Canadian Task Force on Preventive Health Care

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made. (Formerly, these situations were captured under a "C Recommendation".) This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade. For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Prevention of Household and Recreational Injuries in Children (<15 years of age)

Prepared by R. Wayne Elford, MD, CCFP, FCFP, Department of Family Medicine, University of Calgary

Objective
To make recommendations for the prevention of household and recreational injuries of Canadian children < 15 years of age. This is an update of the 1979 Canadian Task Force recommendations.

Burden of Suffering
For Canadians aged 1 to 24, intentional and unintentional injury accounts for 63% of all deaths. The leading cause of death in Canadian children is motor vehicle accidents, followed by drowning, burns, choking and falls. For every fatal childhood injury, another 45 injuries will require hospital treatment; about 1,300 more will require a visit to an emergency department and an unknown number will result in a visit to a physician or clinic. Some of the more common causes of injury include falls (there were 2,100 deaths due to falls 1981), drowning (429 Canadians drowned in 1987), burns, scalds and fire-related deaths (accounting for 402 deaths among Canadians in 1988), poisoning, (resulting in 424 fatal poisonings in Canada in 1987, 2 were under age 15), suffocation (accounting for 415 Canadian deaths in 1987, 36% were under age 15), bicycle and other sports-related injuries (there were 139 fatal bicycle injuries in Canada in 1987), and fire-arm related (resulting in 60 deaths in Canada in 1988).

Options
Interventions involve public health education, legislation, and individual counselling.

Outcomes
Mortality and related morbidity.

Evidence
MEDLINE was searched from 1981 to November 1991 using the term accidents with the subheadings diagnosis, economics, epidemiology, legislation and jurisprudence, mortality, prevention and control, standards, and trends; aviation, occupational, and traffic accidents were excluded. Contact was also made with other resource centres and reports.

Values
The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs
The incidences of falls and related accidents have been shown in descriptive studies to be reduced up to 96% by use of legislation for window guards, safety features such as car restraints, and stair guards. Counselling of parents about safety features in the home has not been shown to be effective.

Before and after studies have been shown to reduce drowning and pool submersions by the use of legislation (fencing and self-closing gates). Expert opinion supports swimming lessons to reduce drowning. A cohort study has shown the association between drowning and young children being left alone in the bathtub.

Before and after studies have show reduced incidence of burns after legislation on smoke detectors, noninflammable sleepwear, and hot water temperature regulation. An RCT supports the use of lower hot water heater temperature to reduce related injuries.

Before after studies have show a reduction in poisoning after legislation on child-proof medicine containers. Education, although useful for increasing the number of families who have and understand the use of ipecac for poisoning, has generally failed to decrease the incidence of poisoning.

Bicycle helmet use is associated with a decrease in the severity of head injuries. This is discussed in a separate guideline.

Recommendations
Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is fair evidence to implement legislation for the use of window and stairway guards [B, II-2].
There is fair evidence to include individual counselling on window and stairway guards in the PHE of parents with young children [B,II-2].
There is fair evidence to implement public health education and legislation to require swimming pools to conform to safety standards to reduce drowning [B, II-2].
There is insufficient evidence to include or exclude individual counselling on the teaching of water safety in the PHE of parents with young children [C, III].
There is fair evidence to include public health education on the dangers of leaving young children (< 36 months of age) alone in the bathtub [B, II-2].
There is insufficient evidence to include or exclude individual counselling on the dangers of leaving young children (< 36 months of age) alone in the bathtub [C, III].
There is fair evidence to implement public health legislation on the use of safety devices (smoke detectors, nonflammable sleepwear, and hot water thermometers) [B, II-1].
There is fair evidence to include individual counselling on the use of safety devices in the PHE of parents with young children [B, I].
There is good evidence to implement public health education and legislation on the use of ipecac and Regional Poison Centre Awareness programs [A, I].
There is fair evidence to include individual counselling on the use of ipecac and Regional Poison Centre Awareness programs in the PHE of parents with young children [B, I].
There is fair evidence to implement public health education and legislation for the use of helmets when riding bicycles [B, II-2].
There is insufficient evidence to include individual counselling on the use of helmets when riding bicycles in the PHE of parents with young children [C, I].

Validation
This report was externally peer reviewed. The 1989 U.S. Preventive Services Task Force recommended counselling for parents regarding household and environmental injuries. The American Academy of Pediatrics recommend physicians counsel on the use of car restraints, smoke detectors, how water temperature regulation, window and stairway guards, and the use of ipecac.

Sponsors
The Canadian Task Force on Preventive Health Care developed this guideline with funding from Health Canada.

Source Document
Elford R.W. Prevention of household and recreational injuries in children (<15 years of age). In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 306-17.