The practice of pediatrics is changing right before our eyes. Look what has happened to invasive Haemophilus influenzae and varicella. Hepatitis B is on the way out, a multivalent pneumococcal vaccine has been introduced, and we almost had (and will have) an immunization for rotavirus. Many more vaccines are in the pipeline. So, as the threat of common infections declines, we will have more time for other dangers to children.
The question of which dangers is easy: injuries are the leading cause of pediatric morbidity and mortality after 1 year of age. This issue covers a range of environmental hazards for children - burns, toxic ingestions, inhalations, envenomations, and drowning. If you add motor vehicle and leisure activities, firearms, fireworks, falls, animal bites, hyperthermia and hypothermia, suffocation, and aspiration injuries, you have pretty much covered the waterfront. These are a lot of topics for anticipatory guidance. Yet, guidelines suggest we address most of these.1,2
HOW WELL DO WE DO?
Pediatricians and other providers of care for children value and espouse anticipatory guidance for injuries, but the evidence suggests our follow-through leaves room for improvement. For example, Barkin et al. sent questionnaires about injury prevention counseling for children below 5 years to 465 pediatricians, family physicians, and pediatric nurse practitioners.3 Most of the 70% who responded indicated they gave some guidance about preventing injuries from motor vehicle crashes (66% did this) and poison ingestion (59%). However, only 32% said they provided guidance about prevention of drowning and 16% gave advice about firearms. The authors found no relationship between provider knowledge and whether guidance was given.
Webster et al. sent a questionnaire to members of the Maryland Chapter of the American Academy of Pediatrics (AAP)4 about firearm safety. These pediatricians largely felt that anticipatory guidance was important and that they had a responsibility to do it, but only 30% reported ever providing such counseling and only 10% did so for at least 25% of their families. Such blanket questionnaire studies, although the best we have, are likely to have flaws. But biases are more likely to overestimate rather than underestimate counseling.
Why don't we do better? Time is almost certainly a factor - the average duration of well-child visits has been estimated at 16 minutes and may be shrinking in managed care. What parents want from us must have something to do with this as well. Many are eager to get all the information they can about protecting their children during visits. Others have to get back to work or have their own list of questions and can get this information elsewhere and at their own convenience. It would be interesting to ask parents in pediatric office waiting rooms how much time they wanted to spend with injury prevention counseling. A study similar to this by Hickson et al. suggested this was not at the top of their lists.5 1 will bet that those who need guidance the least would also be the most interested in getting it.
SO WHAT WILL WORK FOR INJURY PREVENTION?
If it isn't possible to cover everything for all patients, one option is to focus prevention on children at highest risk. Boys and low socioeconomic families would be a priority here.
One might also focus on families who have already had an injured child. It is a consistent observation that most injuries involve a subgroup of 15% to 20% of children. Day care center research is the best resource for this. For example, AIkon et al. studied 141 children longitudinally in four San Francisco Bay child care centers. The injury rate was 8.3 per child-year.6 Most injuries were minor, primarily defined as leaving an abrasion, a bruise, or some mark. Eighteen percent of these children sustained more than 50% of the total injuries and those with more minor injuries were also much more likely to sustain one or more moderate or severe injuries. Minor injuries were predominantly child or child and environment related as opposed to purely environmental. So some children do seem to be accident prone and their families could be priorities for prevention counseling. We probably do this instinctively.
A recent study of injured children in King County emergency departments and hospitals expanded this concept.7 Children had almost twice the hazard ratio for an injury following the injury of a sibling in this large, retrospective study. The risk peaked 4 to 10 days after the sibling's injury, and then fell toward but remained significantly above baseline for 90 days following the first injury. Although cause and effect between the two injuries and the home environment were cloudy, the message was clear. Families should be counseled about prevention following an injury (a kind of secondary prevention).
Another way to "ration" counseling is to concentrate on the most important preventions based on severity and frequency of injury types, and availability of effective prevention. A national Delphi survey of 23 experts placed motor vehicle safety, fires and burns, drowning, poisoning, falls, and scald prevention in the high priority group.8 Middle priorities included choking or aspiration, suffocation, firearms, abuse, baby walkers, and pedestrian safety. Toy related, playground, electrical outlet, animal bites, and bikes /wagons /all terrain vehicles were low priority. The experts preferred environmental interventions such as car seats, smoke alarms, and hot water heater adjustments to pure education ("preaching"). They suggested that guidance be limited to no more than three topics per visit because of parents' ability to absorb information. Pediatricians might also prioritize guidance based on medical evidence of effectiveness by topic. A continuously updated summary is available at the National Guideline Clearinghouse (www. guideline.gov). Remember, a lack of evidence may be due to a scarcity of data rather than lack of effectiveness.
Perhaps the best alternative is to use aids or surrogates for counseling. The 1 -minute parentpatient tests for safety knowledge and The Injury Prevention Program (TIPP) safety sheets that are available from the AAP (888227-1770) are excellent age-specific resources. Most of us use some aids, but we could be more organized and comprehensive. I don't see any other way of communicating a comprehensive review of injury preventions within the time available during office visits. We should also be advocates for laws that improve child safety through regulations about behavior ("buckle-up" laws) or equipment (child car seats). This is where the real gains are made.
1. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents Pocket Guide, rev. ed. Arlington, VA: National Center for Education in Maternal and Child Health; 1998:1-64.
2. American Academy of Pediatrics. 77PP: A Guide to Safety Counseling in Office Practice. Elk Grove Village, IL: American Academy of Pediatrics; 1994.
3. Barkin S, Fmk A, Gelberg L. Predicting clinician injury prevention counseling for young children. Arch Pediatr AdolescMed. 1999;153:1226-1231.
4. Webster DW, Wilson MEH, Duggan AK, Pakula LC. Firearm injury prevention counseling: a study of pediatricians' beliefs and practices. Pediatrics. 1992;89:902-907.
5. Hickson GB, Altemeier WA, O'Connor S. Concerns of mothers seeking care in private pediatrics offices: opportunities for expanding services. Pediatrics. 1983;72:619-624.
6. Alkon A, Genevro JL, Kaiser PJ, Tschann JM, Chesney M, Boyce WT. Injuries in child-care centers: rates, severity, and etiology. Pediatrics. 1994;84suppl pt 2):1043-1046.
7. Johnston BD, Grossman DC, Connell FA, Koepsell TD. High-risk periods for childhood injury among siblings. Pediatrics. 2000;105:562-568.
8. Cohen LR, Runyan CW, Downs SM, Bowling JM. Pediatric injury prevention counseling priorities. Pediatrics. 1997;99:704-710.