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.
Overview
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 Suffering
Injury is probably the most under-recognized
major public health problem facing the nation today, and the study of injury
presents unparalleled opportunities for reducing morbidity and mortality
and for realizing significant savings in both financial and human terms
– all in return for a relatively modest investment.<2>
Injuries 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.
Falls
There were 2,100 deaths due to falls in 1988.<7>
It is estimated that baby walkers are used in 80-90% of Canadian households
with young infants; 300,000 Canadian infants would spend some time in them
during the course of a year and 2,500 would require medical attention because
of falls down stairs, tipping, jamming fingers or contact with a hot item.<8>
Drowning
429 Canadians drowned in 1987, 135 in boating
accidents. It has been estimated that for each pediatric drowning fatality
there are 3-4 hospital admissions and numerous children seen in emergency
departments.<2> A review of Ontario coroners’ reports for 1979-1981
showed that the young adolescent male was at particular risk of drowning,
as were toddlers (aged 1-4) who may wander away from adult supervision.
Approximately half of all accidental drownings took place in lakes or ponds;
75% of children who drowned in swimming pools were under 5 years of age.<9>
Burns, Scalds and Fire-Related Deaths
There were 402 deaths among Canadians caused
by fire and flames in 1988 and 85% occurred in private dwellings.<10>
More than one-third of childhood admissions to burn units are associated
with scalding water (kettles and baths); boys are injured about twice as
frequently as girls, and 74% are under 2 years old; 87% of accidents occur
in the child’s own home and about half of these take place in the kitchen.<11>
Poisoning
There were 424 fatal poisonings in Canada in
1987; however, only 2 of the deaths were among children under 15 years
of age.<10> Data from poison control centres in Canada indicate that
in 1986 there were 103,459 poisoning cases and 365 deaths (0.35% mortality
rate).<12>
Suffocation
Of the 415 Canadian deaths by suffocation in
1987, 274 were related to ingestion of food and 102 to mechanical suffocation.<7>
36% were in children under 15 years of age.<10>
Bicycle and Other Sports-Related Injuries
There were 139 fatal pedal cycle injuries in
Canada in 1987 and 86% of the casualties were male.<7> Deaths were most
commonly associated with motor vehicles or trains; boys aged 10-14 years
had the highest risk of death.<10> In 1988, 568 children were treated
for bicycle-related injuries in an Ottawa study.<13> 70% were boys and
the mean age was 9.4 years. Only 2% of the patients had been wearing a
helmet at the time of the accident though 13% owned helmets. Over 60% of
the accidents were attributed to carelessness or poor bicycle control.
97 children were admitted to hospital; 49% had head and skull injuries
and 40% had skull fractures. Another observational study of 1,963 cyclists
found 10.7% wore helmets; commuting and recreational cyclists had the highest
level of helmet use (17.9% and 14.3% respectively) while helmet use among
students (1.9%) was significantly lower.<14>
Firearm-Related
There were 60 deaths by firearms in Canada in
1988.<7> Most childhood deaths from firearms occur at a residence and
defects in firearm performance were associated with 40%.<15>
Effectiveness of Intervention
Maneuvers
The Haddon Matrix for generating countermeasures
provides a multifactorial model for developing approaches to injury prevention.<16>
Three widely adopted approaches to interventions for accidental injury
based on this model are described in greater detail: public health education,
environmental legislation, and individual counselling.
(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.
Falls
A 96% decrease in accidental falls from windows
was reported following the "Children Can’t Fly" program in New York City,
in which owners of multiple dwellings were required to provide window guards
in apartments where children 10 years or younger resided.<18> Safety
features such as car restraints and window and stairway guards can reduce
the incidence and severity of injury in infants.<19> To date, no studies
of counselling parents about safety features in the home have demonstrated
an impact on the rate of injuries even though intermediate outcomes such
as "recognition of hazards" may have improved.
Drowning
Before there was legislation relevant to swimming
pool design or water safety in Virginia (1982), Fairfax County had legislated
comprehensive safety regulation; the death rate (per 100,000 population)
for drowning was 1.6 for the 620,000 population, as compared with 17.3
for the remainder of Virginia.<20> The incidence of swimming pool submersions
in public and semi-public pools regulated for fencing and self-closing
gates by the Public Health Department decreased during 1974-1983 (from
13 in 1974-75 to 2 in 1982-83; p<0.03) while the incidence of unregulated
private pool submersions remained unchanged.<21>
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>
Burns
Prior to 1953, flame burns were the leading cause
of burn injury among children. The Flammability Fabrics Act of 1967 substantially
reduced this problem by improving safety standards in children’s garments,
especially sleep wear. Acquisition of safety features such as smoke detectors,
non-inflammable sleepwear and lowering hot water thermostat settings reduces
injury from scalds and burns.<21> In a controlled study, couples were
randomly enrolled in one of two well-child care classes that did or did
not include specific information on burn prevention (hot water heater settings
and smoke detectors) in addition to information on nutrition, dental care,
safety in the car and home, child development, child rearing, illness management
and immunizations. Sixty-five percent of couples in the experimental group
had their hot water temperature measured at 54°C or less and all but
one had an operational smoke detector; all couples in the control group
had hot water temperatures above 54°C (p=0.0001) but most had smoke
detectors (p<0.12).<22>
Poisoning
The death rate due to poisonings of children
under age 5 years declined from 2.0 per 100,000 in 1958 to 0.5 per 100,000
in 1978. Poison control centres in Canada reported a 50% decline in numbers
of poisoning cases due to acetylsalicylic acid between 1982 and 1986. The
decline in deaths from accidental poisoning in children was largely the
result of increasing use of child-resistant packaging for chemicals and
therapeutic drugs.<23>
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>
Bicycle and Sports-Related Injury
This topic is discussed in Chapter 45 on Injuries
in Adults. However, a cohort analytic study has shown an association between
the severity of head injury in cyclists and non-use of helmets.<26>
Recommendations of Others
In 1989, the U.S. Preventive Services Task Force
recommended the following: "It may be clinically prudent to provide counselling
on measures to reduce the risk of unintentional household or environmental
injuries from falls, drowning, fires or burns, poisoning, and firearms."<27>
The 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 Recommendations
There is fair evidence (grade II-1) that window
and stairway guards reduce the incidence and severity of injury in infants
(B Recommendation). There is also fair evidence (grade I) to support counselling
parents on the acquisition of such safety features in the periodic health
examination of infants (B Recommendation).
There 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)
Because of the multifactorial etiology of most
injuries, a number of methodologic issues need further study. The problem
of assessing or measuring exposure in the context of household and recreational
injuries makes the design of analytic studies very difficult. There are
persistent limitations in available data. For example, CHIRPP (Canadian
Hospital Injury Reporting and Prevention Program) collects data in collaboration
with all pediatric hospitals rather than from population-based sources.
Evidence
A MEDLINE search from 1981 to November 1991 was
conducted using the following strategy: accidents as a major MESH heading
with the subheadings diagnosis, economics, epidemiology, law and jurisprudence,
mortality, prevention and control, standards and trends; and not aviation,
occupational or traffic accidents. Other sources included Statistics Canada,
Health and Welfare Canada, the Insurance Bureau of Canada, the Izaak Walton
Killam Children’s Hospital Poison Control Centre, supporting documents
of other recommending bodies and references from identified literature.
This review was initiated in 1991 and the recommendations finalized by
the Task Force in November 1992.
Full Citation
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.