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.
Contents
In the 1979 Canadian Task Force report,< 1> home and recreational injuries were acknowledged to constitute an important proportion of accidents. ("Unintentional injury is more appropriate than "accident" in terms of terminology, however, many articles in the literature still use the term "accidental".) The report emphasized the particular risk for young children. At that time there was insufficient literature on the subject to justify a recommendation on scientific grounds. However, the maneuver of encouraging safety in the home and community in the context of periodic examinations scheduled for other purposes was made a "C" recommendation and included in the health protection packages for preschool to adolescent age groups. There is now considerable evidence describing the effectiveness of legislation and public health education in prevention of such injuries. There is, however, insufficient evidence to evaluate the effectiveness of physician counselling except as applied to poison treatment modalities (use of Ipecac and awareness of emergency poison control centre telephone numbers) and the identification of home hazards to prevent falls and burns. In these cases counselling is effective. Household and recreational injuries in adults (Chapter 45) and the elderly (Chapter 76) as well as motor vehicle accidents (Chapter 44) have been reviewed in other sections of the book.
Burden
of SufferingInjuries are the leading killer of our preschool and school-age children, and of adolescents. For Canadians aged 1 to 24, intentional and unintentional injury accounts for 63% of all deaths. In the developed world, injuries cause more than four times more childhood deaths than any other disease.<3> The leading cause of death in Canadian children is motor vehicle accidents, followed by drowning, burns, choking and falls.<4> Injury mortality rates for Canadian children aged 5 to 14 exceed those of children in Japan, Australia and most countries in Western Europe. These injury-related deaths are but the tip of the iceberg. 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.<5> Disfigurement, disability, developmental delay and emotional problems are major sequelae of accidental injuries to children.<3> The Canadian Accident Injury Reporting and Evaluation (CAIRE) project identified the following top 10 circumstances involved in home accidents that resulted in visits to Children’s Hospitals in 1989 – windows or window glass, bicycles, cribs, hot water (excluding other hot liquid), ladders, high chairs/child care, baseboard heaters/electric, glassware (excluding tempered), change tables/child care, and baby walkers.<6>
Table 1 summarizes the mortality and morbidity rates for the most common types of injury in children. A brief description of the predictable factors associated with each of the leading causes of accidental injury in children follows.
Effectiveness
of Intervention Maneuvers(i) Public Health Education – Numerous public health education campaigns have used combinations of leaflets, poster displays in public buildings and T.V. advertisements targeted towards high-risk populations. Several controlled studies have failed to demonstrate any resulting reduction in unintentional injuries.
(ii) Legislative/Environmental – Systematic identification and reduction of environmental hazards prevents accidents. Many studies have demonstrated a far greater impact on home and recreational safety through influencing legislators, who in turn modify the environment through building codes and safety legislation (see Table 2, Chapter 76 on Injuries in the Elderly).
(iii) Individual Counselling – Several studies in the past decade have indicated that physicians can play a supportive role in preventing injuries through anticipatory guidance and counselling on safety measures. A recent publication<17> summarizing the impact of prevention counselling in primary care settings as determined by randomized controlled trials, supports the effectiveness of office counselling in improving parental knowledge and behaviours. Due to sample size and follow-up limitations these studies were unable to show an influence on morbidity or mortality.
Children with pools on their own or neighbouring properties were 2.5 times more likely to be involved in accidents involving domestic pools. Expert opinion holds that toddler or early childhood swimming lessons not only provide a degree of improved survivability for the young child but also place the child in the swimmer category at an earlier age (the greatest proportion of drowning occurs in non-swimmers) and improve survival as an adult swimmer.<20>
An association between drowning and leaving young children alone in the bathtub has also been shown in a cohort study.<19>
Several demonstration projects have failed to document a major impact from educational programs on the prevention of poisoning.<24> In a controlled trial involving 403 families (with children 5 years old or younger) recruited from an emergency clinic, counselling on correct poison treatment methods (plus a written handout, telephone sticker and a bottle of ipecac) resulted in more self-reported ipecac storage (68% vs. 42%, p=0.005), familiarity with the use of ipecac (40% vs. 25%, p=0.04) and use of poison centre phone number stickers at 6-month follow-up (42% vs. 25%, p=.03).<25>
Recommendations
of OthersThe American Academy of Pediatrics (AAP) has developed an Injury Prevention Program (TIPP) for use in office practice.<28> TIPP uses the Framingham safety survey to identify at-risk behaviour, safety sheets to reinforce information provided by the physician in discussion of questionnaire results and a model 12-session counselling schedule (from prenatal/newborn to 4 years). AAP’s policy statement states that all physicians should advise parents to acquire the following items for their children’s safety: 1) Currently approved child car restraints; 2) Smoke detectors in the home that would protect the child’s sleeping area; 3) Safe hot water temperatures at the tap; 4) Window and stairway guards/gates to prevent falls; and 5) A 30-mL (1-oz) bottle of syrup of ipecac. No evaluation of the TIPP program has been published.
Conclusions
and RecommendationsThere is fair evidence (grade II-2) that requiring conformity to water safety standards reduces deaths from drowning (B Recommendation) but insufficient evidence to support counselling parents of young children concerning early swimming class exposure and abiding by water safety guidelines (C Recommendation). A decision on such counselling may, however, be made on other grounds. There is fair evidence that parents of young children should never leave a child under 36 months of age alone in a bathtub (B Recommendation) but insufficient information about the ability of physicians to influence supervision of children in baths by counselling (C Recommendation).
There is fair evidence (grade II-2) that the acquisition of safety features such as smoke detectors, non-inflammable sleepwear, and hot water thermostat settings reduces injury from scalds and burns (B Recommendation). There is also fair evidence (grade I) concerning the effectiveness of counselling the parents of young children to acquire safety features such as smoke detectors, non-inflammable sleepwear, and hot water thermostat settings (B Recommendation).
There is good evidence (grade I) that parent awareness of poison control modalities reduces the incidence of poisoning in infants (A Recommendation). There is also fair evidence to support counselling on prevention of poisoning and the provision of ipecac and poison control centre phone number stickers to the parents of young children (B Recommendation).
There is fair evidence (grade II-2) that wearing helmets reduces the incidence and severity of head injuries in cyclists (B Recommendation). However, there is insufficient evidence that counselling will increase the rate of bicycle helmet use for those who ride the roadways (C Recommendation). Decision concerning such counselling may be made on other grounds.<29>
Unanswered
Questions (Research Agenda) Evidence
Table
1: Canadian Mortality and Morbidity Rates for Unintentional Injury in 19891(per
100,000 – standardized to 1971 population)
| Overall (0-85+ yr) | Pediatric (0-14 yr) | |||||||
| Mortality | Morbidity | Mortality | Morbidity | |||||
| M | F | M | F | M | F | M | F | |
| Falls | 6.77 | 4.16 | 425.0 | 384.0 | .04 | .24 | 420.5 | 283.5 |
| Drownings | 2.31 | .63 | 2.78 | 1.38 | 1.86 | .95 | 5.49 | 3.43 |
| Burns/Fire related | 2.11 | .91 | 11.52 | 4.23 | 1.40 | .91 | 11.01 | 4.88 |
| Poisonings | 1.88 | .90 | 38.84 | 35.19 | .13 | .04 | 63.79 | 54.87 |
| Suffocations | .72 | .21 | .39 | .15 | 1.07 | .48 | .79 | .37 |
| Firearms | .57 | .04 | 4.69 | .52 | .37 | .11 | 3.32 | .43 |
1Extracted from data, Bureau of Chronic Disease Epidemiology, Laboratory Centre for Disease Control, Health and Welfare Canada
Link to Structured Abstract of this review
Link to Summary Table of this review
Link to Selected References list of this review
Link to 1994 chapter: Prevention of Household and Recreational Injuries in Adults
Link to 1994 chapter: Prevention of Household and Recreational Injuries in the Elderly
Reprinted in modified format by the Canadian
Task Force on Preventive Health Care
with permission.
For any technical issues please contact: webmaster@ctfphc.org
Original Copyright
© 1994 Minister of Supply and Services Canada.
Last modified April 1, 1998.
