Traumatic
Deaths
of Children
in the United
States:
Currently
Available
Prevention
Strategies
Frederick
P. Rivara,
MD, MPH
From the Department of Pediatrics and Community Medicine, University of Tennessee
Center for the Health Sciences and LeBonheur Children’s Medical Center, Memphis
ABSTRACT. The causes of traumatic deaths of children 14 years of age and younger in the United States are presented. Available prevention strategies to decrease
injury fatalities due to various causes are described, and
the number of preventable deaths is calculated. With the implementation of only i2 currently available prevention
strategies, childhood deaths from trauma could be
re-duced by 29% in the United States. The implications of
these strategies are discussed, as well as the areas for
which no effective countermeasures exist and which re-quire further epidemiologic and investigative research.
Pediatrics i985;75:456-462; traumatic death, injury
fatal-ities.
Injuries have become the most important cause of death in children i to 14 years of age. For the
last three decades, the death rate from all causes
has decreased by 53% for children aged 1 to 4 years and by 44% for children aged 5 to 14 years.’ Nearly all of this decline is due to deaths from natural causes. In contrast, death rates due to motor vehicle injuries have actually increased in older children. Suicide rates have doubled for 5- to 14-year-old children during this period, whereas homicides have nearly quadrupled in younger children and nearly tripled in the older ones.
Why have childhood deaths due to injuries not decreased in a fashion similar to deaths from nat-ural causes? Where should concern and expenditure of funds and efforts be placed? Pediatricians have been traditionally involved in injury prevention in two ways. As child advocates, they have lobbied, often successfully, for changes in public policy that
Received for publication Nov 10, 1983; accepted April 27, 1984. Reprint requests to (F.P.R.) Department ofPediatrics and Com-munity Medicine, University ofTennessee Center for the Health Sciences, Lebonheur children’s Medical Center, Memphis, TN
38103.
PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the
American Academy of Pediatrics.
would result in a safer environment for children. Child restraint laws, the Poison Prevention
Pack-aging Act, and The Flammable Fabrics Act are a
few of the outstanding successes in this field. Pe-diatricians have also been involved in the study of the epidemiology of childhood injuries, which can and has led to the development of effective coun-termeasures. The present study was precipitated by the need to review areas in which injury prevention
strategies are currently available but have not yet
been effectively applied. The study also reveals the
types
of injuries for which few effectivecounter-measures for prevention have been developed and
for which much more investigative research is
needed.
SOURCE
OF DATA
Mortality data on children aged 0 to 14 years of age were obtained from the published data of the National Center for Health Statistics. The data for
1978 were derived from death certificates sent to
the National Center for Health Statistics by each of the 50 states.2 These deaths included the Inter-national Classification of Diseases Adapted (ICDA-8) “E” codes 800 to 949. In addition, suicide and homicide deaths caused by firearms were included. The causes of death by age group in each category are shown in the Figure.
The reported literature was examined to identify currently developed, realistic prevention strategies for each major category of traumatic deaths
(Ta-ble). These estimates were then applied to the
mortality statistics to derive estimates of the num-ber of deaths in each category as well as the overall number that are currently preventable. Strategies were chosen on the basis of representing currently
available programs that have been shown to be
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Figure. Traumatic deaths of children in United States in 1978. Causes are shown for three age groups. Abbreviation used is: MV, motor vehicle. Data from National Center for Health Statistics, Vital Statistics of the United States, vol 2, part A, 1982.
TABLE. Injury Problems and Loss Reduction Strategies
Injury Problem Method of Loss Reduction References
Motor vehicle occupants Infant seat restraints for ages 4 yr
Air bags for 5- to 14-year-old front seat occupants
3-6
7, 8
Motorcycles Helmets 9
Pedal cycles Helmets 9, 14
Poisoning Expansion/enforcement of Poison Prevention
Packaging Act
15
Drownings Barriers around pools 26, 27
Fire and flames Self-extinguishing cigarettes and smoke detectors 21, 22
Firearms (nonintentional, homicide, and suicide)
Elimination of handguns 31, 32
Choking or suffocation Heimlich maneuver and Consumer Product Safety
Commission regulations
29, 30
Falls Window bars 16
The estimate of preventable deaths was obtained by multiplying the number of deaths in each
cate-gory reported to the National Center for Health Statistics by the proportion of deaths that could have been prevented by the countermeasure as it
was reported in the literature. When data were
available, the number of deaths that would be ex-pected to occur despite 100% use of the counter-measure were subtracted from this estimate to give an overall total of preventable deaths.
MOTOR
VEHICLE
INJURIES
The single largest cause of traumatic death in childhood was motor vehicle-related injuries,
ac-counting for 4,681 or 35% of the total deaths in
1978. These motor vehicle fatalities occurred in four
main categories: motor vehicle occupants,
motor-cyclists, pedal cycle-motor vehicle collisions, and
pedestrian-motor vehicle collisions.
Motor Vehicle
Occupants
Motor vehicle occupant injuries can be separated into two groups: those occurring in children less than age 5 years, and those in children aged 5 to 14
years. Prevention of occupant deaths in the 0 to 4
year-old age group is best achieved through the use
of child restraint devices. Approximately 90% of
these fatalities could be prevented through the use of appropriate restraints.35 In the study by Scherz6 of fatalities in Washington, only one of 39 children was properly restrained. Thus, of the 528 children
less than age 5 years who died in motor vehicles in
unre-strained and 461 of these deaths could have been
prevented.
No
specific data on the protection of older chil-dren in motor vehicle crashes are currentlyavail-able. The data on protection of adults in crashes by
passenger restraint devices must therefore be
ap-plied to children aged 5 to 14 years. There are two
basic restraint devices applicable: the lap and shoul-der belt system and air bags. Although lap and shoulder belts may prevent 50% to 60% of fatalities,
estimates of seat belt use in older children and
adults are only 20% to 30% currently.4 Air bags, by being passive devices requiring no active coopera-tion on the part of passengers appear to be the best
alternative for occupant protection.7 As currently
envisioned, air bags would provide protection for front seat passengers only. Data from the National Highway Traffic Safety Administration, indicate that in the 5- to 9-year-old age group, 56% of the children in occupant crashes are front seat
passen-gers.4 Among the 10- to 14-year-old age group, 66%
are front seat occupants. Thus, of the 331 deaths in 5- to 9-year-old children and the 546 deaths in
10- to 14-year-old children, 185 and 360, respec-tively, would be expected to have been front seat occupants. Data collected by the Insurance
Insti-tute for Highway Safety indicate that for the 1975 to 1978 period, 38,724 or 41.6% of the 93,160 front seat passenger car occupant deaths could have been
prevented by air bags.8 Therefore, 41.6% of the
front seat occupants or 77 of the 5- to 9-year-old children and 150 of the 10- to 14-year-old children or a total of 227 lives could be saved annually by use of air bags alone without the lap-shoulder belt
systems.
Comment. The strategies for motor vehicle injury
prevention are realistic ones. The American
Acad-emy of Pediatrics has been intensely involved in the promotion of child seat restraint use. Pediatri-cians have been largely responsible for the passage
in 49 states of legislation mandating their use. Emphasis must continue to be placed on ensuring universal use of restraints in these children.
General Motors and other automobile manufac-turers have raised the possibility that panic braking may throw unrestrained small children into the instrument panel where they could be vulnerable to injury from the inflating air bag. However, General Motors’ own experience with air bags refutes this as a significant potential danger. More than 10,000 cars with air bags were built by General Motors
between 1974 and 1976. After 800 million miles of
travel, air bags were deployed in more than 200
crashes. Of the 59 children involved in these crashes, there was only one fatality-an unre-strained infant who was thrown under the
instru-ment panel by precrash braking. No children suf-fered more serious injury because of the air bags.4
Motorcycle Injuries
In 1978, there were 159 motorcycle passenger
deaths of children less than 15 years of age in the United States. No specific studies on the epide-miology of motorcycle deaths in children have ever been performed. Thus, adult injury statistics must
be applied to these childhood fatalities. Studies have shown that 70% to 85% of motorcycle
fatali-ties are due to head injuries.9 Reliable statistics indicate that helmets can decrease the rate of all
head injuries by 76%.#{176}Therefore, using the more
conservative estimate of 70% of motorcycle fatali-ties due to head trauma, 76% of which can be
prevented by helmets, 85 deaths could have been prevented through universal helmet usage.
Comment. Motorcycle helmet usage laws have achieved nearly 100% compliance in states where
they are actively enforced; thus they appear to be a
practical means of achieving helmet usage.9 Prior
to 1976, these laws were in effect in 47 states, but
when Congress removed the financial incentive,
many states repealed these laws. Reinstitution of these laws in the 27 states not presently covered
would be an effective means of prevention.
Pedal Cycle Injuries
With the tremendous increase in the popularity ofpedal cycling, nearly half the people in the United
States presently engage in this activity.’0 However,
pedal cycle injuries are the most common cause of injuries severe enough to require treatment in an
emergency room,” and were responsible for 427 deaths of children less than age 15 years in 1978.
Epidemiologic studies indicate that 76% of fatal
bicycle crashes either involving motor vehicles’2 or
non-motor-vehicle-related crashes’3 were due to se-vere head injuries. Fife et al’4 analyzed data from
173 fatally injured bicyclists and found that the age
group 0 to 11 years had the highest Injury Severity
Score, apparently due to the high frequency of head
and neck injuries. It appears, therefore, that the mechanism of fatal injury in bicycle-related deaths
is similar to that of motorcycle fatalities: head
injuries. There are no data on helmet usage among children at present, but use of helmets is probably minimal. If adequate safety helmets were used by child bicyclists, 75% of the fatal head injuries could have been prevented, resulting in a net reduction of 260 lives.
Comment. Encouraging child bicyclists to use
than 10 years of age to wear an appropriate safety helmet while riding in the street. Protective equip-ment for other contact sports involving child
par-ticipants (such as football) have become the norm
in both organized and unorganized activities. The
number of fatal bicycle injuries clearly warrants such an intervention. If 450 children died each year
on the football playing field and thousands more were treated in hospital emergency rooms, parental
outcry would quickly result in a modification of the game, if not its actual ban.
Pedestrian Injuries
Pedestrian injuries are an important component of the entire motor vehicle fatality toll. They
con-stitute 43% of the total deaths due to motor vehi-des. Among children aged 0 to 14 years, fatal
pe-destrian injuries are 37% more common than
oc-cupant deaths. The peak incidence is among the 5-to 9-year age group in which pedestrian fatalities
are 2.5 times more frequent than motor vehicle
occupant deaths. Approximately half of pedestrian
injuries occur at night. One strategy that has been
suggested is the use of reflective clothing or
reflec-tive patches on clothing. Unfortunately, there are
no data available that would allow calculation of the effectiveness of this proposed strategy.
POISONINGS
The number of poisoning deaths among children
has decreased markedly over the preceding decade.
In 1969, there were 414 poisoning deaths among
children aged 0 to i4 years; this had dropped to 245 in 1978, a decrease of 40.8%. The bulk of this drop
was in the 0- to 4-year age group, in which poison-ings were reduced from 290 in 1969 to 132 in 1978,
a 54.5% decrease. Poisonings due to drugs and other
solid and liquid substances have decreased while poisonings by gases and vapors have remained es-sentially unchanged. In 1978, there were 48 deaths
due to drugs among children less than age 5 years.
It is unknown in how many of these products a
child-proof container was involved. Poisoning by
other solids or liquid substances resulted in 45
deaths to children, 33 of which were to children less than age 5 years. Expansion and, more importantly, adequate enforcement of the Poison Prevention
Packaging Act should be able to prevent these
deaths.
The largest category of poisonings in children involves noxious gases and vapors. These account
for 52% of the poisoning deaths in 1978 and are
little changed from the total number of fatalities in this category in 1969 (127 in 1978 v 114 in 1969). The two largest subcategories of these are poisoning
from motor vehicle exhaust gas (29 cases) and
carbon monoxide (45 cases). Properly working
ex-haust systems in motor vehicles and appropriate, properly functioning home heating systems could
have eliminated the majority of fatalities in this
group.
Comment. An important component of the
re-duction in poisoning deaths is due to the Poison
Prevention Packaging Act.’5 Nevertheless, the
77
deaths that did occur represent a failure of the Act.
Further evaluation of these fatalities is necessary. The recent development of dual-closure containers
is not addressed by the Poison Prevention Pack-aging Act and represents a potentially important
undermining of the Act’s effectiveness. The
com-pliance of pharmacists with the Act needs to be
evaluated and methods of improving compliance
may be required.
Poisonings due to carbon monoxide now outnum-bers poisonings from other causes. However, these
deaths must not be considered nonpreventable. The
inspection of motor vehicle exhaust systems and
the inspection of home heating systems could pre-vent the majority of these poisonings.
FALLS
Although falls resulted in 13,690 deaths in 1978,
the majority of those who died were the elderly.
There were a total of 285 fall-related deaths among children in this period. One category of fall-related deaths is of particular interest-falls from heights, which accounts for 209 of the total. These deaths are often due to falls from second story tenement
windows by the wandering toddler. Spiegel and
Lindaman16 developed a preventive program in
New York City using a light-weight, inexpensive
bar that could easily be installed in second story
windows. This program reduced fall-related deaths by 47% in children less than 16 years of age.
Apply-ing this same proportion to national data gives a conservative estimate of 98 lives saved annually.
Comment. The demonstration of an effective pro-gram to prevent falls from heights is an excellent example of identification of a problem followed by the development of an appropriate low-cost coun-termeasure.
FIRE AND FLAME
Death from fire is second only to drownings and pedestrian injuries in causing fatal injury to chil-dren. The majority of fire-related deaths in the United States are residential.’79
The problem of fire-related deaths among chil-dren can be approached in two ways: prevention of
the fire and prevention of injury losses. Between 30% and 50% of house fires are due to cigarette smoking. In a Baltimore study,21 five of 16 (31%)
children died in house fires started by cigarettes.
This problem could be eliminated by the
manufac-ture of cigarettes that are self-extinguishing after a
short period of time. Using this prevention strategy, 459 lives could have been saved in 1978. The second
and probably the most effective method of
prevent-ing fire-related deaths is through the use of smoke detectors. The US Fire Administration reports that
69% of deaths from fires are due to smoke asphyxia-tion.’8 Smoke detectors can give early warning of fires and prevent both asphyxiation and burns. In
a large study in Ontario involving 79,000 homes followed for a four-year period,22 smoke detectors gave initial warning in 85% of the house fires, thereby preventing death or serious injury.
Apply-ing this success rate of 85% to the number of deaths
from fires remaining after subtracting the number prevented by self-extinguishing cigarettes, an esti-mated 870 lives of children aged 0 to 14 years could be saved. In sum, 90% of the fire-related deaths in children could be prevented through these two
mea-sures.
Comment. The use of smoke detectors is probably the single most effective strategy for injury
preven-tion in children. One possible strategy to assure use has been adopted in a number of states: all rental
housing and mobile homes must contain smoke
detectors, and all homes must be adequately pro-tected at the time of their resale. Currently, many homeowner insurance policies have lower fees for
houses so equipped. The cost of burn care for
sur-vivors should lead Blue Cross/Blue Shield and
other medical insurance companies to offer similar
rebates for smoke detector use.
DROWNINGS
Death due to drowning ranks second only to
motor vehicle trauma in the total number of fatal
injuries in the 0- to 14-year old population. In 1978, 622 children died from drowning.
Swimming pools were involved in 13% of the
drowning deaths for those of all ages and 23% of
those to children aged 0 to 14 years.23 More than
half (57%) of these swimming pool drownings were among children in the 0- to 4-year age group. River drownings were responsible for 21.8% of the deaths among individuals of all ages and reservoir
drown-ings for 23%.
Prevention strategies to decrease the incidence of drowning include improving swimming abilities and use of barriers. Prevention by teaching of
swim-ming would not be applicable to the age group less than 5 years. Among older children, Patrick et a125 have reported that 30% of the drowning victims in their series were nonswimmers. Thus, the efficacy of swimming in the prevention of drowning deaths among children is unknown.
Perhaps a more effective strategy would be the erection of barriers, particularly around swimming
pools. Nixon et al26 studied the effectiveness of
childhood safety barriers and found that a 1.4-m barrier would be effective protection for virtually all children aged 4 years and younger. Milliner et a!27 studied the effectiveness of fencing regulations
in Australia and calculated that when strictly
en-forced, swimming pool deaths among children aged
0 to 14 years can be decreased by 80%. No similar
experiments have been performed in the United
States, and it is unknown how many of the 127
children less than 5 years of age drowned in pools
that were fenced. Therefore, the estimate that 80%, or 102 deaths could be prevented by effective
bar-riers may be somewhat optimistic.
Comment. Drowning deaths are difficult to pre-vent. Fencing of swimming pools is an appropriate, effective, passive prevention measure, but it would decrease fatalities overall by less than 20% . Adult
supervision is obviously an important factor,
par-ticularly in the age group less than 5 years. How-ever, the need for adequate supervision appears to be difficult to teach and impossible to legislate.
Bystander cardiopulmonary resuscitation may
re-duce the number of deaths from drowning although no data are available to measure its effectiveness.
Another approach to drowning prevention, of
course, is modification of the victim-that is, swim-ming instruction. Despite the blossoming of many “water baby” types of programs, there is no medical evidence to suggest that these programs are effec-tive in decreasing the number of drownings.28
SUFFOCATION
Suffocation by obstruction of the airway is a
major cause of death among children less than age
5 years. In 1978, 554 children died of suffocation;
84% of these children were less than 5 years of age. Baker and Fisher29 have done an extensive review of this problem in Maryland. In their series, 20 of
42 deaths (47.6%) were due to choking, 12 of 20 instances were due to food. The other 22
strangu-lation deaths were due to a variety of mechanisms, including suffocation in old refrigerators, becoming wedged between the mattress and crib or between crib slats, and plastic bags.
There are effective prevention strategies for
many of these deaths. The Heimlich maneuver
and thus could prevent 29% of the deaths.3#{176}The
Consumer Product Safety Commission now has
standards or regulations covering an additional 29% of the deaths detailed in the series of Baker et al.29 Thus, 58% of deaths in the 0- to 5-year age group should be preventable. In 1978, this would have saved 269 children.
Comment.
Although the back blow has been sug-gested as an alternative to the Heimlich maneuver,experimental data indicate that back blows produce less airway pressure than the Heimlich maneuver.3’
Nevertheless, the preventability estimates given above are based on 100% effectiveness of the
ma-neuver and thus may be optimistic. No data are
available on the actual effectiveness of the maneu-ver in clinical situations.
FIREARMS
Firearms are involved in traumatic deaths of
children in three ways: nonintentional firearm
fa-talities, suicides, and homicides. Suicides and
hom-icides are included because they are a large cause of traumatic deaths in this age group and because the mechanism for prevention is identical with that for nonintentional firearm deaths. Nonintentional firearm deaths resulted in 210 fatalities in the 0- to 14-year old population in 1978. Nearly 60% of the suicides and 50% of the homicides in this age group were due to guns as well. Approximately 90% of homicides due to firearms involve handguns.32 Data on proportion of handguns involved in suicides and nonintentional firearm misuse in children is less sound, but appears to be approximately 50%. Elim-ination of handguns, which would save 454 lives, appears to be the only reasonable solution.
Comment. The only effective strategy appears to be
gun
control. No data exist to support the effec-tiveness of information and education campaigns on firearm safety in decreasing the number ofgun-shot wounds in children. Regardless of the merits
of safety education, firearms around the home pose
a risk to children who have not yet developed
adequate judgment for the safe handling of these weapons. Furthermore, safety education will have no effect on the use of firearms in homicides and suicides. Most homicides are between relations or acquaintances and involve acts of rage.32 The elim-ination of handguns would certainly not eliminate the arguments, but it would decrease the chance of a fatal conclusion. The rate of suicide, could be decreased by eliminating handguns from the envi-ronment of adolescents. In England, until recently,
domestic gas was a common means of suicide.
Re-duction of the carbon monoxide content was
suc-cessful in eliminating these deaths.34 There was not a proportionate increase in suicide deaths by other
means. Nevertheless, a ban on handguns probably would not totally eliminate their use.
DISCUSSION
The data presented here indicate that with 12
currently available prevention strategies, 3,436 or 29% of the nearly 12,000 traumatic deaths of chil-dren occurring yearly in the United States could presently be prevented. This amounts to nearly as many deaths as now due to all infectious diseases among children, including meningitis. Great efforts are made to discover ways to combat these
infec-tions through the development of newer vaccines
and still newer generations of antibiotics. Yet, the
methods
are presently at hand to accomplish the same amount of “good,” from a public health stand-point, through prevention of injury losses. Physi-cians have long been involved in injury prevention;the Poison Prevention Packaging Act, The
Flam-mable Fabrics Act, and more recently, Child Pas-senger Restraint legislation have all been initiated by physicians. Although partly successful, these past efforts are not enough. This study describes areas for further fruitful involvement in both the legislative/regulatory arena and in health educa-tion.
The study also outlines areas in which few
effec-tive strategies are available and hence areas in
which further research and development efforts
should be concentrated. Pedestrian injuries are an enormous problem among children, yet no data are available for any effective countermeasures. There are a number of approaches that require further exploration. The evaluation of reflective clothing has already been mentioned. The shape of the
im-pacting vehicle and the height of the hood and
bumper relative to the victim can have a major
effect on the severity of injury.35 The number of child pedestrian-motor vehicle collisions involving alcohol is unknown. Scherz6 found that 29% of fatal motor vehicle injuries involving occupants aged less than 4 years involved alcohol. Similar studies of motor vehicle collisions involving child pedestrians are needed. The now classic studies by Sandels36 demonstrated that young children do not have the judgment to handle adequately many pedestrian situations. There have been a few studies that have successfully trained children in safe pedestrian be-havior.37 However, their effectiveness in decreasing pedestrian injuries in these children is unknown.
Another approach might be the analysis of the
socioeconomic factors involved in pedestrian inju-ries. Can high-risk neighborhoods be identified and then modified to decrease the risk of such injury?
beyond infant years riding in the back seat, the
only protection is a lap belt. Because of the low
level of use, few children are actually protected. Passenger restraint systems need to be developed to protect these children. Even with the present use of infant seat restraints and air bags, only
approx-imately half of deaths among children in motor
vehicles could be prevented.
Drowning has proven frustratingly difficult to prevent. The strategy suggested here, barriers
around pools, can prevent only about 10% of the
drownings. Other methods, particularly modifica-tion of the victim through water safety training and swimming skills, need to be evaluated. In particular,
children from socially and economically deprived
backgrounds must be included in this prevention scheme. They are at greatest risk, but least likely
to receive intervention.
The magnitude of the injury problem need not
lead to paralysis of action. The prevention
strate-gies suggested here can represent realistic goals for
the medical community interested in decreasing childhood mortality. The directions for educational and legislative actions are clear, as well as the areas requiring further research and injury
countermea-sure development.
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