of parents, educational background, socioeconomic status and the number of siblings was completed. Optimal car safety seat restraint usage in the Attica region was 10.4% for infants 0-6 months old, 37.6% for infants 7-12 months old, 40.9% for children aged 1-2 years and 12% for children aged 3-4 years; the use of restraint systems in the provincial area was even lower at 4.9%, 15.2%, 24% and 6.6%, respectively. The mother's age, number of children and the socioeconomic status of the family seemed to influence the purchase and usage of the car safety seat. Such a high percentage of non-usage of car safety restraint seats has led to the Paediatric Society's initiative to create informative general public educational programmes and to urge governmental legislation regarding mandatory usage of children's car safety seats.