CHAPTER 45

Injury Prevention

Sarah J. Atunah-Jay, MD, MPH, FAAP, and Iris Wagman Borowsky, MD, PhD, FAAP

Traditionally, unintentional injuries have been called “accidents.” The problem with this term is that it implies unpredictability, carrying with it connotations of chance, fate, and unexpectedness. The perception that injuries are chance occurrences that cannot be predicted or prevented has been a major barrier to progress in injury prevention and the study and control of injury as a scientific discipline. According to the modern view of injury, accidents must be anticipated to be prevented. Specialists in injury prevention have tried to replace the word accident with injury and have developed the idea of reducing injury risk. Thus, injuries are not random events at all; they occur in predictable patterns determined by identifiable risk factors. For example, if a 16-year-old is texting while driving, which has been shown to be a dangerous driving distraction, the resulting injury can hardly be called an accident. On the contrary, the injury is entirely predictable.

Epidemiology

Unintentional injuries are the leading cause of death among people aged 1 to 44 years in the United States. In 2016, unintentional injuries claimed the lives of more than 18,000 Americans 21 years and younger. Suffocation is the third leading cause of death among newborns and infants; drowning is the leading cause of death among 1- to 4-year-olds; and motor vehicle crashes are the leading cause of death among 5- to 21-year-olds. Fires and burns are another major cause of unintentional injury-related death in young people.

Intentional or violence-related injuries are also a major cause of mortality in young people. Suicide is the second highest cause of death among 10- to 21-year-olds. Homicides are the third highest cause of death among 15- to 21-year-olds and fourth highest cause of death among 1- to 14-year-olds. Most suicides and homicides are firearm related.

In addition to deaths, in 2016, nonfatal injuries led to almost 9 million hospital emergency department visits in people younger than 21 years in the United States. The most common causes of nonfatal injuries in children are falls, followed by injuries from being struck by or against something, overexertion, motor vehicle occupancy, cuttings/piercings, and bites/stings.

Several epidemiological factors are associated with higher rates of pediatric injuries, including sex, race, income status, and family stressors (eg, death in the family, new residence, birth of a sibling). There is a bimodal age distribution of injuries, with newborns/infants and adolescents at greatest risk. Males are more likely than females to die from injuries and slightly more likely to experience injuries. Females are more likely than males to experience sexual assault. American Indian/Alaska Native and black children have higher rates of total injury-related deaths than other racial and ethnic age-matched populations. Geography influences injury rates; drowning deaths tend to be higher in coastline states (ie, Alaska and California) or states with a higher number of swimming pools (eg, Texas), and injury-related deaths are higher in rural areas and may be related to decreased access to emergency medical care.

Strategies for Injury Prevention

Efforts to prevent injuries have shifted from changing the behavior of individuals to modifying the environments in which injuries occur. William Haddon, MD, a medical epidemiologist, devised 2 useful frameworks for developing injury prevention strategies: the Haddon matrix and a list of 10 countermeasures to prevent injuries or reduce the severity of their effects.

Haddon Matrix

This matrix relates 3 factors (host, vector, and environment) to the 3 phases of an injury-producing event (pre-event, event, and post-event). The 3 factors interact over time to produce injury. Table 45.1 shows a Haddon Matrix of motor vehicle crash injuries. The precrash phase describes elements that determine whether a crash will occur; the crash phase describes the variables that influence the nature and severity of the resultant injury; and the postcrash phase describes the factors that determine the degree to which the injury is limited and repaired after the crash occurs. By describing the “anatomy” of an injury, the Haddon Matrix illustrates the numerous characteristics that determine an injury and the many corresponding strategies for interfering with the production of an injury.

Abbreviation: EMS, emergency medical services.

Adapted from the National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. Am J Prev Med. 1989;5(3 suppl):1–303.

Haddon’s list of 10 countermeasures to prevent injuries or reduce the severity of their effects are as follows:

1. Prevent creation of the hazard (eg, stop producing poisons, toys with small parts, and non-powder firearms; do not participate in dangerous sports; support community centers that engage children in safe after-school activities).

2. Reduce the amount of the hazard (eg, package drugs in nonle-thal amounts; reduce speed limits).

3. Prevent the release of the hazard (eg, use child-resistant caps for medications, toilet locks, and safety latches on cabinets and drawers; pass and enforce distracted driving laws; implement restrictions on handgun purchases; counsel families who keep guns to store them unloaded in a locked case, with the ammunition locked separately).

4. Modify the rate or spatial distribution of release of the hazard (eg, require airbags in cars; use child safety seats and safety belts; make poisons taste bad).

5. Separate people from the hazard in space or time (eg, make side-walks for pedestrians, bikeways for bicyclists, and recreation areas separated from vehicles).

6. Separate people from hazards with material barriers (eg, use bicycle helmets and protective equipment for athletes; install fences around swimming pools; build window guards).

7. Modify relevant basic qualities of the hazard (eg, place padded carpets under cribs; require guns to have safety locks; develop inter-vehicle communication systems).

8. Increase resistance to damage from the hazard (eg, train and condition athletes; make structures more earthquake-proof; use flame-retardant sleepwear).

9. Limit the damage that has already begun (eg, use fire extin-guisher; begin cardiopulmonary resuscitation).

10. Stabilize, repair, and rehabilitate injured individuals (eg, develop pediatric trauma centers and physical rehabilitation programs; improve emergency medical services).

Haddon’s work serves as a practical guide for thinking about ways to prevent injury. It emphasizes the importance of considering injuries as a result of a sequence of events, with many opportunities for prevention. The shift of emphasis away from changing human behavior to preventing injury is particularly appropriate for injuries in children because inhibiting children’s curiosity is impractical as well as undesirable.

Passive and Active Interventions

Interventions to prevent injuries can also be categorized as passive or active. Passive or automatic strategies protect whenever they are needed, without the action of parents or children. An example is the automobile airbag that automatically inflates to cushion occupants during a crash. Other examples of automatic strategies are water heater temperatures set to 48.9°C (120°F) or lower, not having guns in the home, and the use of energy-absorbing surfaces under play-ground equipment. In contrast, active interventions require action to become effective, such as in the case of nonautomatic safety belts, which require individuals to “buckle up” every time they enter an automobile. Supervision of swimming children is another example of an active injury prevention strategy.

Some strategies are partially automatic, requiring some action by individuals. Smoke detectors can be very effective in preventing injury and death in house fires, but roughly one-third of smoke detectors do not have working batteries. Batteries should be changed once a year and ideally tested once a month. As might be expected, the greater the effort required for children to be protected, the smaller the chance that protection occurs. Therefore, whenever possible, passive measures are preferable because they are the most effective.

Several approaches have been used successfully to prevent childhood injuries, including engineering, education, legislation, and enforcement. An engineering intervention, the car safety seat, is extremely effective (Table 45.2). When used correctly, child safety seats in passenger cars reduce the risk of death by 71% for infants and 54% for toddlers aged 1 to 4 years. Booster seats reduce injury risk by 59% for children aged 4 to 7 years compared with safety belts alone. Unfortunately, studies indicate that between one-third and two-thirds of car safety seats are used incorrectly. To address this, newborn care units often have car safety seat education programs, and some require possession of an infant car safety seat prior to hospital discharge. Police departments and private motor companies hold free public events to teach and manually check appropriate car safety seat use. In addition to engineering and education, passage and strict enforcement of child restraint laws are essential to compliance. All 50 states and the District of Columbia have child restraint laws (www.iihs.org/topics/seat-belts#laws). Nevertheless, loopholes still exist, such as exemptions in some states for safety belt use if older children are riding in rear seats; for safety belt use in school buses, taxis, and police vehicles; and if all safety belts are already in use. Such exemptions reinforce parental misconceptions, particularly that the lap of an occupant (ie, the “child crusher” position) is a safe position.

^a All children younger than 13 years should be restrained in the rear seats of vehicles.

Adapted from Durbin DR, Hoffman BD; American Academy of Pediatrics Council on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2018;142(5):e20182460.

Counseling by Pediatricians

Although the existence of significant gaps in parental knowledge about injury prevention has been clearly established, studies have shown that pediatricians spend surprisingly little time counseling parents about childhood safety. One survey found that only 42% of caregivers of children younger than 15 years who had a medical visit in the past year recalled receiving injury prevention information. Another survey found only 15% of patients presenting with an unintentional injury reported receiving injury prevention counseling. Reasons for limited discussion of safety issues may include lack of emphasis on preventive medical care in medical schools and pediatric training programs, inadequate time or payment, and lack of perceived self-efficacy or effectiveness. Research, however, has shown that injury prevention counseling in primary care settings is effective, resulting in increased knowledge and improved safety practices. Parents report that they would listen to physicians much more than any other group about child safety.

TIPP—The Injury Prevention Program was developed in 1983 by the American Academy of Pediatrics (AAP) to firmly establish injury prevention as a cost-effective standard of care for pediatricians. The AAP suggests that health professionals focus their safety counseling on a few topics targeted to individual risk factors (eg, age, sex, location, season of the year, socioeconomic status of family). Table 45.3 shows the age-specific counseling schedule of TIPP, which indicates the minimum topics to cover at each visit. Specific preventive measures should be reinforced at each visit. Areas of injury prevention guidance recommended for adolescents include traffic safety (eg, safety belts, alcohol use, motorcycle and bicycle helmets), water safety (eg, alcohol use, diving injuries), firearm safety, sports safety, and distracted driving.

Adapted from the American Academy of Pediatrics Council on Injury, Violence, and Poison

Prevention. TIPP—The Injury Prevention Program: A Guide to Safety Counseling in Office Practice.

Itasca, IL: American Academy of Pediatrics; 2019

Connected Kids: Safe, Strong, Secure is a violence prevention tool introduced by the AAP in 2006 to augment TIPP. Acknowledging that injury and violence prevention are intertwined, it uses an asset-based approach to engage parents in understanding and fostering healthy child development. An emphasis is put on support and open communication to promote emotional and physical safety.

Health professionals should involve parents and patients in educational efforts (eg, have a bicycle helmet in the office for children to try on). Safety counseling is most effective if limited to 2 or 3 topics per visit. Advice should be well defined and practical rather than general information (eg, write the Poison Help number on the phone; never leave children unattended in water). Advice should be tailored to each family after exploring individual situations through open-ended questions (eg, “Where does your baby spend awake time during the day?”; “What do you think is the biggest safety risk for your child?”). Health professionals should be aware of different levels of health literacy and confirm understanding rather than rushing through a prepared statement. Access to interventions should be considered, such as cost and accessibility of helmets and child safety seats. Whenever possible, pediatricians should coordinate their educational efforts with current community injury prevention efforts (eg, bicycle helmet campaigns, handgun regulation).

Recent Recommendations

The AAP has multiple safety recommendations. Following are newer and revised recommendations:

•Health equity is fundamental to child safety. Children should be protected from injury within their built environment and provided with access to quality, patient-centered, and culturally effective medical care (Reaffirmed 2013).

•All children should be restrained in a rear-facing–only or convertible car safety seat used rear facing as long as possible. Importantly, nearly all currently available convertible car safety seats have weight limits for rear-facing use that can accommodate children 35 to 40 lb (15.9–18.1 kg) (2018).

•Motor vehicle crashes are the most common cause of mortality and injury for adolescents and young adults in developed countries. Now present in all 50 states, graduated driver’s license programs introduce driving in a staged manner of increasing risk and responsibility. The AAP recommends that pediatricians know their state laws addressing teenage drivers, encourage seat belt use, help parents identify acute or chronic medical or behavioral risk factors that might affect their teenager’s driving ability, discourage distracted driving, encourage restrictions on nighttime driving and limits on number of passengers, and counsel teenagers about the dangers of driving while impaired (2018).

•Research suggests both benefits and risks of media use for the health of children and teenagers. Parents and pediatricians can work together to develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that considers children’s developmental stages to individualize an appropriate balance for media time and consistent rules about media use (2016).

•Pedestrian injuries are a significant traffic-related cause of morbidity and mortality. Emphasis should be given to community- and school-based strategies to reduce exposure to high-speed and high-volume traffic, and to promote improvements in vehicle design, driver manuals, driver education, and data collection to reduce pediatric pedestrian injury (Reaffirmed 2019).

•The absence of guns from homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children. The AAP supports a number of specific measures to reduce the destructive effects of guns, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on semiautomatic assault weapons; and the strongest possible regulations of handguns for civilian use (Reaffirmed 2016).

•Drowning is a leading cause of injury-related death in children.

•Pediatricians should provide specific targeted messages by age, sex, risk of drowning, alcohol or drug use, water competency, and geographical location. Children with special health care needs should have tailored anticipatory guidance related to water safety (2019).

•Injury is the leading cause of death in children 1 to 18 years of age in the United States. The unique needs of injured children must be integrated specifically into trauma systems and disaster planning at the local, state, regional, and national levels. Pediatric injury management should include an integrated public health approach from prevention through prehospital care, to emergency and acute hospital care, to rehabilitation and long-term follow-up, as indicated (2016).

•Children exposed to intimate partner violence are at an increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social sequelae later in life. It is recommended that pediatricians receive training on the identification, assessment, and documentation of abuse; interventions to ensure patient safety; culture and values as factors that affect intimate partner violence; applicable legal responsibilities; and violence prevention (Reaffirmed 2019).

•The overall death rate attributable to sleep-related infant deaths remains high. Recommendations for a safe sleep environment include supine positioning, the use of a firm sleep surface, room sharing without bed sharing, and the avoidance of soft bedding and overheating (2016).

•Sport-related concussions are a major health concern in young athletes. Although all concussions cannot be prevented, reducing the risk through rule changes, educational programs, equipment design, and cervical strengthening programs may be of benefit. Health care professionals should have an understanding of their individual state’s laws regarding return to play after a concussion (2018).

Additional policies and guidelines can be found at www.aappublications.org/search/%20subject_collection_code%3A100using the key words “injury prevention.”

Pediatricians as Advocates

As advocates for child safety, pediatricians can play a major role in injury prevention outside the clinical setting. Pediatricians have started community programs or provided support to ongoing programs. Safe Kids Worldwide (www.safekids.org) is an organization made up of safety experts, educators, corporations, foundations, governments, and volunteers whose mission is to prevent childhood injury through education and advocacy. Safe Kids and other issue-specific organizations, such as the Children’s Defense Fund (www.childrensdefense.org) and Everytown for Gun Safety (https://everytown.org), can provide resources to support pediatricians in local or national projects and provide avenues for legislative participation. Through community pediatrics programs (www.aap.org/commpeds), the AAP provides grants to pediatricians and pediatric residents who want to create innovative community projects promoting child health.

Legislative advocacy is an exciting opportunity for health professionals to effect wide-reaching change. States have enacted laws covering many aspects of injury prevention, including car safety seats, poison centers, cribs, playgrounds, amusement parks, protective gear for sports, swimming pools, and school buses. Dramatic reductions in injuries often follow safety legislation. For example, infant walker-related injuries have decreased by 76% since the introduction of the ASTM International F977 Consumer Safety Performance Specification for Infant Walkers in 1997 and the introduction of stationary activity centers as alternatives to mobile infant walkers. Other examples of product-related legislation include federal crib standards of 1974 mandating close spacing of vertical slats to reduce the risk of entrapment, the Child Safety Protection Act of 1994 requiring toy safety labels on any balls with a diameter less than 1-3⁄₄ in (4.44 cm), window blinds manufactured with tassels instead of loops and children’s clothing without drawstrings to prevent strangulation, and toy boxes manufactured with safer lids and air holes in case a child is trapped within. Similarly, in December 2010, the US Consumer Product Safety Commission voted to ban drop-side cribs, citing the recall of more than 9 million cribs over the previous 5 years and the entrapment and death of 30 babies over the previous 10 years. The ban went into effect in June 2011 and prohibits the sale of such cribs even at garage sales.

Pediatricians can heighten awareness about the magnitude of childhood injuries through calls or letters to legislators, testifying about the benefits of specific safety legislation, or partnering to introduce new legislation. Pediatrician legislative involvement is critical to ensuring evidence-guided local and national injury prevention.

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