Pediatric Annals


A Pediatrician's View

Robert A Hoekelman, MD


Why Deaths From Head Injuries Are on the Decline


Why Deaths From Head Injuries Are on the Decline

This month's issue of Pediatric Annals, with its Guest Editor Kenneth M. Jaffe, MD, Director and Professor of Rehabilitation Medicine, and Adjunct Professor of Pediatrics and Neurological Surgery at the University of Washington, addresses head injuries in children. This is a most important subject in that head injuries are the reason for 75% of all trauma admissions to hospitals and the cause of 70% of all trauma deaths,1 some 7 000 annually.2 Approximately 185 per 100 000 infants and children from birth through age 14 years and 295 per 100 000 adolescents and young adults from age 15 through 24 years are hospitalized annually for traumatic brain injury (TBI).3 During 1990 (the most recent year for which we have population figures for these age groups), those numbers added up to 208 310 hospitalizations. The number of head injuries, of course, was much, much higher because many children die from TBI before they can be hospitalized (approximately 50% of TBI fatalities4) and the vast majority who suffer head injuries do not require hospitalization.

Most head injuries are the result of accidents - falb, motor vehicle accidents involving drivers, pedestrians, and bicyclists, and sports and recreational activities. About 10% are due to assaults, including child abuse. Great gains have been made in reducing accidental deaths from all causes and, with them, those due to TBI. The National Center for Health Statistics (NCHS) reports annual deaths and death rates from all causes. The number of deaths and death rates for all accidents and motor vehicle accidents for 1981 and 1990 (the last year reported at this writing) involving infants, children, adolescents, and young adults from birth through 24 years of age are shown in the Table.

These figures are very encouraging: they show 24% to 28% declines both in deaths and death rates from all accidents and motor vehicle accidents over a 10-year period. Although the NCHS does not provide data for deaths and death rates for accidental TBIs per se, we can assume that similar trends have occurred and will continue to occur for them. There are many reasons for these trends. Important among those reasons have been active and passive accident prevention in the home, in recreational settings, and in the school and work place. The list is long, and pediatricians have provided the leadership for implementing these preventive measures through instructing parents and patients about them and by advocating their use in public places.

Most important in reducing TBI deaths has been the reduction in motor vehicle accidents, which, as shown in the Table, accounted for 67.5% of all accidental deaths in persons from birth through age 24 years in 1990; motor vehicle accidents also caused 30% of deaths from all causes in the 1- through 24-year age group (15 594 of 52 100) that year. The reasons for the steady decline in motor vehicle-related deaths, including those from TBIs, have been listed in Pediatric Annals previously5:

* Passing and enforcing speed limits up to 55 miles per hour.

* Requiring annual inspection of motor vehicles.


TABLEDeaths and Death Rates in the United States: Birth Through 24 Years of Age


Deaths and Death Rates in the United States: Birth Through 24 Years of Age

* Imposing severe penalties for driving while intoxicated.

* Mandating the use of seat belts and infant car seats.

* Improving automotive design and construction, including rear- and side-view visual aids, head and brake lights, turn signals, and speed control mechanisms.

Last, but not least, among the reasons for the decline in the number and rate of deaths nom head injuries have been improvements in our medical care system designed to deal with such injuries after they occur. These include establishment of:

* Regional Emergency Medical Service systems that use emergency medical technicians who are able to stabilize TBI patients at the scene of accidents before they die, get them to local hospital emergency rooms, and transfer them to regional medical centers by helicopters or ambulances if needed for specific high-technology treatment.6

* Emergency Medicine as a separate discipline with its own academic departments in schools of medicine and its own residency programs to train physicians to staff hospital emergency rooms throughout the country.

* Pediatric Emergency Medicine as a subspecialty with fellowship programs designed to train pediatricians to staff large medical center emergency rooms.

* Pediatric Critical Care as a subspecialty, with fellowship programs to prepare pediatricians to treat critically ill infants, children, and adolescents in university medical center pediatric intensive care units.

While we are sure that these agents of change will continue to be effective, we must make similar efforts to reduce deaths from inflicted (rather than accidental) brain injuries due to child abuse and other violent behavior.


1. Davis RJ, Fan Tait V, Dean JM, Goldberg AL, Rogers MC. Head and spinal coni injury. leu Rogen MC, ed. Textbook ? f Pediatric Intensive Care. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992:805-857.

2. Schutzman SA. Injury - head. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 3rd ed. Baltimore, Md: Williams & Wilkinsil995:268-275.

3. Kraus JF, Nourjah R The epidemiology of uncomplicated brain injury. Trauma. 1988;28:1637-1643.

4. Rivata FR Epidemiology and prevention of pediatric brain injury, ftrfar Aim.l994;23:1217.

5. Hoelceiman RA. A pediatrician's view: causes of death among the young. Pediatr Ann. 1992;21:407-408.

6. Barkin RM, Luten RC. Emergencies in pediatrics and the child in the emergency medical services system. PeSaa Ann. 1990;19:571-577.


Deaths and Death Rates in the United States: Birth Through 24 Years of Age


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