Injuries
in Children
of Adolescent
Mothers:
Home
Safety
Education
Associated
With
Decreased
Injury
Risk
Elizabeth A. Jordan, MD, PhD*; Anne K. Duggan, ScD; and Janet B. Hardy, MDCM
ABSTRACT. The purpose of this study was to describe the epidemiology of injuries in children of adolescent
mothers (<18 years old at delivery) in Baltimore, MD, and to explore the relationship between maternal receipt of home safety information and child injury. A random sample of 363 adolescent mothers and their children were followed longitudinally by home interview at 3 and 15 months postpartum. Receipt of home safety information and information source were assessed at the 3-month interview. Injuries requiring medical attention were as-sessed at the 15-month interview. Sixty-eight children sustained injuries during follow-up and 14% required hospitalization. Falls and burns predominated as the cause of injury, with burns much more common in girls. The children of mothers who received home safety infor-mation from family and community-based sources by 3 months postpartum had significantly lower risk of injury during follow-up than children of mothers who had not received home safety information. As the number of in-formation sources increased, the injury rate decreased. Further work is needed to examine the most appropriate timing, repetition, format, and content of injury preven-tion education. Pediatrics 1993;91:481-487; injury, infant,
child, adolescent parenting, education, injury prevention,
home safety.
ABBREVIATIONS. WIC, Special Supplementation for Women,
In-fants, and Children; CI, confidence interval; OR, odds ratio.
Injury is the leading cause of death in children
aged 0 to 19 years and accounts for 20% of childhood
hospital admissions. Each year, almost 16 million
in-jured children are seen in emergency departments
across the United States.’ Childhood injuries cost our
nation more than $7.5 billion per year, and future
productivity losses may exceed $8 billion.2 These
data suggest that childhood injury prevention should
be an area of prime concern among pediatricians and
public health officials alike.
Child injury incidence rates are bimodal, with a
peak among 2-3-year-olds and among teenagers.3 Children born to adolescent mothers have higher
in-jury risk than children of older mothers. It is not
clear whether maternal age is an independent risk
From the *Department of Epidemiology. Johns Hopkins University School
of Hygiene and Public Health; and Department of Pediatrics, Johns Hop-kins University School of Medicine, Baltimore, MD.
Received for publication Mar 24, 1992; accepted Oct 13, 1992.
This research was presented at the meetings of the Society for Epidemio-logic Research on June 12, 1990, and at the meetings of the American Public Health Association on October 3, 1990.
Reprint requests to (J.B.H.) Dept of Pediatrics, Johns Hopkins University School of Medicine, 403 N Caroline St. Baltimore, MD 21231.
PEDIATRICS (ISSN 0031 4005). Copyright ©1993 by the American Acad-emy of Pediatrics.
factor for child injury or simply correlated with other child injury risk factors that frequently coexist with
low maternal age such as single parenthood,
unem-ployment, low educational status, and poor urban
environment.5’9
In young children, the majority of injuries occur
within the home setting.3’10” Traditionally,
pediatri-cians dispense home safety information to parents
during office visits. Many home safety educational interventions using a variety of educational formats have been evaluated.122#{176} In general, most of the
in-terventions were successful in raising parental
awareness of household hazards but had only
mod-est effects on household hazard reduction. Only a
few studies have attempted to correlate educational
intervention with injury reduction, most without
great success.12’2#{176} However, a recent study
demon-strated that injury prevention counseling based in
the offices of participating pediatricians was
associ-ated with a decrease in community-wide child injury
rates compared to a control community with no
in-dividualized injury prevention counseling except
those educational programs operating on a
commu-nity-wide basis throughout the state of
Massachu-setts.2’
The impact of home safety education on injury risk
has not been evaluated among adolescent mothers.
The goals of this paper are (1) to describe the
epide-miology of child injuries in a population-based
ran-dom sample of adolescent mothers, and (2) to
de-scribe the relationships between home safety
educational efforts and other maternal and environ-mental characteristics and child injury risk.
METHODS
The data for this study were collected as part of a longitudinal
study on health care and community resource use by pregnant and
parenting adolescents (<18 years at delivery) in Baltimore,
MD.22’21 The target population, enumerated through livebirth cer-tificates, consisted of all Baltimore City residents aged 17 years or
younger who gave birth in Baltimore in 1983. The study
popula-tion (N = 529) was selected through stratified random sampling
by maternal age, race, and parity to ensure sufficient sample si7e
in these subgroups for comparisons. The mothers were contacted
by mail shortly after delivery to elicit study participation. Three
hundred eighty-nine mothers permitted a home interview when
their infants were approximately 3 months of age, for a 74%
re-sponse rate. A second home interview was conducted with 363 of
the mothers when their infants were approximately 1 5 months of
age, for a 93% follow-up rate.
The home interviews, conducted by trained interviewers
expe-rienced with the urban adolescent population, focused primarily
on knowledge of, access to, use of, and satisfaction with various
community resources, including birth control/family planning,
demo-30
25
20
15
10
5
.
Ca
cx:
>
E
0
0 2 4 6 8 10 12 14 16 18
Age (Months)
482 INJURIES IN CHILDREN OF ADOLESCENT MOTHERS
graphic characteristics, household structure, educational attain-ment and goals, paternal characteristics, and financial indepen-dence.
At the 3-month interview, the mothers were asked whether they
had ever received information about how to make their house safe
for a baby, and if so, to identify the source(s) of that information.
At the 15-month interview, mothers were asked to describe child
injuries since birth that had required a visit to a physician. From the mother’s descriptive account of the child’s injury, information
was coded on age at the time of injury, body part(s) injured, and
cause and consequences of the injury. Injury causes were coded
using codes E800 to E999 of the 9th revision of the International
Classification of Diseases, Injuries, and Causes of Death. In the case of multiple injuries, the most severe injury was coded. Injury severity
was judged based on the type of injury sustained and extent of
medical intervention required.
The National Center for Health Statistics recommends 3 months
as the optimum recall period for injuries resulting from motor
vehicle accidents24 and 4 weeks for accidental injuries in general.25
Because the 12-month period of recall used here was substantially
longer, maternal reports were compared with medical records for
children enrolled in Hopkins pediatric clinics. Close agreement
was found in both the number of injuries reported and their
de-scription.
The data were analyzed using the SAS statistical package.26
Weighting was applied to correct for disproportionate sampling so
that the results could be extrapolated to the city-wide adolescent
parent population. Chi-square and t tests were used to test for
differences between groups for categorical and continuous
van-ables, respectively. For multivaniable analyses, all covaniates were
transformed into binary (0, 1) variables. Multiple logistic
regres-sion modeling was performed by stepwise backward elimination;
variables were retained in the model if P < .10. Likelihood ratio tests were used to assess significance in multiple logistic regres-sion modeling after each variable was removed individually.27
RESULTS
Representativeness of Sample
Study nonparticipants at the first interview did not differ significantly from study participants in
preg-nancy and birth characteristics, including
birth-weight, 1- and 5-minute Apgar scores, gestational
age, method of delivery, presence of complications during pregnancy, trimester of initiation of prenatal care, and medical assistance status. The mothers lost to follow-up by the second interview were less likely
to receive Special Supplementation for Women,
In-fants, and Children (WIC) after delivery (P = .002),
more likely to have another child (P = .02), and more likely to have dropped out of school prior to the 1983
pregnancy (P = .01) than mothers who stayed in the
study. However, those lost to follow-up were not
significantly different on the following variables:
re-ceipt of home safety information; receipt of welfare, food stamps, or medical assistance; age; race; marital status; mean infant birth weight; or household struc-ture.
Descriptive Epidemiology of Injuries
Over the average follow-up time of 16 months
(range 13 to 20 months), 74 injuries requiring physi-cian visits occurred in 68 children. Six children had 2 injuries, and no child had more than 2. The overall
injury rate was 14.9 per 100 person-years. Through I
year of life, the risk of injury was 12.2%. As so few children were injured more than once, the remainder of the paper will focus on the first injury sustained during follow-up.
The risk of injury was low during the first 6
months of life but increased steadily thereafter (Fig
1). Nineteen percent of boys and 18% of girls were
injured (P = .89), and 13% of infants of 2500 g birth
weight were injured compared to 19% of infants
weighing more than 2500 g at birth (P .26).
The causes of first injury are listed in Table I. The
cause of first injury differed by gender and
ap-proached statistical significance (P = .08). Falls
ac-counted for 53% of the injuries. Boys were more
likely than girls to be injured in falls. More than half of the falls were from one level to another (21/37), and 12 of these falls involved stairs and steps.
Thirty percent of injured children were burned.
Girls were much more likely than boys to experience burns. The vast majority of burns in this population were caused by contact with hot surfaces including, in order of frequency, clothing irons, curling irons,
space heaters, ovens, and hot water pipes. There
were no flame burns, and only two children were
burned by hot liquids.
Other causes of injury, including accidental
poi-soning, choking on food, near drowning, and being
struck by a falling object, were more common in boys than girls. No children were injured in motor vehicle accidents.
Table 2 describes the body site injured and injury severity. The head was the site of injury for at least
49% of the children. Most of the head injuries were
minor, although one child suffered a concussion, and several had severe burns to the face.
Fig 1. Cumulative injury risk in
chil-dren of adolescent mothers, adjusted for length of follow-up.
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*Values are percentages.
TABLE 2. Characteristics of First Injury During Follow-up
c/c Of Injured Children (n = 68)
13.6 0.0 6.1 0.9 9-5 38.3 7-4 6.8 5.0 10.8 2.9 12.4 43.6 5.9 19.7 2.0 9.5 19.4
TABLE 1. Ca use of First Injury D uring Follow-u p by Gendcr*
Cause of Injury Boys Girls Total
(n = 36) (n = 32) (n = 68)
Fall 58 46 53
Burn 19 43 30
Other 23 11 17
Characteristic Hospitalization Injury consequence Death Fracture Concussion
Laceration requiring sutures Abrasions, contusions First-degree burn
Second-degree burn
Third-degree burn
Burn, unknown degree
Other
Unspecified
Body part(s) injured Head only
Head and other sites Arms only
Upper torso only Legs only Unspecified
Although most of the injuries were minor in
na-ture, 14% of injured children required hospitalization with a median length of stay of 3 nights (range 1 to 30
nights). There were no known deaths due to injury in
this population. The majority of children experienced mild lacerations, bruises, or first-degree burns, but 12% of injuries could not be classified due to lack of detail regarding injury consequence and severity.
The majority of injured children were taken to the
emergency department for initial treatment (78%),
while fewer were taken to hospital or
community-based public clinics (16%) or a private physician’s office (6%).
Maternal Characteristics and Infant Injury
This sample of adolescent mothers was
represen-tative of the adolescent parent population in
Balti-more. The majority of mothers were 16 or 17 years of
age (78%), single (95%), and black (82%). Most
moth-ers were economically disadvantaged; although
more mothers qualified for welfare support, 68%
ac-tually reported receiving welfare payments.
Twenty-two percent of mothers had dropped out of school
prior to conception, and of those in school at concep-tion, only 53% were still enrolled in school by
deliv-ery. Thirteen percent of mothers had a child prior to
the birth of the study infant. Seventy-nine percent of
the adolescent mothers lived with their own
moth-ers, often in crowded conditions.
Table 3 summarizes the relationships from
bivari-ate analyses between maternal characteristics from
the first interview and risk of injury. The only factor
associated with a reduction in injury risk at the 5%
level was receipt of home safety information by the
3-month interview. The children of mothers who
re-ported receipt of home safety information by the first interview were significantly less likely to he injured
than children of mothers who reported receiving no
home safety information. The unadjusted relative
risk of injury was 0.63 for children of mothers who
received home safety information compared to those
who did not (95% confidence interval [CU 0.41 to
0.97).
Several maternal factors were marginally
associ-ated with risk of child injury. Children living in a
household where other young children were present
had lower injury risk. The children of mothers who
reported failing grades in school prior to pregnancy
were almost twice as likely to he injured compared to
those whose mothers reported passing grades.
Chil-dren whose parents were married were at higher risk
of injury than children of unmarried parents; the
highest risk of injury occurred in the subgroup of
children whose parents were married at the first
in-terview and had separated or divorced by the second
interview. Variables not associated with injury
in-cluded mother’s age; race; parity; source of prenatal or pediatric care; number of well-child care visits; receipt of welfare, medical assistance, food stamps,
or WIC; number of adults in the household; and the
presence of the infant’s maternal grandmother or
grandfather in the household.
Early Receipt of Home Safety Information
Overall, 73% of the adolescent mothers reported
receipt of home safety information by the 3-month
postpartum interview. Many mothers reported
re-ceiving home safety information from multiple
sources. Health professionals provided information
to 71% of young mothers during prenatal and early
pediatric care. The infant’s maternal grandmother
was another common source of home safety
infor-mation (59%), followed by school professionals
(27%), other family members (26’), and other
sources (8%).
The relationship between number of home safety
information sources and injury risk is shown in Fig 2.
The risk of child injury decreased as the number of
home safety information sources increased ( Trend
Test, P = .006).
Receipt of home safety information was associated
with decreased numbers of falls and burns but not
other types of injuries (Table 4). Hospitali7ation for injury was not associated with receipt of home safety information.
Several maternal characteristics were associated
with decreased likelihood of receiving home safety
information (Table 5). Twenty-seven percent of
young mothers reported that they had not received
any home safety information by 3 months
postpar-turn. Mothers who were less likely to receive home
safety information were more likely to have dropped out of school at any time but especially before
preg-nancy and were more likely to have received failing
grades in school. The young mothers who did not
receive home safety information were more often
TABLE 3. Maternal Characteristics at Baseline and Risk of Injury During Follow-up
Characteristic Total
No.
% of Children P RR* 95% CIt
Injured
Mother’s age at delivery
13-15y
l6-l7y
81
281
15
20
.40 1.0
1.3 0.7-2.3
Parity
I 315 18 .71 0.9 0.5-1.6
2 48 21 1.0
Race
Black 296 18 .19 1.0
White 67 24 1 .4 0.9-2.3
Education
In school during pregnancy 192 18 .55 1.0
Dropped out during pregnancy 92 16 0.9 0.5-1.6
Dropped out before pregnancy 79 23 1 .3 0.8-2.1
Grades before pregnancy
Passing 340 18 .08 1.0
Failing 16 36 2.0 1.0-4.0
Marital status
Never married 344 18 .13 0.6 0.3-1.1
Ever married 19 32 1.0
Infant’s grandmother lives in household
Yes 285 20 .37 1.0
No 77 15 0.6 0.4-1.4
Other children in household besides siblings
Yes 104 14 .11 0.7 0.4-1.1
No 256 21 1.0
Mother receives welfare
Yes 245 18 .47 1.0
No 117 21 1.2 0.8-1.8
Source of health care
None 6 0 .39 0.0
Adolescent parenting clinic 44 16 0.9 0.4-1.8
Other clinic 275 19 1.0
Private physician 38 26 1 .4 0.8-2.5
Health care payment
Medicaid 193 15 .18 1.0
Private insurance 80 24 1.4 0.9-2.4
Self/no assistance 90 22 1.6 0.9-2.6
Mother received home safety information by 3 months
postpartum
Yes 266 16 .04 0.63 0.4-0.9
No 96 26 1.00
30
20
10
0 1 2 3 4 5 6
484 INJURIES IN CHILDREN OF ADOLESCENT MOTHERS
*Relative risk.t Confidence interval.
Fig 2. Risk of child injury during
fol-low-up by total number of home safety
information sources.
0
a)
C
V .C
0
health clinics. Maternal age, parity, marital status, and presence of other children in the household were not associated with maternal receipt of home safety
information.
Number of Information Sources
Multivariate Analysis
Since receipt of home safety information varied on
several maternal characteristics, some of which
dem-onstrated a weak association with injury, multiple
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TABLE 4. Causes of First Injury by Receipt of Home Safety Information
Cause of Injury Received Home Safety Information, No. (%)
Yes(n=266) No(n=96)
Fall 22(8.3) 13(13.5)
Burn 12(4.5) 9(9.4)
Other 9(3.4) 3(3.1)
Not injured 223(83.8) 71 (74.0)
logistic regression modeling was applied to assess
the independence of the relationship between home
safety information and injury and to explore possible
multiplicative interactions between home safety
in-formation and other variables. The protective
rela-tionship between home safety information and
in-jury risk remained significant at P < .05 after
controlling for race; maternal age; parity; school
grades; marital status; receipt of welfare; medical
as-sistance; WIC, or food stamps; infant gender and
birth weight; and presence of other young children or
infant’s maternal grandmother in the household.
Af-ter individual elimination of variables from a fully saturated logistic regression model, the final model contained variables associated with injury at P < .10
and included receipt of home safety information,
presence of the infant’s maternal grandmother in the
household, and marriage by 3 months postpartum.
The adjusted odds ratio (OR) for home safety
infor-mation was 0.48 with a 95% CI of 0.3 to 0.9. Marriage at the time of the first interview was a marginally
significant risk factor for injury (OR = 2.93, 95% CI
I .0 to 8.6), as was presence of the infant’s
grand-mother in the household (OR = I .92, 95% CI 0.9 to
4.2). No multiplicative interactions were found
be-tween home safety information and the other
van-ables listed above.
DISCUSSION
The findings in this study are based on a random
sample of the adolescent mother population in a
de-fined geographic area and are believed to be
repre-sentative of this community’s infant injury morbid-ity. Several factors might have led to underestimates of injury morbidity. First, it is possible that injuries
resulting from child abuse may have been
underre-ported. Even in the absence of abuse or neglect,
mothers might have underreported injuries they
feared would suggest maltreatment. Among mothers
whose children received care within our institution,
we did not find underreporting of injuries
docu-mented in the medical record. In addition to
under-reporting, barriers to care might have reduced our
estimates of morbidity. By definition, injuries were
TABLE 5. Characteristics of Mothers Associated W (HSI) by 3 Months Postpartum
ith Failure to Receive Home Safety Information
Characteristic Total
No.
Did Not
Receive HSI, %
P
Mother’s age at delivery
13-15y 16-17y
Parity I
81 280
314
22 28
27
.26
.54
2 48 23
Race
Black 296 23 .002
mWhite 66 42
Education
In school during pregnancy Dropped out during pregnancy Dropped out before pregnancy Grades before pregnancy
Passing Failing Marital status
191 93 78
339 16
21 71 62
26 44
.009
.10
Never married 343 26 .78
Ever married 19 29
Infant’s grandmother lives in household
Yes 285 22 .000
No 76 46
Other children in household besides siblings
Yes 104 22 .20
No 256 28
Mother receives welfare
Yes 244 22 .004
No 116 36
Source of health care
None 5 44 .03
Adolescent parenting clinic Other clinic
44 274
10 30 Private physician
Health care payment Medicaid
38
193
20
78 .11
Private insurance 80 28
486 1NJURIES IN CHILDREN OF ADOLESCENT MOTHERS limited to those for which medical care was sought.
it is uncertain how often mothers did not seek
needed care or were unable to obtain it.
Our estimate of injury risk in I-year-olds (12.2%) is
similar to McCormick and coworkers’ estimates of
injury risk in 1-year-old normal birth weight infants (11.3) and low birth weight infants (11.4%) of moth-ers I7 years of age in a multiarea study.5
As in other studies of young children, falls
pre-dominated as the cause of injury. in this population,
the incidence of burns was higher than reported by
other studics3”#{176}’ .2o; however, increased burn
fre-qucncy in children of teenage mothers has been doc-umcntcd.4.b An interesting finding in our study is that hot liquids were responsible for causing burns in
only 2 children, while 20 children were burned by
hot surfaces, primarily clothing irons and curling
irons. The fact that girls were more likely than boys to be burned may reflect the female child’s attempt to
imitate the mother’s grooming habits or
uninten-tional burns inflicted by the mother while trying to
curl the child’s hair. A better understanding of burn
epidemiology in children, including more
knowl-edge about the frequency and practices surrounding use of instruments with hot surfaces in households, is needed to promote child injury prevention.
Maternal receipt of home safety information by 3
months postpartum was associated with a 37% re-duction in risk of child injury. It is important to note that no injuries occurred before the first interview at
3 months postpartum, so there was no temporal bias
between receipt of home safety information and
in-jury risk. In other words, receipt of home safety
in-formation by 3months postpartum was not the result
of the child’s having been injured during that inter-val.
Most of the injuries sustained in this population
were not serious; however, the fact that 14% of
in-jured children required hospitalization cannot be
ig-nored. Receipt of home safety information was
asso-ciated with reduced number of injuries but was not
associated with decreased hospitalization rates.
However, since the number of serious injuries and
hospitalizations was low, the power to detect an
as-sociation with receipt of home safety information was not optimal.
Several circumstances suggest that the association
between home safety information and lower risk of
injury is not spurious. First, the observed trend
be-tween number of information sources and lower
in-jury risk would be highly unlikely if the association
between home safety information and injury were
spurious or due to some other factor that was not
measured. Second, the independent association
be-tween receipt of home safety information and
de-creased injury risk after controlling for
socioeco-nomic, educational, and household differences
provides further evidence for consistency in the
re-lationship.
Repetition of information as an aid to learning is a
concept that has long been embraced by the health
education community. in this study, it was clear that repetition of information from different sources,
in-cluding both health professionals and non-health
professionals, was associated with the lowest risk of
injury. While health professionals are probably the
foremost injury educators for parents, other sources
may provide important reinforcement of injury
pre-vention concepts.
Some important points could not be addressed in
this study. Information was not available regarding
the content, quality, or educational methods used to
dispense home safety information. Given the
spec-trum of health care sources used by this population, it is likely that a variety of educational vehicles was
used, including verbal instruction, discussion, and
written materials. Mothers who received home safety
information by 3 months postpartum probably
con-tinued to receive similar information from their
health care providers, parents, and other family
members. It is also likely that many of the mothers
who had not received home safety information by 3
months postpartum may have received some
infor-mation in the following months. Validation of receipt of home safety information was not possible. Finally,
it was not possible to rule out selection bias as a
confounder. Unrecognized characteristics of the
mother may have influenced her interest in injury
prevention.
Studies evaluating the efficacy of injury education
are plagued by many factors: inability to employ a
comparison group that receives no education,
diffi-culty establishing previous knowledge and
aware-ness of injury risk, inability to control injury
educa-tion from outside sources, and the need for large
sample sizes to evaluate the relationship between
education and injury incidence. This study, while ob-servational and simplistic in the attempt to correlate receipt of injury education to injury risk, nevertheless suggests that early receipt of home safety education is associated with decreased risk of injury during the
subsequent 12 months. The difference between these
two groups may demonstrate the effect of early,
re-peated information; many of these mothers were
“safety conscious” prior to delivery or early in the
postpartum period. Perhaps the early introduction of
home safety information helped these mothers learn
safety-promoting behaviors as they learned other
parenting skills.
More than one fourth of our population reported
that they had not received home safety information
by 3
months postpartum. These young women wereless likely to have frequent contact with the medical
and educational communities and were more likely
to be living away from their parents. It is important
to identify mothers who are less likely to receive
injury prevention information through the
tradi-tional channels and make efforts to reach these
young women through other means.
The medical community should strive to meet
5ev-eral objectives with respect to reducing the frequency
of injury in childhood. One, public awareness of the
risks, consequences, and possibilities for prevention of injury should be increased. Two, further research
is needed to elucidate relationships between
knowl-edge of home safety and adult behavior
modifica-tion. Three, further knowledge about the effect of
home safety information content and format, timing,
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repetition, and childhood developmental context on actual injury prevention is needed for methodologi-cal purposes. Finally, research focusing on the cost-effectiveness of health professional and nonprofes-sional efforts toward preventing injury is required for effective program planning.
ACKNOWLEDGMENTS
This work was supported by grant 000906-03-0, Office of
Ado-lescent Pregnancy Programs, US Department of Health and
Hu-man Services; the Maryland State Department of Human
Re-sources; and the Governor’s Council on Adolescent Pregnancy.
We gratefully acknowledge the technical assistance provided
by Shelby Roth. We thank Adolfo Correa-Villasenor, Penelope
Keyl, Modena Wilson, and Bernard Guyer for their critical review
of the manuscript.
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NO KIDDING!
Lawyers are moving from a profession to a trade, with a corresponding decline
in ethics, and they are developing many of the attitudes exhibited by used car
dealers. . .Suits against hospitals and doctors, which went up 300-fold since the
1970’s, increased doctors’ medical insurance premiums more than 30-fold for some.
We have more lawyers per 100,000 people than any other society in the world. We
have almost three times as many lawyers per capita as Britain, with whom we share
a common law system.
Former Chief Justice Warren E. Burger. In a Review of: Olson WK. The Litigation Explosion. New York:
EP Dutton; 1991 . The New York Times. May 12, 1991.
1993;91;481
Pediatrics
Elizabeth A. Jordan, Anne K. Duggan and Janet B. Hardy
Decreased Injury Risk
Injuries in Children of Adolescent Mothers: Home Safety Education Associated With
Services
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