Accidental trauma in children has come to be recognized as a major child health problem in North America and Europe only within the past 20 years. Pediatricians, by successfully applying their knowledge of nutrition, immunology and child development to the prevention of many of the childhood infectious diseases and of other serious threats to child health, have brought the accident problem to the fore. Accidents now claim more lives of children between one and fifteen than the six leading pediatric disorders - cancer, congenital anomalies, pneumonia, heart disease, homicide and stroke1 - combined. The study and prevention of accidental trauma are assuming new importance in both clinical and social pediatrics.
Understanding the etiology of childhood trauma requires a new and more profound understanding of the child's environment, knowledge of those high accident risks associated with different periods of development and better insight into the emotional climate of the child's family. Preventing trauma involves the pediatrician in educational, engineering and legislative processes. The pediatrician's role extends beyond the family to the community and the state.
ORIGIN OF THE STUDY OF CHILDHOOD ACCIDENTS
While it had been apparent for some years that accidents led all causes of death in children from one to fifteen, pediatricians did very little in studying the problem until the American Academy of Pediatrics established its Accident Prevention Committee in 1952. The committee began its work by surveying the Academy's 3,000 members for information on the most common household factors associated with children's accidents.2 It sought information about those accidents involving hazards such as flammable clothing, poorly constructed children's furniture and toxic paint. Approximately 40 per cent of the Academy's members replied. There were relatively few cases of strangulation or other serious accidents from poorly constructed cribs, playpens or equipment although these accidents accounted for one-fifth of all deaths reported. Thirty per cent of all the reported accidents were burn accidents, a large proportion of which were associated with flammable clothing.
This was the first organized effort to secure information bearing on product-related injuries. It has been the basis for continuing efforts by the Academy of Pediatrics, in cooperation with many other organizations and manufacturers, to improve products used by children. Ultimately, such information was instrumental in the passage of legislation on flammability standards for clothing and in the establishment of the Bureau of Product Safety. In this issue William V. White, the director of the Bureau, describes its work.
A wholly unexpected finding of the Academy's survey was that 50 per cent of the reported accidents involved some type of poisoning. Further analysis of the poisoning cases (Table 1) showed most were nonfatal and caused by common household items such as cleaning agents, aspirin and barbiturates.
These findings may be the earliest documentation of the experience of every busy pediatric practitioner - namely, that household agents are important causes of poisoning in children. The study reported that among the medicines, aspirin and barbiturates were the most common causes of poisoning (and they continue to be); among household agents, pesticides and petroleum products such as kerosene have been frequent causes. Cases of childhood lead poisoning reported by pediatricians from such areas as Baltimore, Cincinnati and St. Louis focused attention on peeling paint as a source. This data helped initiate the Academy's project with the American Standards Association to develop the first standard for paint that would be safe to use on children's toys, furniture and other surfaces likely to be exposed to children. This standard limited to one per cent or less the lead content of paint intended for such use.
The study also spoke of poison control and suggested the establishment of centers for immediate information on the treatment of poisoning.
After Dr. Edward Press established in Chicago the first poison control center in the world and began publishing his results,3 a network of poison control centers sprang up across this country and in Europe.
MAGNITUDE OF THE PROBLEM
The following table ( 2 ) shows the importance of accidents at various ages about the time when pediatricians began a more concerted preventive effort, compared with the latest figures from the 1972 edition of Accident Facts, p. 8.
ACCIDENTS IN CHILDREN UNDER ONE YEAR
Pediatricians are well aware that among infants less than one year old, congenital anomalies, asphyxia of the newborn, immaturity and respiratory conditions of early infancy continue to account for the great majority of all deaths. Fewer of us may realize that in the category of childhood accidents, infants have the highest mortality rate. Most of the accidental deaths under one year tend to take place between the third and twelfth months of age. This period in child development corresponds to the first phases of the child's independent physical activity - rolling over, sitting up, crawling, standing and beginning exploration of his world. This is also the time when the infant is likely to be under greater supervision than at any other time of life by parents and ideally by a pediatrician. Thus, the need and the opportunity for safety education are greatest at this time.
LEADING CAUSES OF DEATH
ACCIDENT MORTALITY RATE IN CHILDREN
We have no idea of the quantity or quality of safety education in pediatric practice. We know that some pediatricians offer personal advice to the parent and/or distribution of pamphlets. Since the pediatrician is more likely to see more children at more frequent intervals when they are under one year, this would be the age group where such preventive efforts might be most intensive. Therefore, it is of interest that this is the only age group where a significant reduction in mortality has occurred in the period under review. As will be seen in Table 3, except for the age group under one year, there has been no improvement in the total accident mortality rate in children in the United States during the past two decades. In Europe, the trend appears to be upward. As will be discussed later, the principal cause of this negative trend is the increase in fatalities from motor vehicles.
In viewing Table 3, one should note that direct comparison of childhood accident mortality rates under one year in the United States and European countries should not be made because of different criteria used to measure infant mortality in various countries.
THE PRESCHOOL AGESAGES ONE TO FOUR
Accidents are the leading cause of death in preschool children ages one to four.5 The rate is 50 per cent above that at ages five to 14. Yet, this is a period during which children spend most of their time in the home environment, supposedly under care and supervision. During World War II, there was a sharp increase in fatal accidents at the preschool ages.7 Many families were disorganized by the war with fathers away and mothers of young children often working. Somewhat similar conditions exist today. Family disorganization and stress seem to increase the risk of accidents to children.
Where comparisons have been possible between children who attend organized day care programs and those who do not, the accident rate is higher among children who do not attend day care facilities. For example, in Sweden, a survey of accidents among all children in Stockholm in 1955 found that 12 per cent of pre' school age children (one to six years) had some form of accident.8 This was the highest incidence of accidents among children of all ages. On the other hand, the rate of risk of accidents in nursery schools and day care facilities was five per cent compared to 12 per cent for those children who were at home.
Household interviews conducted by the National Center for Health Statistics for the period 1965-67 show mat preschool children had the highest percentage of injuries necessitating medical attention (67.3 per cent). Whether this was due to severity of the injury or to parental concern is not clear, but it does suggest that many of these injuries do involve the physician and thus provide an opportunity for study and possibly the means of prevention.
THE SCHOOL AGESAGES FIVE TO 14
From a mortality and morbidity standpoint, the school years are the healthiest period of life. The mortality rate of 43/100,0005 for all causes is half the next lowest rate for any period of life, which occurs at ages one to four. But half of all deaths at ages five to 14 are due to accidents, and half of these are caused by motor vehicles.
Data based on household interviews from the National Health Survey in 1959-61 indicates that in the United States as a whole activity restricting injury rates and bed disabling injury rates for children six to sixteen were significantly higher than for any other age group. However, a comparison of accident morbidity rates in 1965-67 with those obtained from 1959-61 shows that the severity rates have decreased for all age groups under six years.9
The majority of nonfatal accidents to children under 15 are home accidents. Motor vehicles account for a comparatively small proportion of these nonfatal injuries. There are no details on a nationwide basis about nonfatal accidents to school age children. However, there are surveys of various localities which provide some evidence of the types of accidents occurring at these ages.
For example, in the 1970-71 school year, the Kansas State Department of Health found in a survey of 402,000 students from kindergarten through the 12th grade that there were 8,744 nonfatal injuries reported by students which required medical attention or absence from school of one-half a day or more.10 More than one-sixth of the injuries were outside of the school's jurisdiction. The average severity of these injuries was twice that of the school jurisdiction cases. Cuts or lacerations of the head, face or neck occurred most commonly in this group. Sprains, strains of foot or ankle and fractures of the arm ranked next in order of frequency.
While youngsters tend to be safer inside the school than outside, the industrial arts shop can be quite hazardous. The National Safety Council found in a review of 35,000 school accidents occurring during the school year 1968-69 that interscholastic football was the only type of activity that exceeded vocational and industrial arts shops in accident frequency rates.
There is very little solid statistical data on the number of eye injuries to children. But virtually all of them are needless and preventable. Pointed sticks, BB guns, bows and arrows, slingshots and fireworks are dangerous playthings. Games and sports may also be dangerous. School shops and laboratories have hazardous situations.11 Injuries to the eye can be prevented through the wearing of proper safety eye protection, supervised play, safety education and legislative control of the sale and use of potentially dangerous toy weapons and fireworks. The Academy of Pediatrics, through the Accident Prevention Committee, has supported the National Society for the Prevention of Blindness in an effort to ban all fireworks except those for display which are not sold to the general public.
As was found in the preschool ages, when the child is under supervision in an organized program, the risk and severity of accidents are significantly reduced. This is not surprising but tends to be overlooked when we consider the opportunity for programs of prevention and education. Again, pediatricians can help parents make homes and communities safer for their children through educational programs.
MOTOR VEHICLE ACCIDENTS
The accident cases submitted by pediatricians in the Academy's first survey pinpointed a number of important causes, but none called attention to the motor vehicle as the major cause of accidental death in children. This is explained perhaps by the fact that these tend to be surgical problems which are generally not first seen by the pediatrician as are home accidents. It may be an indication of the unconscious acceptance of the automobile in our culture even by pediatricians.
Largely through the efforts of a pediatrician, Dr. Seymour Charles, one of the first to call attention to the lethal role of the automobile for children, this threat is not only clearly recognized today but preventive measures have been greatly stimulated. Recently under his leadership, the Physicians for Automotive Safety, a group which he founded, formed Action for Child Transportation Safety (ACTS). This is a citizens' group led by young mothers to campaign to increase the protection of young passengers riding in motor vehicles.
The article in this issue by Dr. Diamond discusses some of the efforts to control this chief cause of accidental death and injury to children. The mortality data shows that we have not had much success so far.
A comparison by the Council of Europe of accident fatalities in children of 17 European countries between 1958-1968 showed that traffic accidents were largely responsible for the increase in the accident fatality rates in children of all ages.
Motor vehicle deaths under one year tend to be evenly divided between boys and girls. This is to be expected since these fatalities would take place in almost every case under circumstances where the infant would be a passenger or in some other passive role. However, at a very early age, boys begin to dominate the mortality data. At nearly every age from one to fifteen, boys more frequently than girls are killed crossing streets or are hit by a car while playing in their driveway. This supports the view that boys are willing to take greater risks, are more heedless or take out their aggressive or hostile feelings by exposing themselves to danger.
A large number of deaths in children one to four occur in driveways and streets close to the child's home. In the ages five to 14, when motor vehicles cause half the deaths due to accidents, most of these deaths are due to the child being hit or run over by the vehicle. In a study of death certificates of 186 children five to 14 years old killed by motor vehicles, 145 were hit or run over.12
Heimstra, Nichols and Martin13 have developed a novel technique using cinematography with a concealed camera to study child pedestrian behavior. They gave special attention to curb behavior. For instance, the boys and girls who stopped and looked before crossing could be identified; in the study, girls stopped and looked for traffic much more frequently than boys. Such a technique could be used to study other types of high-risk behavior.
Read14 has done a detailed study of specific behavior patterns that are associated with traffic accidents of children which can provide a base for developing countermeasures.
In an attempt to discover social factors which may increase the susceptibility of the child to accidents, Backet*15 reported a family study which compared children who had survived road accidents to children matched for age, sex, school and neighborhood who had not had such accidents. He found that family disorder or stress such as illness and maternal preoccupation with outside work, other children or pregnancy greatly increased the risk of a road accident. The most vulnerable or those for which these factors were most common appeared to be the youngest children in the accident group.
The child as a passenger in the motor vehicle is in the care of the driver. Pediatricians should advise parents to use a fastened car bed for the infant rather than hold the child. The bed should be placed in the back seat. When the child can sit up, he belongs securely and comfortably fastened in his own well-anchored car seat. Children should be taught the rules for safe behavior in the car. Young passengers who have outgrown their car seats should be buckled into seat belts, even for short jaunts close to home. The safest place in the car for children is the back seat. In case of a collision or sudden stop, there is less chance of hitting the dashboard or windshield. Parents should also realize that their own safety practices and driving habits are extremely important in the safety education of their children and will influence their driving when they grow up.
Death Rates From Accidents Other Than Motor Vehicle Accidents - U.S.
ACCIDENTS OTHER THAN THOSE RELATED TO MOTOR VEHICLES
In the United States in the past 20 years, there has been a significant decline in mortality from accidents other than those related to motor vehicles for children under 15. Unfortunately, motor vehicle deaths have continued to rise accounting for our failure to show improvement in child accident mortality. The following table (Table 4) gives the composite death rate for accidents other than those from motor vehicles in each age group from one to 19 between the years 1949-50 and 1968-69.
The rates have generally declined over the same period for fires and explosions, firearms, poisoning, falls and drowning for ages under 15. However, death rates for nonwhites from fires and explosions are still substantially greater than for whites. The death rate among nonwhite males one to four years old from firearms also shows an increase in the 20 year period under review.
Despite the lowering of the death rate, deaths from fires and burns rank second to those due to motor vehicle accidents in children one to four. Nearly half of the 3,000-5,000 persons who die every year when their clothing catches fire and the 300,000 who are seriously burned are children. The American Academy of Pediatrics has studied children's wearing apparel involved in fires and found that threefourths of the garments were made of cotton or rayon which have a high degree of flammability.16
Smith has proposed several areas for preventive efforts:17
1) Use of flame retardant fabrics.
2) Improved design of appliances to minimize the chance of overturning and spilling hot liquids. Scalds dominate the burn situation in the toddler age group.
3) Kitchens designed for child safety as well as convenience for the housewife.
4) Open flame heating units should contain a visual warning against the use of volatile liquids in proximity to the open flame.
Oglesby18 provides an excellent discussion of flammable fabrics in burn accidents and approaches to improving preventive measures. A recent study reported by him found that 50 per cent of the 4,900 burn cases treated at 15 hospitals between 1964 and 1968 were associated with clothing ignition. Of 231 consecutive second and third degree burn cases admitted to the University Hospital in Oklahoma City over a five-year period, 66 per cent involved the ignition of clothing.19 Sixty-one per cent of the victims were under 12 years of age. Thirty-nine per cent were preschool age. The female to male death ratio was 31 to one. This is the only accident in the five to 14 age group in which females have a higher risk than males.
As a result of the work of the Academy's Accident Prevention Committee in cooperation with interested surgeons, the National Fire Protection Association and others, legislation has been enacted requiring that children's sleepwear as large as size 6X must be flame-proofed. According to the Commerce Department's new regulation, when the nightwear is exposed to a flame for three seconds, the fire must be selfextinguishing and leave no charring more than 18 cm. (seven inches) from the point of contact. This regulation, although helpful, will affect only one part of the problem. It will be difficult to enforce and, according to one manufacturer, will cause the price of such garments to increase by 30 per cent.
Of the 2,000 youngsters under age 15 who die in home fires every year, about one-third are left unattended. Many parents see no harm in leaving the house for as briefly as 15 minutes or half an hour while young children are asleep or playing. Fires often start while parents are away for such brief periods. Last year children died in fires while parents ran errands to the corner mailbox, across the street for a loaf of bread or to a nearby kindergarten.20
The primary danger of leaving children alone is their tendency to play with fire. Small children may take advantage of the parent's absence to explore forbidden places - closets, attics, basements - and use a match to light a dark corner filled with combustibles. Almost as dangerous as leaving children unattended is entrusting them to an incompetent babysitter. Those put in charge of small children must be instructed about what to do in case of fire. Explicit information on escape routes should be given. The basic rule should be at the first suspicion of fire, get everybody out of the house as quickly as possible.
The following are ten rules for fire safety which pediatricians should bring to the attention of parents:
1. Get out of the house fast. Do not delay for any reason.
2. Be sure everyone knows at least two ways to get out of the house from each room, especially upstairs bedrooms.
3. Teach older children how to open windows (and screens) which face onto a fire escape or roof.
4. Teach children that in the case of fire never to hide under beds, in closets or to lock themselves in the bathroom.
5. Feel a door for heat before opening it. If hot, do not open. Closed doors hold back flames and smoke.
6. Always close a door you have opened in a burning house whether you leave the room or not.
7. Remember that smoke and hot gases can be as dangerous as flames.
8. If you have to go through a smoke-filled room, keep low, take short breaths, and cover your nose and mouth with a cloth - preferably a damp one.
9. Decide beforehand where everyone should meet after leaving the house.
10. Don't return to a burning house. "Once out - stay put."
11. Report the fire at once on your neighbor's phone or at the nearest alarm box.
1. Keep calm.
2. Know alternate exit.
3. Close door on fire.
4. Don't re-enter.
The Accident Prevention Committee of the AAP has established a subcommittee on the prevention of burns which is intended to act as a consumer advocate to encourage significant legislation to regulate the vectors of burns; to sponsor educational programs concerning the cause, effects and prevention of burns; and to accumulate statistics on burns in children to validate the effectiveness of countermeasures.21
One sign of affluence in our society is the home swimming pool, but with it comes the increased risk of drowning, especially to small children. According to the National Safety Council, there are now 65 times as many in-ground pools as there were just 20 years ago, an increase from over 10,000 pools to an astounding 700,000-plus figure. In addition, there are at least two million portable onsurface swimming pools and about 10 million plastic wading pools.
The National Safety Council estimates that in 1971, 300 persons drowned in home swimming pool accidents.22 In 1964 the number who drowned in home pools was 180. Twenty years ago the number of deaths was so small that home pool drownings were not reported by the National Safety Council. In many communities, building codes specify that pools must be fenced in. This is important in preventing drowning accidents although even fences may not prevent venturesome youngsters from getting into danger. Water, even in small amounts, may be perilous for small children. In a study by the United States Public Health Service23 of accidental drownings at home, of 38 infant deaths, 29 drowned in the bathtub. Two toddlers drowned by falling head first into five-gallon buckets.
The risk of drowning is particularly great for children under five with both boys and girls at greatest risk at ages one to four. Drowning is on the increase at these ages. In a recent study,24 it was found that drowning among boys aged one to four rose by as much as 17 per cent between 1958 and 1968, and increased by about 40 per cent for boys aged three and four. As children get older, males are at greater risk. According to the National Safety Council, about twothirds of drowning victims do not know how to swim.
There is general agreement by authorities that age three is the minimum age for organized swimming instruction. While infants can be taught to swim, the Academy of Pediatrics25 questions whether such immature youngsters can be taught water safety concepts and how to handle themselves properly in an emergency. It engenders a false sense of security in the parents. The National Council for Cooperation in Aquatics states that parents should realize that even though preschoolers may learn to swim, no young child, particularly the preschooler, can ever be considered "water safe" and must be carefully supervised when in or around water.
Some drownings are the result of falling through thin ice. Every year a number of youngsters, usually venturesome little boys, lose their lives in this way. Sometimes, the would-be rescuer becomes a casualty, too, because of ignorance. The popularity of winter sports and convenient transportation extends the danger to many areas of the country. Children at an early age should be impressed with the risk of walking, playing or skating on any ice without knowing its thickness.
Here is a basic guide:
1 inch - everyone keep off;
2 inches - one person may;
3 inches - yes, for small groups;
4 inches - a crowd's okay;
To measure thickness, chop a small hole through ice and lower a stick with a nail driven near the lower end. Catch the under edge of the ice with the nail, and measure the distance between the nail and the surface. Children must be warned to stay off ice in tidal rivers, salt water, fast-running streams, spring-fed areas and all water following a thaw.
If a child falls through the ice, he should be instructed to level out by kicking his feet vigorously so he can be more easily pulled onto the ice without catching his body on the edge of the hole. He should stay prone when he gets on top of the ice and roll quickly away from the hole. A rescuer should move toward the victim on his belly. A group of rescuers should grasp hands in a side-by-side pattern, moving their bodies on the elbows and toes with some help from the knees. On reaching the victim, the end person grasps him or extends a tree branch, belt, jacket or anything he can hold.
ACCIDENTAL DROWNING* IN THE UNITED STATES24 1958 and 1968
SPECIFIC CAUSATION OF ACCIDENTS
In order to pinpoint the need for accident prevention aimed at specific problems, data on a regional, state and local basis is needed. Pediatricians should interest themselves in such an effort and secure the help of their state health departments. For example, 20 years ago Carithers pointed out that in Florida there was a higher death rate from drowning accidents than in the nation as a whole.26 A recent analysis shows that the situation in Florida has not improved. Indeed, it appears to have worsened.
Kravitz in this issue presents examples of studies which the pediatrician can make from his own experience with patients. While there is an increasing amount of data on the types of accidents children have and the agents involved, there is a paucity of information on the relationship of social and psychological factors which contribute to, or indeed may be the actual cause of, an accident. Backett's study, referred to in the discussion of road accidents, is an example of this kind of investigation.
Watson27 has suggested an ecological approach. He proposes multidisciplinary studies which consider the person, the event and the situation in a multifactoral analysis. He points out that hazards, the social use of them and the injury are separate factors. He also reminds us that in the 19th century, before the age of bacteriology, the identification and correction of social factors such as poverty, crowding, filth and pollution improved mortality and morbidity from communicable diseases prior to the identification and use of specific measures to control them.
Three factors which distinguish accidents in children from those in adults are immediately apparent: the nature of the child, the social and physical environments.
NATURE OF THE CHILD
A child, by virtue of his inexperience, natural curiosity, and physical and emotional immaturity, is susceptible to accidents. Much of his learning is through experience. Accidents occur because he is placed in situations, either by himself or by someone responsible for his care, to which his adaptation is slow or inadequate. Most of these mishaps are minor and are hardly recognized as such. For example, he falls many times in learning to walk. In his desire to learn more about what he sees or touches, he puts many objects into his mouth. He experiences minor cuts and burns before he understands the meaning of "sharp" and "hot." Parents can use such minor mishaps to point out in an objective manner the causeand-effect relationship of injuries.
But, as we well know, not all of the mishaps that may occur are minor. How then can the young child, by nature accident susceptible, be protected from serious injury? The pediatrician must know the common or most likely serious hazards at certain months or years of age related to characteristic drives or behavior of the infant. These facts should be used to help parents understand and anticipate those accidents likely to occur at each stage of development.
Parents need to know, for example, that accidental poisoning is a problem chiefly between the ages of one and three since during this period of early ambulation, there is great curiosity about the world, the grasping functions and drinking functions are well developed, and the child's most naturally developed method of learning about the physical properties of the world is to put objects or materials in his mouth.
Parents who clearly understand the general pattern of child growth and development can prevent or reduce accidents. The process, as Dietrich28 long ago pointed out, involves protection, training, and supervision and education. These shift in significance with the growth of the child. During the child's first year, he needs 100 per cent protection. As he begins to acquire simple skills and learns how to walk and talk, he needs a gradually increasing amount of training, supervision and education accompanied, of course, by a gradually diminishing amount of protection.
How best to provide this accident prevention education is a problem. There is skepticism on the part of many physicians about the value of handing out a safety pamphlet to parents. They have given out so many in their practice, and still the accidents occur. This is expecting too much from a pamphlet. The physician must not underrate the importance of his own attitude and advice on the subject. Where there is a pediatric assistant, she should be trained to conduct the safety education program with visual aids, taped messages for the waiting room and printed advice on specific hazards.
Fuller,29 Langford30 and others have observed certain personality traits in accident repeaters. They are described as over-active, impulsive and dare-devil types with emotions that are easily aroused. Langford was impressed with the number of accidents experienced by other members of the family of the accident repeater. More recent studies by Sobel,31 Baltimore and Meyer32 and Husband and Hinton33 emphasize the importance of investigating family relationships and problems. As Husband and Hinton state, these children are led into situations where they more frequently face hazards than do other children. At the same time, their impulsiveness impairs their ability to make risk-reducing decisions. They act out their difficulties rather than thinking about them. These authors have found that when they give these families help by discussing matters in which they are experiencing difficulty and by helping them understand how these anxieties can contribute to accidents, the children frequently stop injuring themselves.
During the child's early years, his parents are the most important factors in his social environment. If they are unaware of the hazards to which he is exposed, he may be injured. If his parents practice poor safety habits, he is likely to imitate these habits and attitudes. In order to assess more accurately the role of the social environment, we need more information about the parents' safety attitudes and habits.
As the child grows older, the social climate of the play or school group has a strong influence. In some schools, competition in sports is overstressed, and in such an environment, more accidents occur. Then, too, in some play groups, the daredevil personality is more admired than in others.
As noted earlier, studies show that we must have a dynamic concept about the etiology of accidents. The family constellation is in constant change. There are new social and environmental conditions being introduced. In a young child, one is dealing with a growing, intelligent but inexperienced organism. We must acquire more knowledge of these conditions through interviewing parents and studying their circumstances.
The Accident Prevention Committee of the Academy is exploring techniques to identify families with high risks of accidents. One approach is to study the social and psychological factors in the environment of children who sustain a large number of accidents. The Committee is seeking the help of pediatricians and family physicians to furnish such data.34
The child must learn to adapt to the adult world. While he must acquire some knowledge of safety through trial and error, many hazards can and must be prevented. He must not be exposed to hazards beyond his capacity to understand.
When judging the safety of a particular physical environment for a child, it is always necessary to keep in mind the limitations, capabilities and characteristics of the child. Adults will often evaluate a situation from their perspective rather than from the child's. An adult may look at a bottle of aspirin and see only a pain-killer. He must also see it as a substance poisonous and inviting to children. When an adult moves into a new home with a lily pond in the backyard, he may look upon the pond only as an attractive feature of the garden; he should also see it as a hazard for his young children. These facts seem so obvious, but these accidents continue to occur. The pediatrician can take nothing for granted but must assume that those responsible for the care of children need to be informed of these risks.
There are a number of ways of protecting children from dangers in their physical environment. One is recognizing the potentially hazardous agents and preventing interaction between the child and the agents. Keeping medicines on the top shelf of the medicine chest, erecting a fence around ponds and pools, using gates at the tops and bottoms of stairs, keeping sharp knives out of children's reach - these are all examples of such intervention.
Lessening the injurious nature of the agent either by changing the agent or by training the child in the proper use or avoidance of it is the other way of protecting the child from environmental dangers. As it is neither possible nor desirable to isolate a child indefinitely from all hazards, it is important that the child receive a sound safety education which will enable him to escape injury despite the presence of hazards. And wherever possible, hazards should be mitigated.
Due to the efforts of pediatricians in poison control programs35 and the studies of Chisolm36 and others, great progress has taken place not only in cleaning up slums but also in the development of improved screening procedures for blood lead determination and in understanding lead metabolism and its toxicity. As a result, a lower level for normal blood lead in children was suggested by Chisolm,37 who in 1965 proposed a downward revision to 40 micrograms per 100 ml. Applying this standard to child slum populations in major cities, it was found that 20 per cent or more of the children in Chicago and New York City, one to six years old, had blood lead values of 40 or more micrograms per 100 ml. These findings have spurred public health authorities and pediatric leaders to renewed efforts at detecting children with undue absorption of lead and the source of their exposure. LinFu's38 review of this problem reveals how much has been accomplished and raises a number of questions which remain to be answered.
As a result of these studies, a new standard for paint has been promulgated by the FDA. The new regulations, requiring a level of 0.5 per cent, effective January, 1973, are intended to limit lead in paint by January, 1974 to 0.06 per cent. The Academy of Pediatrics, as it was 20 years ago in developing the first American Standard, has been a leading advocate in securing the passage of this standard. This is one of the best examples of symbiotic action between laboratory, clinical and social pediatrics evoked by the study of a hazardous agent.
THE BATTERED CHILD
Twenty years ago most pediatricians would have equated childhood trauma with accidental injury. More careful inquiry into childhood accidents has revealed that a certain number of accidents are deliberate injuries infìicted on the child. Kempe39 was one of the first pediatricians to spotlight the syndrome of the battered child. It is conservatively estimated that 60,000 cases occur annually. Many physicians still may not suspect the cause of the injury or may not want to get involved in spite of the growing awareness of the problem. Gil40 estimated after a twoyear study of 13,000 child-beating reports in all 50 states that there may be as many as 2.5 million children abused each year.
Caffey41 reported that shaking of young infants can cause serious cerebral and skeletal lesions and even death. Kempe42 described factors believed to put a child in jeopardy: 1) parents who have had poor mothering themselves and who may look to a newborn child to give them the love and understanding they never had; when the newborn cries and in other ways cannot live up to the parents' expectations, they take out their frustrations by hitting or slapping the child and 2) a family crisis, ranging from an unwanted pregnancy to the washing machine breaking down, any of which may trigger the actual injury-producing act.
Starbuck43 believes that cases of inflicted injury cause a significant "pollution" of accident statistics. Morse, Sahler and Friedman44 found in a survey of children under six years of age seen for injuries at a general hospital emergency department that in 10 per cent of injuries the trauma was related to physical abuse. An additional 10 per cent had injuries due to gross parental neglect. Gregg and Elmer45 in another study reported approximately 20 per cent of children seen for accidents had experienced physical abuse.
SUDDEN INFANT DEATH SYNDROME
The cornerstone of any program of prevention is scientific investigation of causes of accidents. There is no better illustration of the value of such works than the studies by Bergman and others of sudden and perplexing infant deaths. These deaths have usually been called accidental under such terms as "suffocation" or "crib death" but are better termed the sudden infant death syndrome.46 An estimated 10,000 infants die annually from this condition. The deaths tend to occur in male infants mostly at two to three months of age while asleep. Usually, they are of low birth weight and in lower socioeconomic class families. A high percentage of the babies have a history of upper respiratory infections in the two-week period prior to death. A recent study suggests a predisposing factor may be if the infant is apneic and his condition is aggravated by a respiratory infection. Research into the syndrome has yielded much clearer understanding of the possible sequence of events leading to death and often helps to allay guilt feelings in the parents. Further knowledge of the etiology could well lead to prevention. Recently, the National Foundation for Sudden Infant Death, a self-help group composed of bereaved parents and public-spirited pediatricians, prompted a Congressional resolution calling upon the National Institute for Child Health and Human Development to give top priority to investigations into crib deaths.
Some important developments have occurred in minimizing accidents in childhood. Poison control centers have been established. Standards for safer paint and clothing have been developed. Many people have worked on educational programs. Pediatricians have played a leading part. Through their studies, a greater depth of understanding has emerged. The importance of social and psychological factors is more apparent. The need to investigate sudden infant deaths and bruised and battered children is recognized.
Pediatricians have an honorable history of working for laws to improve child health. In the early years, they recognized the need for legislation to improve milk and water supplies, to provide immunization for all children and to strengthen child health services. Today, the tactics remain the same, but the subject matter is different and the control of the problem is more in the hands of the public. Child accident preventive measures have required new relationships with industry such as furniture, textile and paint manufacturers; legislators and citizen groups. Creating educational programs has meant developing new approaches, often involving the mass media.
No one can be certain that such efforts have accounted for the slight improvement in mortality and morbidity in the past 20 years.47 Better treatment may account for the change. Regardless, given the evidence that accidents are such an important threat to children, the pediatrician must include a program of safety education in his care of the child.
As a minimum prescription, we suggest the following unbreakable rules for the families under your supervision:48
Unbreakable rules for parents of babies
When it comes to baby's safety, it doesn't pay to beflexible. By following a few rigid rules, you will prevent many accidents.
* Never leave your baby alone in the house.
* Never leave him alone on anything from which he might fall.
* Always keep the sides of the crib up when not tending the baby.
* Always stay with your baby when he is in the tub. Even if he can sit up well, in a split second he might slip under the water.
* Always keep tiny, swallowable objects - pins, beads, buttons and the like - out of the baby's reach. No toy should be smaller than the baby's mouth.
* Always keep medicines, aspirin, tranquilizers, cosmetics, poisons and household cleansers well out of reach or, preferably, locked away.
Unbreakable rules for parents of preschoolers
* Never leave a child alone at home.
* Never allow play in or near driveway or garage.
* Keep matches in containers in places too high ever for a threeor four-year-old to reach.
* Always stay with your child near water. Be sure that pools, fish ponds, wells and cisterns are protected.
* Dispose of as many poisons as possible, such as rat poison, roach paste and powders. Store out of sight and reach or lock up other potential poisons: disinfectants, strong cleansers, cleaning fluids, kerosene, aspirin, medicines.
* Equip upstairs windows with sturdy screens and guards. Use gates at top and bottom of stairs until your child knows how to navigate steps.
* Store knives and sharp objects out of reach.
* Always use seat belts in the car.
1. Accident Facts. National Safety Council, 425 N. Michigan Ave., Chicago, III. 60611. 1972, p. 9.
2. Wheatley, G. A formula for child safety. Ohio Med. J. 49(1953). 609-613.
3. Press. E. A poisoning control program. Am. J. Pub. Health 44 (1954), 1520.
4. Accident Facts. Chicago: National Safety Council, 1958, p. 5.
5. Accident Facts. Chicago: National Safety Council, 1972. p. 8.
6. Accidents in Childhood as a Public Health Problem. Published by the Council of Europe, Strasbourg, 1972.
7. Wheatley. G. Prevention of Accidents in Childhood. In Advances in Pediatrics. Vol. VII. Chicago: Yearbook Publishers, 1956.
8. Sweden Today: Prevention of Childhood Accidents in Sweden. The Swedish Institute and the Joint Committee for the Prevention of Childhood Accidents, Box 3306. Stockholm 3, Sweden. 1968.
9. Health statistics from U.S. National Health Survey, July. 1959-June, 1961. Series B 37; July. 1965June. 1967. Series 10 58.
10. Accident Facts. Chicago: National Safety Council. 1972. p. 89.
11. Fact Book. Estimated Statistics on Blindness and Vision Problems. National Society for the Prevention of Blindness. New York, 1966.
12. Wheatley, G. Prevention of Accidents in Childhood in Advances in Pediatrics. Vol. VIII. Chicago: Yearbook Publishers. 1956.
13. Heirhstra, N.; Nichols, J. and Martin. G. An experimental methodology for analysis of child pedestrian behavior. Pediatrics Sup. 44 (1969), 832-838
14. Read. J. Traffic accidents involving child pedestrians. Pediatrics Sup. 44 (1969), 838-846.
15. Backett, E. and Johnston, A. Social patterns of road accidents to children. Brit. Med. J. 1 (1959). 409.
16. American Academy of Pediatrics Committee on Accident Prevention. Investigation of fabrics involved in wearing apparel fires. Pediatrics 34 (1964), 728.
17. Smith. E. The epidemiology of bums. The cause and control of burns in children. Pediatrics Sup. 44 (1969), 821-827.
18. Oglesby. F. The flammable fabrics problem. Pediatrics Sup. 44 (1969), 827-832.
19. Yockers, J- Burning characteristics of fabric clothing. Nat. Fire Protect. Quarterly 4 (1958).
20. Wheatley. G. Relationship of home environment to accidents. Arch. Environ. Health 13 (1966). 489-495.
21. Mofenson, H. Personal communication.
22. Accident Facts. Chicago: National Safety Council. 1972, p. 81.
23. Public health reports. U.S. Dept. of Hearth. Education and Welfare, May, 1961. p. 452.
24 Accidental Drowning. Statistical Bulletin. Metropolitan Life Insurance Co., June, 1972.
25. Newsletter Amer. Acad Peö. 22:4 (1971). 4
26. Carithers. H Drowning accidents among Florida children leading cause of death. J. Flor. M. A. 39 (1952). 97.
27. Watson, W. Childhood injuries: a challenge to society. Pediatrics Sup. 44 (1969), 794-798.
28. Dietrich, H. Accidents, childhood's greatest physical threat, are preventable. JAMA 144 (1959). 175.
29. Fuller, E. Injury prone children. Am. J. Orthopsychi. 18(1948). 708.
30. Langford, W. et al. Pilot study of childhood accidents. Pediatrics 1 1 (1953), 405.
31 . Sobel, R. Traditional safety measures and accidental poisoning in childhood. Pediatrics Sup. 44 (1969), 811-816.
32. Baltimore, C. and Meyer, R. A study of storage, child behavior traits, and mother's knowledge of toxicology in 52 poisoned families and 52 comparison tamilies. Pediatrics Sup. 44 (1969), 816-820.
33. Husband. P. and Hinten, P. Families of children with repeated accidents. Arch. Dis. Child. 47 (1972), 396^00.
34. Academy of Pediatrics Newsletter 23:10 (June 15. 1972).
35. Jacobziner, H. Lead poisoning in childhood: epidemiology, manifestations and prevention. CI. Ped. 5 (1966). 277-286.
36. Chisholm. J. and Harrison. H. The exposure of children to lead. Pediatrics 18 (1956), 943-958.
37. Chisholm, J. Chronic lead intoxication in children. Dev. Med. Child Neurol. 7 (1965), 529-536.
38. Lin-Fu. J. Undue absorption of lead among children - a new look at an old problem. New Eng. J. Med. 286 (1972), 702-710.
39. Kempe. C. and Heifer. R. Helping the Battered Child and his Family. Philadelphia: JB. Lippincott, 1972.
40. Gil, D. Physical abuse of children: findings and implications of a nationwide survey. Pediatrics Sup. 44(1969). 857-864.
41. Caffey, J. Interview. Medical World News (June 2, 1972). 21.
42. Kempe. C. Interview. Medical World News (June 2. 1972). 21.
43. Starbuck. G. Personal communication.
44. Morse, C; Sahler, O. and Friedman. S. Abused and neglected children. Amer. J. Dis. Child. 120 (1970). 439-446.
45. Gregg. G. and Elmer. E. Infant injuries: accident or abuse. Pediatrics Sup. 44 (1969), 434-439.
46. Bergman. A.; Ray. C; Pomeroy, G.; Wahl. P. and Beckwith. J. Studies of the sudden infant death syndrome in King County. Washington, III. Epidemiology. Pediatrics 49 (1972), 860.
47. Disaster and Emergency Medical Services for Infants and Children. Committee on Disaster and Emergency Medical Care. American Academy of Pediatrics. PO Box 1034. Evanston. III. 60204.
48. Your Child's Safety. Metropolitan Life Insurance Co.. 1970.
LEADING CAUSES OF DEATH
ACCIDENT MORTALITY RATE IN CHILDREN
Death Rates From Accidents Other Than Motor Vehicle Accidents - U.S.
ACCIDENTAL DROWNING* IN THE UNITED STATES24 1958 and 1968