Version May 2024
INTRODUCTION — Injuries are a leading cause of death for infants and children in the United States and around the world [1]. Treated as diseases, both intentional and unintentional injuries are cured by prevention. The clinician's role in injury prevention includes education, instruction, and advocating for changes to improve child safety [2,3].
Pediatric injuries are such a significant health care problem that major authorities, including the American Academy of Pediatrics (AAP), the American Medical Association, and the American Academy of Family Physicians, have issued recommendations that injury prevention counseling be provided as a part of the well-child examination [2,4-6]. The AAP developed a policy statement recommending age- and locale-appropriate injury prevention anticipatory guidance for all infants, children, and adolescents [2]. Although the contributing factors for intentional injuries (ie, gun-shot wounds, assault) differ from those for unintentional injuries, many of the principles of injury prevention are the same [7].
The epidemiology of pediatric injuries, historical trends, and principles of injury control are reviewed here. Evidence-based interventions for specific mechanisms of injury are discussed separately.
●(See "Bicycle injuries in children: Prevention".)
●(See "Firearm injuries in children: Prevention".)
●(See "Prevention of falls and fall-related injuries in children".)
●(See "Prevention of poisoning in children".)
EPIDEMIOLOGY — Trauma is the leading cause of pediatric mortality, potential years of life lost, and medical cost in the developed world [3,8]. In addition to the financial burden, injuries lead to emotional trauma for children, caregivers, and society.
Unintentional injuries are the leading cause of death and disability for children ≥1 year of age, adolescents, and young adults in the United States (table 1) [8,9]. In 2020, unintentional injuries resulted in the deaths of more than 17,000 children, adolescents, and young adults ages 0 to 24 years [10]. Unintentional injury deaths peak during adolescence and young adulthood (ages 15 to 24) (table 2). Primary mechanisms of injury are development- and age-dependent [11,12].
In 2020, more than 6 million children and young adults younger than 25 years old were injured seriously enough to require a visit to a hospital emergency department [13]. Unintentional falls are the leading cause of nonfatal injury in children and adolescents presenting to hospital emergency departments in the United States, followed by being struck by or against an object (table 3). In a population-based study of injury among 96,359 Canadian children (0 to 10 years of age) for which any medical attention was sought, the types and severity of injuries range from superficial injuries and contusions to multiple fractures and increased intracranial pressure [11]. The most common injuries were open wounds; superficial injuries and contusions; and dislocations, sprains, and strains, followed by upper-limb fractures; intracranial injury; foreign body; burns; and poisoning. Fractures are the leading type of injury resulting in hospitalizations for children under 18 years old [14].
According to data from the CDC, the lifetime medical cost (ie, treatment and rehabilitation) of unintentional injury among children ages 19 and younger is over $77 million [15]. The total work loss cost (ie, lost wages, benefits, and self-provided household services) is approximately $12 billion [15]. Worldwide unintentional injury accounts for 12 percent of the years lost due to disabilities among young people age 10 to 24 [16].
Historical trends in pediatric injury control reveal the effectiveness of certain prevention activities. Between 2000 and 2009, the unintentional injury death rate for children ages 19 and younger declined by 29 percent in the United States (from 15.5 to 11.0 per 100,000) [8]. In 2020, the unintentional-injury death rate for children age 0 to 19 years was 10.5 per 100,000 [10]. Reduction in mortality can be attributed to the increased use of seat belts and child safety seats, the reduction in drunk driving, the increased use of child-resistant packaging, better safety awareness, and improved medical care [7,17].
Numerous reliable sources provide injury statistics. The National Center for Injury Prevention and Control, the National Center for Health Statistics, the National Highway Traffic Safety Administration, the Kids' Inpatient Database, and Safe Kids Worldwide are examples of such sites. Safe Kids Worldwide maintains a useful, up-to-date website that dramatically illustrates the scope of pediatric injuries for children ages 19 and younger. The National Center for Injury Prevention and Control provides a useful website of injury data for all ages.
RISK FACTORS — The health care provider should recommend patient-specific and age-appropriate prevention measures based upon well-known risk factors for pediatric injury, including age, development, sex, socioeconomic status, behavior (both caregiver- and patient-specific), the child's environment or regional factors [18], and caregiver mental health problems (eg, depression, anxiety) [19-21].
The age of a child is predictive for risk and type of injury:
●Infants are more likely to sustain fatal injuries from suffocation, motor vehicle crashes, drowning, and burns (table 2) [8,9].
●Toddlers and preschool children are more likely to die from drowning, motor vehicle collisions, fires and burns, and suffocation [8,9]. Children at this age lack the motor skills to maneuver and the cognitive skills necessary to recognize safety hazards.
●The school-age child is more likely to engage in risk-taking behaviors that lead to pedestrian injuries, bicycle injuries, drowning, and unintentional firearm injuries [22]. Motor vehicle occupant injury is the most significant mechanism of injury for children 5 through 19 years of age [8,9].
●Adolescents also are at risk for poisonings, drowning, firearm injury, falls, burns, and intentional injury. Data from the National Vital Statistics System indicate that between 2000 and 2009, an increased misuse of prescription drugs contributed to an increase in unintentional poisoning deaths among adolescents 15 to 19 years of age (from 1.7 to 3.3 per 100,000) [8]. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Epidemiology'.)
PRINCIPLES OF INJURY PREVENTION AND CONTROL — In 1986, Congress passed the Injury Prevention Act and in 1992 funded the National Center for Injury Prevention and Control (NCIPC). The NCIPC works with other federal agencies and funds research for injury prevention [23]. Increased research has led to new knowledge and strategies for the prevention and control of childhood injures. Injury prevention has become recognized as a field of science with its own theoretical framework and body of research. One well-accepted model of injury prevention, the Haddon Injury Control Model, proposes that all injuries are attributable to five forms of energy (kinetic, chemical, thermal, electrical, and radiation) and that injuries result when energy emanating from a vehicle or agent source is transferred to the host or child [24].
Countermeasure strategies can modify the potential or severity of energy transferred to the host or child and thereby prevent or diminish injury [25]. Examples of countermeasure strategies are listed below:
●Reduce the amount of energy produced – Reduce the temperature of the hot water heater
●Prevent the release of energy – Trigger locks to prevent discharge of the gun
●Modify the rate of spatial distribution of the energy release – Reduce the slope of ski trails
●Separate the energy and the host in space or time – Build sidewalks for pedestrians and bike paths for bicyclists
●Separate the energy and the host via barriers – Use bike helmets or safety glasses
●Modify the contact surface – Soften the playground surface
●Strengthen the structure that receives the energy – Train athletes with appropriate conditioning and stretching
Based upon the matrix of event phases and epidemiologic factors for injury prevention, 12 possible areas for injury-modifying interventions exist in the Haddon model (form 1) [25].
An injury event is divided into three phases:
●Pre-event phase – Production or release of the energy has yet to occur and is modifiable
●Event phase – Release of the energy has occurred, but potential transfer to the host is modifiable
●Post-event phase – Energy has been transferred, but the extent of damage is modifiable
Epidemiologic factors in injury prevention include:
●Host – Human body that is affected by energy transfer
●Vehicle or agent – That which carries or transfers energy (eg, mechanisms of injury)
●Physical environment – Changes to the environment that physically affect the impact of any of the three injury phases
●Sociocultural and political environment – Attitudinal, legal, regulatory, or other changes that can affect the three injury phases
The advent of this model brought the realization that 90 percent of injuries are both predictable and preventable, and, for that reason, experts in the field no longer use the term "accident" [15,26]. The principles of primary, secondary, and tertiary prevention strategies (eg, education, product design, and modification of the environment) can be used to develop interventions to prevent or control injury.
Injury prevention strategies are active or passive [27-29]. Passive interventions (eg, automatic seat belts or air bags) are more effective than are active interventions (eg, manual seat belts) [30]. However, certain mechanisms of injury have not lent themselves to passive interventions. Child safety seats, for example, are an active intervention. Adults must purchase and install them and then ensure that the child is appropriately secured in the seat each time the car is driven. Despite these encumbrances, evidence shows that the frequency of safety seat use increases with the implementation of child safety seat laws, enhanced enforcement campaigns, community-wide information distribution, and interventions that combine giving incentives or distribution of free safety seats with educational efforts [31,32].
Another model for conceptualizing the potential impact of pediatric injury prevention interventions is the Health Impact Pyramid [33]. In this model, the lower tier interventions (at the base of the pyramid) have greater population impact and require less individual effort; the higher tier interventions have less population impact and require more individual effort:
●Tier 1 – Socioeconomic factors (eg, poverty reduction, improved education)
●Tier 2 – Changing the environmental context to encourage healthy decisions (eg, improved road and vehicle safety)
●Tier 3 – Long-lasting protective interventions (eg, car seat loaner programs, smoke detector installation programs)
●Tier 4 – Clinical interventions (eg, clinic-based car seat or bicycle helmet inspection for proper fit and use)
●Tier 5 – Counseling and education (eg, counseling to wear seat belts, provision of patient education handouts, such as "The Injury Prevention Program" handouts from the American Academy of Pediatrics) (see 'Injury prevention resources' below)
INCORPORATING INJURY PREVENTION INTO PRACTICE — Office-based or outpatient injury prevention counseling is an integral part of medical care for infants, children, and adolescents [2,34]. The American Academy of Pediatrics (AAP) recommends that every well-child visit include age-appropriate injury prevention counseling [2,34].
Caregiver education appears to be helpful in reducing injuries and improving home safety, particularly in families from disadvantaged populations [35-39]. In a 2013 meta-analysis of 10 randomized trials (5074 participants), caregiver interventions decreased the risk of medically attended unintentional injury (relative risk 0.83, 95% CI 0.73-0.94) [37]. There was also fairly consistent evidence that caregiver interventions improved home safety.
However, integrating injury-counseling practices during the average 16-minute well-child visit can be problematic [40]. In a survey conducted during 2001 to 2003, only 42 percent of the children younger than 15 years of age who had a medical visit in the previous year received any injury prevention information, according to a random-digit-dial telephone survey of 2541 households [35]. In another survey, 55 percent of clinicians responded that they provided injury prevention counseling always or most of the time, yet only 19 percent of their patients recalled receiving any safety information [41].
Pediatricians report concerns of adequate time, perceived self-efficacy, perceived effectiveness of counseling, and reimbursement for counseling as barriers to counseling practices [42,43]. These concerns are not without merit. Injury prevention strategies, such as legislation and product or environmental changes, can be more effective in preventing certain childhood injuries than education [44]. A 2016 systematic review found inconclusive evidence for school-based education injury prevention programs, primarily due to poor quality of the research measures [45]. However, evidence indicates that the most successful and effective interventions tend to combine all three strategies [46].
Pediatric clinicians can help effect change by advocating at the federal, state, or community level. The AAP Advocacy and Policy website provides numerous resources to help those with little or no previous experience in legislative advocacy.
Although reimbursement concerns are not primary predictors of counseling, financial concerns are legitimate and should be addressed in the appropriate forum [42]. Managed-care companies have an interest in keeping their clients healthy and their costs down. Interventions that meet both goals should be considered in capitation analysis. Philosophic concerns about societal costs and burdens also can be problematic for the health care practitioner. One study estimated that injury prevention counseling for patients between the ages of zero and four years would result in a lifetime savings of $800 per child in future medical spending on injury treatment [47].
INJURY PREVENTION RESOURCES — The use of office resources (eg, chart aids, educational materials) was an important factor in the provision of preventive care, according to a survey of randomly selected members of the American Academy of Pediatrics (AAP), the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists [48]. Total resource use was significantly correlated with total preventive service provision and counseling, regardless of the origin of the resource.
●The Centers for Disease Control and Prevention website provides information about the steps you can take to prevent the leading causes of childhood injury.
●The Children's Safety Network published a guide to evidence-based pediatric injury prevention strategies from five leading health organizations [49]. This guide is targeted to providers interested in child and adolescent injury prevention and is available .
●The AAP has developed a program to assist pediatricians and other health care providers with systematic and age-appropriate injury prevention counseling materials: the Injury Prevention Program (TIPP), available by subscription from the AAP [50]. The program offers safety surveys and age-specific safety information sheets to be given to caregivers and children [50]. The surveys identify areas of specific individual risk, which can direct the counseling. Although some authors argue about the efficacy of these tools [51,52], the interventions do help to prioritize the delivery of safety counseling and aid in the development of a comprehensive and organized approach to injury prevention. The AAP also provides injury prevention information for parents and other caregivers through the healthychildren.org website.
●Safe Kids Worldwide also offers brochures, videos, injury prevention programs, and resource guides. Another American Academy of Pediatrics program, Bright Futures, provides patient education materials.
●The "Make Safe Happen" smart phone application (available at https://makesafehappen.com/) provides room by room safety tips and can be customized for various ages.
Additional injury prevention resources are listed in the tables (table 4).
SUMMARY
●Epidemiology – Unintentional injuries are a leading cause of death and disability for children older than one year and young adults in the United States (table 1 and table 2). (See 'Epidemiology' above.)
●Risk factors – The age of a child is predictive for risk and type of injury (see 'Risk factors' above):
•Infants are more likely to sustain fatal injuries from suffocation, motor vehicle crashes, burns, and falls.
•Toddlers and preschool children are more likely to die from motor vehicle collisions (both occupant and pedestrian), drowning, fires and burns, suffocation, falls, and poisonings.
•The school-age children are more likely to sustain motor vehicle occupant injuries, pedestrian injuries, bicycle injuries, drowning, and unintentional firearm injuries.
•Adolescents are more likely to sustain motor vehicle occupant injuries, poisonings, drowning, firearm injury, falls, burns, and intentional injury.
●Prevention – The majority of injuries are predictable and preventable through modification of human factors, the agent or vehicle of injury, the physical environment, or the sociocultural environment (form 1). Injury prevention strategies are active (eg, manual seat belts) or passive (eg, air bags); passive strategies are more effective than are active interventions. (See 'Principles of injury prevention and control' above.)
Injury prevention counseling is an integral part of medical care for infants, children, and adolescents. Injury-specific prevention counseling is associated with changes in behavior. (See 'Incorporating injury prevention into practice' above.)
Injury prevention resources are listed in the tables (table 4). (See 'Injury prevention resources' above.)
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