Pediatric Annals

Injury Control: Issues and Methods for the 1990s

Frederick P Rivara, MD, MPH

Abstract

You have heard the statistics about injuries time and again: the leading cause of death during childhood and young adulthood . . . 2200 deaths each year1 ... 14 000 000 physician visits and 600 000 hospitalisations for the treatment of injuries to children and adolescents each year in the United States1-2 . . . medical care costs of 7.5 billion dollars annually1 . . . over 1 000 000 years of potential Hie lost.1 The numbers numb the mind and make the eyes glaze over.

For me the problem is real because of the children I care for each day. It is real because of the patients I saw on our trauma unit today: the 13-year-old boy with a severe traumatic brain injury from a bicyclemotor vehicle collision; the 2-year-old boy with a forearm amputation from felling off a riding lawn mower; the 9 month old who underwent skin-grafting for a burn from a cup of hot coffee pulled over when the child was in her walker; the 10 year old who has 50% burns from a housefire; the 7 year old and the 10 year old with seat-belt related injuries from riding in the back seats of cars that were not equipped with combination lap-shoulder harnesses.

In years past, we would either throw up our hands and ascribe such events as "acts of God," or "accidents happen* or as random, unpredictable experiences beyond anyone's control. Fortunately, this is not the attitude today because of the growing body of knowledge in the science of injury control. The articles in this issue of Pediatrie Annals are products of this new field and share a few simple but important concepts chat have been empirically derived and tested. Together, these principles guide the work of practitioners in this field and should guide the clinician in his or her practice.

Passive strategies are likely to be more effective than active strategies and should be preferentially used, injury prevention strategies based solely on repeated behav' ior change (active strategies) on the part of individuals, particularly parents, are less likely to be effective than those strategies that work wholly or partly automatically (passive prevention). For example, air bags will protect more people than seat belts because they do not require active intervention every time someone climbs into a car.3 Turning down water heater settings is likely to be more effective in preventing tap water scald burns than asking parents to test the bath water temperature every time the tap is turned on.4 Smoke detectors and fire-safe cigarettes will prevent more residential fire deaths than imploring people not to smoke in bed.5,6 While many interventions cannot rely on purely passive strategies, passive intervention components should be incorporated into injury prevention programs as much as is feasible.

Specific advice is much more effective than vague advice. Individuals, including parents, are likely to follow advice on injury prevention if it is clear and precise rather than diffuse and general. Asking parents to "supervise their children," "be careful," and "childprooP their homes is likely to be less effective than suggesting countermeasures for specific injury problems. Counseling a parent of a newborn coming in for a 2-week check-up on the use of child seat restraints, lower water heater settings, and smoke detectors is likely to save more lives and prevent more serious injuries than giving that parent a large laundry list of measures that may not be developmentally appropriate for the child or effective.

The concept of injury control expands the focus of efforts to include postinjury care of the trauma patient. The science of injury control considers three separate…

You have heard the statistics about injuries time and again: the leading cause of death during childhood and young adulthood . . . 2200 deaths each year1 ... 14 000 000 physician visits and 600 000 hospitalisations for the treatment of injuries to children and adolescents each year in the United States1-2 . . . medical care costs of 7.5 billion dollars annually1 . . . over 1 000 000 years of potential Hie lost.1 The numbers numb the mind and make the eyes glaze over.

For me the problem is real because of the children I care for each day. It is real because of the patients I saw on our trauma unit today: the 13-year-old boy with a severe traumatic brain injury from a bicyclemotor vehicle collision; the 2-year-old boy with a forearm amputation from felling off a riding lawn mower; the 9 month old who underwent skin-grafting for a burn from a cup of hot coffee pulled over when the child was in her walker; the 10 year old who has 50% burns from a housefire; the 7 year old and the 10 year old with seat-belt related injuries from riding in the back seats of cars that were not equipped with combination lap-shoulder harnesses.

In years past, we would either throw up our hands and ascribe such events as "acts of God," or "accidents happen* or as random, unpredictable experiences beyond anyone's control. Fortunately, this is not the attitude today because of the growing body of knowledge in the science of injury control. The articles in this issue of Pediatrie Annals are products of this new field and share a few simple but important concepts chat have been empirically derived and tested. Together, these principles guide the work of practitioners in this field and should guide the clinician in his or her practice.

Passive strategies are likely to be more effective than active strategies and should be preferentially used, injury prevention strategies based solely on repeated behav' ior change (active strategies) on the part of individuals, particularly parents, are less likely to be effective than those strategies that work wholly or partly automatically (passive prevention). For example, air bags will protect more people than seat belts because they do not require active intervention every time someone climbs into a car.3 Turning down water heater settings is likely to be more effective in preventing tap water scald burns than asking parents to test the bath water temperature every time the tap is turned on.4 Smoke detectors and fire-safe cigarettes will prevent more residential fire deaths than imploring people not to smoke in bed.5,6 While many interventions cannot rely on purely passive strategies, passive intervention components should be incorporated into injury prevention programs as much as is feasible.

Specific advice is much more effective than vague advice. Individuals, including parents, are likely to follow advice on injury prevention if it is clear and precise rather than diffuse and general. Asking parents to "supervise their children," "be careful," and "childprooP their homes is likely to be less effective than suggesting countermeasures for specific injury problems. Counseling a parent of a newborn coming in for a 2-week check-up on the use of child seat restraints, lower water heater settings, and smoke detectors is likely to save more lives and prevent more serious injuries than giving that parent a large laundry list of measures that may not be developmentally appropriate for the child or effective.

The concept of injury control expands the focus of efforts to include postinjury care of the trauma patient. The science of injury control considers three separate phases that lead to damage to an individual.7 The first phase considers factors that lead to the injury event, ie, drunk driving, alcohol use during swimming, diving into unknown bodies of watei; and smoking in bed. The second phase encompasses the actual injuryproducing event - the motor vehicle crash, the fell into a swimming pool, or the bed catches on fire from a smoldering cigarette. The final phase includes the care of the injured patient - bystander cardiopulmonary resuscitation (CPR), advance paramedic care, trauma center treatment, and pediatrie rehabilitation centers. In each of these phases, there is the potential for intervention and prevention or minimization of the long-term consequences to the child. Circumferential barriers around swimming pools may prevent the toddler from getting access to water; pool alarms and swimming classes may prevent submersion; bystander CPR and advance paramedic care combined with rehabilitation may prevent long-term consequences to the child.8

Concentrate attention on problems that occur frequently, are severe, and for which effective interventions are available. As self-evident as these guidelines are, only recently have they been routinely applied. For many years, well-meaning individuals expended a great deal of energy on poorly conceived programs, implemented unproven (or ineffective) countermeasures, and focused on unimportant problems as often as on important ones. The topics chosen for this issue are ones that meet all three of these criteria.

Effective injury contrai by the pediatrician must include efforts with individua/ patients , as well as efforts at the community level. Many injury prevention strategies can be incorporated into the routine anticipatory guidance given as part of health maintenance visits. These should be geared to the developmental level of the child or adolescent as well as any presenting concerns of the family or patient. Such advice, if specific and practical, stands the greatest chance of being followed and effective.

The physician, however, should look beyond the individual physician-patient encounter and consider addressing some of these injury problems on a more community-wide basis. As pointed out by the authors in this issue, such actions may prove to be the most effective strategies to ensure protection of children from hazards. Pediatricians have led the medical community in lobbying for mandatory seat restraint use, first for children and more recently for individuals of all ages.9 The effectiveness of the Poison Prevention Packaging Act is powerful testimony to the efforts of pediatricians working on injury problems on a larger community level.10 However, many challenges remain: helmets on all children who bicycle; complete fencing of swimming pools; revised building codes to include sprinkler systems and hard-wired smoke detectors; and the regulation of handgun and ammunition sales.

Intentional injuries of homicide and suicide are as important to consider as are the unintentionai injuries that have been the focus of most past ejjorts at injury prevention. Many of the same strategies for preventing unintentional injuries may be effective for these intentional injuries as well. Restriction of access to handguns and bullets will likely decrease the rate of homicides and suicides among teenagers as well as decrease the smaller number of unintentional firearm injuries that occur to this and younger age groups.11 Intentional injuries should not be viewed as a "mental health" issue or a "criminology" issue but as a health issue that demands the attention of the primary care physician. The pediatrician seeing a depressed adolescent in his or her office has the responsibility to ask about the availability of guns or other lethal means of self-harm.12 Research into the effectiveness of various interventions is even more crucial for intentional injuries than for unintentional injuries.

I hope that the reader gleans from the following pages a sense of excitement about the reduction of morbidity and mortality from trauma that those of us who labor each day in this field believe is possible.

REFERENCES

1. Division of Injury Control, Center for Environmental Health and injury Control, Centers fot Disease Control. Childhood injuries in the Uniteti Stales. Am J Dis Child. 1990; 144:62 5-646.

2. Rice DP, Mackenzie EJ. Cost of Injury in the United States: A Report in Congress. San Francisco, Calif: Institute for Health and Aging, University of California and Injury Prevention Center and The Johns Hopkins University; 1989.

3. US National Highway Traffic Safety Administration. Fmoi Regtdaiory Andysis; Amendment to Federal Motor Safety Standard 208, Passenger Cat Front Seta Occupant Protection. Washington, DC: US Dept of Transportation; 1988.

4. Katcher ML. Prevention of tap water burns: evaluation of a multi-media injury control program. Am J PuWic HeoM. 1987;77:1 195-1197.

5. McLoughlin E, Marchone M, Hanger L, el al. Smoke detector legislation: itseffecton owner-occupied homes. Am J Public Health. 1985;75:855-862.

6. McLoughlin E. Stop carelessness? No, reduce burn risk. Pediatr Ann 1992;21:423-428.

7. Baker SP, O'Neill B, Karpf RS. TKe Injury Fact Boot. 2nd ed. New York, NY: Oxford University Press Ine; 1991.

8. Winternute GJ. Drowning in early childhood. Pediatr Ann. 1992;21:417-421.

9. Decker MD, Dewey MJ, Hutchinson RH. The use and efficacy of child devices: the Tennessee experience, 1982 and 1983. JAMA. 1984;252:2571-2575.

10. Walton WW. An evaluation of Poison Prevention Packaging Act. Pediatrics. 1982;69:363-370.

11. Chlistoffel KK. Pediatrie firearm injuries: time to target a growing problem, ftdwrr Ann. 1992-,2 1:430-436.

12. Grossman D, Risk and prevention of suicide. Pediorr Ann. 1992;2 1:448-454.

10.3928/0090-4481-19920701-05

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