Prevention
of Traumatic
Deaths
to Children
in the
United
States:
How
Far Have
We
Come
and
Where
Do
We
Need
to Go?
Frederick P. Rivara, MD, MPH and David C. Grossman, MD, MPH
ABSTRACT. Objective. To describe the changes in
in-jury mortality from 1978 to 1991 and determine the
num-ber of preventable deaths with currently available
inter-vention strategies.
Methods. Comparison of injury mortality data for
children and adolescents 0 to 19 years in 1978 and 1991.
Review of the literature to determine the effectiveness of
currently available prevention strategies and application
of these to deaths in 1991.
Results. The injury death rate declined by 26% over
the 14-year period. Death rates of unintentional injuries
decreased by 39%, with declines in all categories of
un-intentional injuries. Homicides increased by 67% and
suicides by 17%; nearly all of this increase was in deaths
from firearms. If currently available prevention
strate-gies were fully used, 6640 deaths could have been
pre-vented, a further 31% decrease.
Conclusions. Although great strides have been made
in preventing deaths from trauma, the application of
currently available prevention strategies could save a
large number of additional lives. However, the
increas-ing problem of intentional injury will partly
counterbal-ance the success in unintentional injury control.
Pediatrics 1996;97:791-797; injuries, mortality, homicide,
suicide.
A decade has passed since we published an
anal-ysis of trauma deaths to children in the United States
and estimated the number of deaths that could be
prevented with injury control strategies available at
that time.’ In the interval there has been a substantial
increase of interest in injury control. The National
Academy of Sciences commissioned the National
Re-search Council to conduct a study on the status of
injury control in the United States.2 The National
Center for Injury Prevention and Control has been
created as part of the Centers for Disease Control and
Prevention, centers of excellence have been initiated
in universities around the country, and much new
research has been conducted and published.3
Com-munity programs in injury control have been
devel-oped and have achieved some remarkable successes.
Nevertheless, injuries still remain as the most im-portant cause of mortality and disability to children
beyond the first few months of life. How far have we
come in our pursuit of decreasing the burden from
From the Harborview Injury Prevention and Research Center and the
Departments of Pediatrics, Epidemiology and Health Services, University of Washington, Seattle.
Received for publication Feb 22, 1995; accepted Aug 9, 1995.
Reprint requests to (F.P.R.) Harborview Injury Prevention and Research Center, 325 Ninth Avenue, Seattle, WA 98104.
PEDIATRICS (ISSN 0031 4005). Copyright © 1996 by the American Acad-emy of Pediatrics.
both unintentional and intentional injuries? What
else can be done to decrease mortality and morbidity
even further with the information we now have
available to us? Where should our efforts be placed
in the future? This article provides an update on
injury mortality and attempts to answer these
ques-tions.
SOURCE OF DATA
Mortality data on children from birth to age 19
years were obtained from the National Center for
Health Statistics for the years 1978 and 1991.’
Deaths were included if the death certificate
in-cluded an external cause of injury (“E”) code of
E800-E999. Information from the Bureau of the
Cen-sus provided estimates of the population (in 1978
and 1991) used to calculate rates of injury and
death.6’7
The published literature was examined to identify
currently available realistic prevention and injury
control strategies for each major category of
uninten-tional and intentional trauma deaths. These were
then applied to the mortality data to derive estimates
of the number
of deaths
in each
category
that werepreventable. Assumptions used in these estimates
are described in the text.
OVERVIEW OF CHANGES
Deaths from all injuries decreased by 26.5% over
the 14-year period, from 40.22/100,000 in 1978 to
29.58/ 100,000 in 1991 (Table 1). Unintentional deaths
decreased by 38.9% compared with a 47.1% increase
in intentional injury deaths. The largest absolute
de-creases were in pedestrian (1325), occupant (1557),
and drowning (615) deaths, whereas the greatest
de-creases in rate of deaths were from poisoning due to
gases/vapors, motorcyclist, and pedestrian injuries.
Deaths from both homicide and suicide increased,
largely due to increases in firearm deaths from both
causes. Specific categories of trauma deaths are dis-cussed in more detail below.
MOTOR VEHICLE DEATHS
Motor vehicles (E810-E825) continue to be
respon-sible for the largest number of trauma deaths to
children, accounting for 8486 deaths in 1991, a 40%
decrease both in the absolute number of deaths and
in fatality rates since 1978. Motor vehicle traffic
deaths accounted for a smaller proportion of the total
deaths in 1990, 39.7% compared with 59.8% in 1978.
Three important categories of motor vehicle injuries
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TABLE 1. Comparison of US Injury Counts and Rates Among 0 to 19-Year-Old Children and Adolescents by Type of Injury*
E Codes 1978
Count
1978 Rate per 100 000
1991 Count
1991 Rate per 100 000
Interval Change
All injuries E800-E999 28 905 40.22 21 367 29.58 -26.50%
All unintentional Injury deaths E800-E949 23 649 32.90 14 510 20.09 -38.90%
Motor vehicle deaths E810-E825
Occupant deaths Pedestrian deaths
E810-E825 (.0, .1) E810-E825 (0.7)
6 585 2 727
9.16 3.79
5 028 1 402
6.95 1.94
-24.10%
-48.80%
Motorcyclist driver deaths E810-E825 (.2) 841 1.17 352 .49 -58.10%
Pedalcyclist deaths E800-E807 (0.3)
E810-E825 (0.6) E826-E829 (0.1)
562 0.78 361 .50 -35.90%
Drowning deaths E830, E832, E910 2 610 3.63 1 595 2.21 -39.10%
Residential fire/burn deaths E890-E899 I 674 2.33 1 314 1.82 -21.90%
Fall deaths E880-E888 543 0.76 264 0.37 -51 .30%
Poisoning (solid/liquids) deaths Poisoning (gases/vapors) deaths
E850-E866 E867-E869
283 385
0.39 0.54
186 121
0.26 0.16
-33.55% -70.28%
All intentional injury deaths E950-E978 4 635 6.45 6 857 9.49 47.10%
Homicide and legal intervention E960-E978 2 796 3.89 4 692 6.49 66.80%
Firearm homicide E965.0-E965.4 I 517 2.11 3 274 4.53 114.70%
Suicide deaths E950-E959 I 839 2.56 2 165 3.00 17.10%
Firearm suicide deaths E955.0-E955.4 I 149 1.60 1 436 1.98 23.80%
* 1978 denominator used, 71 874 000; 199
1 denominator used, 7 2 335 000.
need to be considered: occupants of motor vehicle
collision, pedestrians, and motorcyclists.
MOTOR VEHICLE OCCUPANTS
The use of child restraint devices is the key to the
prevention of occupant deaths to children under the
age of 5 years. Available data indicates that
approx-imately 71% of these deaths can be prevented
through the use of an appropriate restraining
de-vice.8’#{176}In 1991, of the 529 deaths in this age group,
63% occurred among children who were
unre-strained)’ Thus, an estimated 237 deaths could have
been prevented in 1990 among children under the
age of 5 years involved in motor vehicle crashes.
As in 1985, there are no age-specific data on the
effectiveness of restraining devices or airbags in
older children and adolescents. The effectiveness of
these devices depends on both seating position and
direction of the force of the crash. Data from the
National Highway Traffic Safety Administration
in-dicate that 56% of 5- to 9-year olds, 66% of 10- to
14-year olds, and 90% of 15- to 19-year olds are
front-seat passengers in motor vehicles at the time of
a crash”2 Of these, 77%, 83%, and 83%,
respec-tively, can be expected to be unrestrained or improp-erly restrained.’2 The effectiveness of lap/ shoulder belts is 42% and airbags plus lap/shoulder harnesses approximately 47%#{149}1315 Use of the most effective means of protection available, ie, lap/shoulder belts
and airbags, would save 1480 lives of children and
adolescents 5 to 19 years of age who are improperly
restrained. An additional 33 lives would be saved
among those who currently die in motor vehicle
crashes in which they are protected with lap/shoul-der belts alone. This calculation discounts the effect
of airbags in cars on the road in 1991, because less
than 2% were equipped with airbags and these were
only in the driver position.
Children disproportionately occupy the rear seat
of motor vehicles: 44% of 5 to 9 year olds and 34% of
10 to 14 year olds are rear-seat passengers at the time
of a crash compared with 10% of all occupants in
motor vehicle crashes.’2 Although the rear seat is
safer than the front seat, lap belts alone in the rear seat offer only limited protection in a crash; they are estimated to decrease fatal injury by approximately
18%, primarily through the prevention of ejection.’4
Lap belts for children in the rear seat, although
de-creasing the risk of death, may increase the chance of
certain types of nonfatal injury. They have been
as-sociated with severe flexion-distraction injuries of
the lumbar spine, occasionally with spinal cord
in-jury, and with perforation and degloving injuries of
the hollow V15CUS’6 Lap/shoulder belts present less
of a risk of such injuries as well as somewhat more
protective against fatal injury; 27% compared with a
19% decrease in fatalities in the rear seat from lap
belts only.’4 Thus, use of lap/shoulder belts would
save 184 lives among those 5 to 19 years old
pres-ently unrestrained in rear seats and an additional 11
lives among those restrained with lap belts alone.
Although airbags in the rear seat are not available,
there are no theoretical reasons why they cannot be
developed and combined with properly designed
lap/shoulder belts to offer children riding in the rear
seat protection equivalent to that of adults in the
front seat. However, because of the absence of any
data on rear-seat airbags, we have not included their potential protective effect in our calculations.
Approximately 25% of fatal crashes in 1991 were
due to side impact.” Motor vehicles currently on the
road offer little in the way of side-impact protection,
although this has been mandated in Federal Motor
Vehicle Safety Standard 214. Volvo currently offers a
side-impact airbag on some models. Although the
exact magnitude of the effect of side-impact
protec-tion is unknown, even a 10% effect on mortality on
side-impact crashes could save an additional 70 lives
of children and adolescents involved in crashes
while riding in the front and rear seats.
In summary, 2010 additional lives could be saved
of children now dying as motor vehicle occupants.
This represents 40% of all motor vehicle occupant
PEDESTRIAN INJURIES
Pedestrian injuries remain as an important cause
of motor vehicle fatalities among children and
ado-lescents. For children under 14 years in 1991, pedes-trian injuries accounted for 36.7% of all motor vehicle
fatalities compared with only 6.9% of motor vehicle
deaths in the 15- to 19-year old age group. Rates of
pedestrian fatalities among children under 15 years
have decreased by 49% in the United States since
1978. This is a fascinating finding given that
preven-tion of pedestrian injuries through education and
enforcement has proved frustratingly difficult. A
number of studies have documented similar changes
in child pedestrian mortality around the world.’719 One possible explanation is a reduction in exposure to traffic, ie, less walking by children than in the past.
A recent study in Great Britain found that the
pro-portion of 7- and 8-year old children walking to
school unaccompanied decreased from 80% in 1971
to 9% in 1990.20
Nevertheless, reduction in child pedestrian
inju-ries does seem feasible without decreasing the
amount of walking by children. Sweden has taken a
comprehensive community approach to pedestrian
safety and structured the environment in such a way
as to minimize the risk of child pedestrian injury. It
has accomplished this through environmental
mea-sures to slow the speed of traffic, decrease its
vol-ume, route it away from neighborhoods, and to place
major traffic thoroughfares around the periphery of
towns and neighborhoods rather than through
them.2’ If the United States rates of child pedestrian
fatalities were equivalent to those of Sweden’7 in
1987 of 0.3/100,000 for 0 to 4 year olds and 1.2/
100,000 for 5 to 14 year olds, 550 lives could be saved, a further 52.9% reduction in pedestrian fatalities. We
realize that these changes in roadway design are
major, if not radical. However, they do provide a
target for us to strive to achieve.
MOTORCYCLES
Motorcycle fatalities in the pediatric age group are
confined almost exclusively to adolescence. The
ma-jority of deaths in motorcycle crashes are a result of head trauma. From 1978 to 1991 the rate of motorcy-clist deaths among 15 to 19 year olds fell from 3.48/ 100,000 to 1.78/ 100,000, a 48.9% decrease. Although
there are no national data on helmet use by age in
fatal crashes, National Highway Traffic Safety
Ad-ministration Fatal Accident Reporting System data
indicate that overall 54% of fatally injured motorcy-clists in 1991 did not wear helmets. In careful studies
of helmet effectiveness,22 helmet use has been found
to reduce all motorcycle deaths by an average of
28%. Therefore, an estimated 53 of 190 motorcycle
deaths of children and adolescents not wearing
hel-mets could have been prevented through the use of
helmets.
BICYCLE INJURIES
A number of studies have indicated that 75% of
serious and fatal injuries to bicyclists involve the
head.23’24 A rigorous case-control study in which
col-lision with a motor vehicle was taken into account
demonstrated that currently designed helmets can
prevent 88% of brain injuries.25 Although there were
too few deaths in the study to determine the exact
protective effect against fatal head injuries, recent
data from an ongoing case-control study at our
in-stitution found no deaths among more than 1000
helmeted cyclists; 14 deaths occurred in this and the
previous study, all among unhelmeted cyclists. Thus, we estimate that at least 66% (0.75*0.88 = 0.66) of the
361 children and adolescents killed while cycling, or
238, could be prevented through helmet use.
DROWNING
Drowning continues to be second only to motor
vehicles as a cause of unintentional trauma deaths in
the overall pediatric age group, accounting for some 1595 deaths to children and adolescents in 1991. This
represents a 39% decrease in drowning deaths since
1978.
Swimming pool drowning is totally preventable
through the use of four-sided fencing and
self-latch-ing gates and adult supervision of children while
swimming. Estimates from population-based studies
are that 33% to 42% of children and adolescents 0 to
19 years of age drown in swimming pools, mostly in
the preschool age group.26’27 Using an average from
these studies of 37.5%, we estimate that 598
drown-ing in this age group occur in pools and that all or
nearly all could be prevented through adequate
fenc-ing and appropriate supervision. Although difficult
to achieve, it represents a goal for prevention
pro-grams.
Similarly, bathtub drowning should also be
viewed as completely preventable. This accounted
for 7% and 14% of submersions in two different
population-based studies.26’28 Thus, using an average of the two studies of 10.5%, an estimated 165 children
and adolescents drowned in the bathtub in 1991. The
groups at greatest risk are toddlers and those with
epilepsy; the latter condition increases the risk of
bathtub drowning 96-fold.28 Toddlers should never
be left alone or with nonadult supervision and
chil-dren with seizure disorders should shower rather
than use a bathtub.
According to one rigorously conducted
popula-tion-based study, 37% of drowning deaths among
adolescents are associated with alcohol, an associa-tion that is almost certainly causal.29 In contrast, only
1 of 111 drowning deaths of children under 15 years
involved alcohol. Alcohol use and boating should be
viewed as activities that do not mix, particularly
among adolescents. Thus, an additional 168
drown-ing deaths in adolescents 15 to 19 years should be
considered preventable (37% of the 453 drowning
deaths in this age group).
Drowning in other bodies of water are difficult to
prevent. The effect of the promotion of personal
fib-tation devices is currently unknown and certainly
deserves close evaluation. The effect of swimming
lessons in decreasing drowning deaths is also
FIRE AND FLAME
Fire and flame deaths continue to be a leading
cause of trauma deaths (1314 deaths in 1991) for
children and adolescents in the United States, with
children under the age of 5 years having the highest
death rate of any age group, except for those over 75
years. The majority (80%) of fire and burn deaths in
the Unites States are from residential fires.
Cigarettes are the leading preventable cause of
residential fires, accounting for 28% of fatal house fires.#{176}The technology for self-extinguishing
ciga-rettes is already available, and it appears we are
slowly moving in that direction in this country. If the self-extinguishing cigarette was fully effective in
pre-venting house fires and all cigarettes were of this
type, it could have prevented 294 fire deaths to
chil-dren and adolescents.
Many of the remaining 757 residential fire deaths
can be prevented through the use of smoke detectors.
Recent studies3’ indicate that smoke detectors
de-crease the risk of fatal injury by 71%. For less than the price of a fast food meal, a family can dramatically decrease its risk of fire and burn death. In the United
States this would save the lives of 537 children and
adolescents annually.
Ultimately, nearly all fire deaths and serious
inju-ries could be prevented through the use of
residen-tial sprinkler systems.32 These are now economically
feasible for newly constructed homes. With the
con-struction of 1.8 million new homes each year in this
country, 36 million homes could be protected by
sprinkler systems within 20 years.
POISONING
There were 62 poisoning deaths from solids and
liquids to children under the age of 5 years in 1991.
Most of these deaths should have been completely
preventable through the adequate application of the
Poison Packaging Prevention standards. Iron
supple-ments have emerged as the single most frequent
cause of pediatric unintentional ingestion fatalities.33
The reduction of iron poisoning fatalities will likely
involve regulatory restriction of iron to prescription
status and repackaging of iron supplements in child-proof containers.
The preventability of poisoning deaths among
older children and adolescents is more difficult to
interpret. Most of the 97 deaths in 15 to 19 year olds
probably represent either unintentional overdoses of
drugs of abuse or misclassified suiddes.” The
lead-ing cause of fatal unintentional drug poisonings are
opiates and related narcotics and cocaine.33 Most of
the fatal poisonings from other solids and liquids are
due to alcohol ingestion.33 Methods to prevent these
deaths probably should include programs beginning
in early childhood to prevent the onset of substance
abuse, as well as appropriate treatment programs for
substance abusing teens and adults. The
effective-ness of these programs is not clear, thus no estimate
of the number of deaths that might be preventable
through such programs has been made.
There were 121 deaths among persons under 19
years related to poisoning from gases and vapors in
1991. These are likely to be nearly all due to carbon
monoxide.35 Nationally, 57% are due to motor
vehi-cle exhaust gas,36 and as many as one third are due to
home heating devices.37 In one series of cases of
carbon monoxide poisoning, 29.4% of the pediatric
cases were associated with riding in the back of a
pick-up truck, usually under a closed canopy.38 All of
these deaths should be viewed as completely
pre-ventable with the use of smoke detectors, carbon
monoxide detectors, adequate ventilation of heating
equipment, inspection of motor vehicle exhaust
sys-tems,39 and not using the back of enclosed pick-up
trucks to transport children.
FALLS
Although most morbidity and mortality from falls
occurs in the elderly, 264 children and adolescents died from falls in 1991 . Forty percent of these
fatali-ties occurred to children under 5 years, with the
remainder occurring to adolescents 15 to 19 years.
Deaths to young children from falls usually involves falls from heights of more than three stories.”#{176} The
history must be closely examined in any young child
with serious or fatal injuries from a short fall, partic-ularly from furniture or while playing on one level.’#{176}
One program in New York City using window bars
virtually eliminated falls of young children from
windows.42 Thus, all 1 1 1 of the deaths from falls
among toddlers and preschool-age children should
be viewed as preventable.
There are no studies in the literature specifically on fatal fall injuries in older children and adolescents.
Thus, appropriate prevention strategies cannot be
suggested at this time.
FIREARMS
There were 5356 deaths to children and
adoles-cents in the United States in 1991 from firearms.
There are three categories of firearm deaths: uninten-tional shootings, homicides, and suicides. Homicides
have increased by 67% since 1978 and suicides by
17%; the vast majority of the increase for both has
been due to gun violence. The 551 deaths that
oc-curred unintentionally must be viewed as fully
pre-ventable. Safe storage of guns, safe design and use of
guns, and consideration given to the removal of guns
from the home can prevent access to guns and hence
eliminate the risk of unintentional deaths from this
vector. This follows from the general principles of
injury control laid down by Haddon43 many years
ago.
The deaths from suicide and homicide involving
guns may not all be preventable by decreasing access
to guns in the home environment of children and
adolescents. However, access to guns clearly does
increase the risk of these fatalities from occurring. Data from several rigorously conducted case-control
studies indicate that home ownership of guns
in-creases the risk of suicide among teens and young
adults 10.4-fold and the risk of homicide 3.4-fold.45
In these studies 70.4% of the suicides occurred in
the victim’s home. Applying this to the 2164 youth
suicides in 1991, an estimated 1523 occurred in the
58.8%. Thus, restriction of access to guns could po-tentially save 896 adolescents from suicide. Similarly,
23.9% of the homicides occurred in the victim’s
home. Because homicides of children under 10 years
are usually due to abuse and are different from those
in adolescents, we have chosen not to include them
in the following calculations. Applying the 23.9% to
the 3746 homicides to adolescents 10 to 19 years, an
estimated 895 occurred in the home. The attributable
proportion due to guns is 32%. This translates into
286 deaths that could be potentially saved by restrict-ing access to guns in the home.
These are very conservative estimates because
they do not take into consideration the effects of
restricted gun access on suicides and particularly
homicides occurring outside the home. However,
because of the dearth of data on this by which we can
calculate an estimated protective effect, we have
cho-sen to focus only on deaths in the home.
Neverthe-less, this would eliminate 1733 deaths or 32.3% of the
gun deaths experienced by youth in 1991.
SUMMARY
The data presented here indicate that 6640 lives of
children and adolescents could be saved per year
through the application of currently available
strat-egies to prevent death from injury (Table 2). This
represents 31% of current deaths from injury and
amounts to more deaths than are now lost from heart
disease, cancer, and infections in this age group. There has been a substantial (34% overall) decrease
in deaths from all causes of unintentional trauma
during the period 1978 and 1991 . Deaths to motor
vehicle occupants are due to improvements in
vehi-cle design and occupant packaging, as well as
de-creases in drunk driving. The rate of death for all
ages per 100 million vehicle miles traveled has fallen from 3.3 in 1978 to 1.9 in 1991, a decline of 67%.” The
number of deaths in which alcohol was involved
have also declined to a low of 48% in 1991. The
importance of alcohol should not be underestimated.
As discussed above, seat belts and airbags are far
from 100% protective; although improvements are
possible, decreases in the number of crashes is clearly
important. Numerous studies of adolescents
admit-ted for trauma have documented positive blood
al-cohol levels and problem drinking in a sizable
por-tion of the population. Loiselle et al47 found that 34%
of 13 to 19 year olds admitted to a level 1 pediatric
trauma center were positive for alcohol or drugs on
admission. Alcohol can markedly impair driving
performance by teens.48 Teenagers are not only the
least experienced drivers, they are also the least ex-perienced drinkers. As a result, impairment of
driv-ing performance for younger drivers begins at a far
lower blood alcohol level than 100 mg/dL, the level
most commonly used in the United States for the
legal definition of intoxication. This has precipitated some states to lower this level to 80 mg/ dL or even lower for teenage drivers.
The decrease in injuries from bicycling probably
do not reflect the impact of helmet use, because the
rate of use in 1991 was still low nationally. The
reasons for the decline are unknown, but may be due
to a combination of better trauma care (see below)
and decreased exposure to traffic. Bike helmet
cam-paigns can certainly impact on this further; our cam-paign in Seattle has resulted in a reduction of head injuries in child cyclists by more than two thirds.49
The large reduction in pedestrian fatalities is
al-most certainly due to decreased exposure to traffic.
The limited data available indicate that far fewer
children walk today than 20 years ago.2#{176}The
de-crease in pedestrian fatalities has clearly come at a
price.
Reduction in motor vehicle-related and other
trauma deaths is probably, at least in part, due to
improved trauma care. Numerous studies have
doc-umented the decrease in trauma fatalities and
pre-ventable deaths through the institutionalization of
regionalized trauma systems.#{176} The further
regional-ization of trauma care will continue to have an
im-pact on pediatric trauma deaths nationally.
How-ever, the limits of this may soon be reached because
most pediatric trauma deaths are due to severe head
injuries for which medical and surgical care at the
present time have limited ability to further decrease mortality.5’
The role of improved medical care in the 39%
reduction of drowning deaths is less clear. Most sub-mersion incidents in children fall into two relatively
distinct groups: children who are awake and
breath-ing on arrival in the emergency department and
children who require ongoing CPR.27 The former do
well; the latter die or survive with serious neurolog-ical disability.27 Although prehospital care may have
contributed to some of the decline in mortality over
time, the impact of such care is likely to have been
TABLE 2. Injury Prevention Strategies and Lives Saved
Injury Strategy Potential Lives
Saved
Percent Decrease
Motor vehicle occupants Airbags, lap/shoulder harness 2010 40.0
Pedestrian injuries Community approach 550 39.2
Motorcycle crashes Helmets 53 15.1
Bicycle injuries Helmets 238 65.9
Drowning Pool fencing, prevention of bathtub drowning,
prevention of alcohol use in adolescents
931 58.4
Fire/burns Fire-safe cigarette, smoke detectors 831 63.2
Poisoning Poison packaging, elimination of carbon monoxide deaths 183 59.6
Falls Window bars 111 42.1
Firearm violence Elimination or secure storage of handguns in the home 1733 36.8
small. Recent studies on out of hospital cardiac arrest
underscore the poor survival rate in the pediatric age
group.52 The reductions in drowning deaths may
thus be due to better pool fencing and better
aware-ness by parents of the hazards of water to young
children.
Medical care has probably been responsible for a
significant part of the reduction in burn mortality.
The size of a burn wound in which one half of
children die, the LD,, has increased dramatically
over time and is now a total body surface area of
more than 80% in children beyond infancy.55 In
ad-dition, the large number of smoke detectors in
Amer-ican homes is probably responsible for much of the
remaining decline.
The remarkable decrease in poisoning deaths since
1960 should rightly be viewed as one of the success
stories in pediatrics and injury control. The use of
child-resistant packaging is a clear example of the
effectiveness of passive strategies.
The decline in deaths from unintentional trauma
contrasts dramatically with the rise in deaths from
intentional trauma. Intentional injuries are almost
unique in that they are one of the few health
prob-lems in the United States to increase in incidence in
the last few decades.57 As discussed above, nearly all
of this increase has been due to guns. We as
pedia-tricians must acknowledge the impact of guns on the
lives of America’s children and become involved in
various ways to address
the problem.
The American
Academy of Pediatrics and the Center for the
Pre-vention of Handgun Violence have developed the
STOP (Steps to Prevent Firearm Injury) educational
program for pediatricians to help make them more
effective in educating parents about the risks of guns
in the home. This is an important step in beginning to
address this problem. Perhaps the largest step has been taken already, realizing that guns are one of the most
pressing public health problems in America today.
The proportion of deaths from injury calculated as
preventable with currently available strategies is
similar to that in our previous article: 31% compared
with 29%. Even given the dramatic reductions in
trauma deaths over the last 14 years, nearly one third
of injuries can still be prevented. We realize that this
may be an optimistic estimate. However, our
previ-ous estimate of a 29% reduction in 1978 deaths as
being preventable was more than surpassed by the
34% actual decrease in trauma deaths by 1991. The
lesson of this article thus remains the same as the
prior report. The means are available and within our
grasp to have a significant impact on the health and
welfare of children in this country. It is up to us to
make it happen.
ACKNOWLEDGMENTS
This work was supported by Centers for Disease Control and Prevention grant #CCR002570.
We greatly appreciate the assistance ofJeffrey Saks, MD, MPH.
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the Status and Progress of the Injury Control Program at the Centers for
Disease Control. Washington, DC: National Academy Press; 1988
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MULTIPLE BIRTHS: A WAKE-UP CALL
Miss Helen can recall when the Dionne quints were born in 1934, an event as rare
and heralded as the birth of a white buffalo. But today, in the United States alone, there are 42 sets of quintuplets with all members living, including the three little
girls and two boys born recently at Long Island Jewish Medical Center to Pnina and
Shmuel Klaver of Flatbush. Triplets are more plentiful still. About 2500 sets are
born annually.
Twins and other multiples often delight their families, but they also present
challenges for them and society as a whole.
Multiples are much more prone to premature birth, a situation that can produce
a whopping first-year health care tab-more than $1 billion for all low birth weight
multiples, 35% of it borne by Medicare and Medicaid. Birth defect rates are also
elevated in multiples. The rate of cerebral palsy, for example, is six times that for
singletons, according to one study. And financial and child care burdens are
heavier. One side effect: studies show child abuse is more common in families of
multiples.
. . .There is no data about how many multiple births are the result of fertility
treatment. But it is estimated that 25% of pregnancies resulting from fertility
treatment are multiple pregnancies.
Martin A. New York Times. February 8, 1996.
