Article Text

Download PDFPDF
Unintentional injury prevention: what can paediatricians do?
  1. D H Stone,
  2. J Pearson
  1. Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, Division of Developmental Medicine, Faculty of Medicine, University of Glasgow, Glasgow, UK
  1. Professor David Stone, PEACH Unit, Glasgow University, Yorkhill Hospital, Glasgow G3 8SJ, UK; d.h.stone{at}clinmed.gla.ac.uk

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Paediatricians, in common with all clinicians, rightly regard patient care as their prime responsibility. At the same time, all doctors have an opportunity and indeed obligation1 to prevent disease and promote health wherever and whenever possible. This paper summarises the scale and nature of the public health challenge posed by unintentional injuries in children, outlines the key preventive approaches, indicates the wide range of available evidence based countermeasures, and suggests ways in which paediatricians can contribute to injury prevention both in the course of their routine clinical duties and in partnership with others.

INJURY IS A GLOBAL AND GROWING PUBLIC HEALTH CHALLENGE

In most developed countries, injuries are the largest single cause of death in children and young people (numerically comparable to malignancy) and a major cause of morbidity2 as reflected by hospitalisation, emergency department attendance, primary care visits and long term disability. The direct costs of injury to the National Health Service in the UK are around £2 billion per annum, with global costs to society perhaps 10 times that figure.3 The costs of child injury care at accident and emergency (A&E) departments in the UK have been estimated at £146 million annually.4

Two related reports published by the World Health Organization recently highlighted the continuing importance of unintentional injuries in children from a European5 and a world perspective.6 In the UK, unintentional injury mortality (though not necessarily incidence) has declined over the past 20 years for reasons that are not entirely clear. Declining mortality may reflect improved trauma care and survival rather than declining incidence,7 although specific injury prevention measures are assumed to have contributed to this trend. By contrast, intentional injury mortality (violence, suicide) has increased and may overtake unintentional injury rates within a few years. Globally, injury mortality is expected to rise up the burden of disease league table in the coming decades, from around 5 million deaths to over 8 million by 2020.8

Injury risk reflects developmental stage. Most injuries to pre-school children occur at home (eg, falls, burns and scalds), while school age children are injured on the roads or at play.9 After infancy, boys are at a higher risk than girls.10 There is a strong correlation between injury risk and social deprivation in general11 and with dysfunctional parenting in particular, possibly mediated through child behavioural problems.12 Minor bumps and scrapes are an inevitable part of growing up and cannot be prevented, but serious injury is potentially avoidable through the implementation of evidence based measures.

Multiple agencies have responsibilities for safety (eg, police, fire, roads, schools, consumer protection, health and safety at work, architects/urban planners). Achieving an integrated cross-departmental approach is one of the major challenges for policy makers and practitioners. There have been several recent attempts to address this issue. Among the various reports and policy statements in the UK that fall into this category are the Staying Safe Action Plan,13 covering all forms of threats to child safety, that followed fairly rapidly on the heels of a highly critical review of child injury prevention,4 the Child Safety Action Plan project, and the NICE decision to issue guidance in 2010 on child unintentional injury prevention.14

The specific NHS role in injury prevention is not always obvious, but there are underexploited opportunities in both primary and secondary care as well as public health.

APPROACHES TO INJURY PREVENTION

Injuries are not random events. They are predictable and avoidable, perhaps to a greater extent than most other causes of mortality and morbidity in childhood. Over the past few decades, a formidable amount of research evidence has accumulated that is available to guide practitioners and policy makers. Although more research is always required, the full implementation of the existing body of evidence could reduce the incidence and impact of injury substantially. A study15 of child injury mortality in the United States estimated that a third of all childhood injury deaths could be avoided if interventions of known efficacy were implemented across the country. Assessing the extent of this implementation gap has never been attempted in detail in the UK, although it seems reasonable to assume that a substantial further reduction in the incidence of injuries to children might be achievable in this country.

The public health literature includes a wide range of injury prevention approaches, the two most popular of which are the three levels of prevention and the three Es.

Primary, secondary and tertiary prevention

Applying the classical model of preventive medicine, injury prevention may be primary, secondary or tertiary. These three levels are defined in relation to the stage of the natural history of the condition.

Primary prevention

Primary prevention refers to the removal of circumstances, risks and hazards that lead to injury. Examples are child resistant packaging, the manufacture of fire-resistant nightwear, the fitting of thermostatic mixing valves and intensive parenting interventions.

Secondary prevention

Secondary prevention refers to the reduction of injury severity in incidents that do happen. Examples are the fitting of seat belts (see supplementary file online for a summary of child car restraints), the wearing of motorcycle or bicycle helmets and the use of impact absorbing playground surfaces.

Tertiary prevention

Tertiary prevention refers to the optimal treatment and rehabilitation of the injured person to minimise the impact of injury. Examples are the administration of effective first aid, the rapid evacuation of injured patients to specialist care facilities, acute surgery and intensive care for trauma victims and the provision of services for the disabled injury victims.

The three (or four) Es

An alternative and widely quoted conceptualisation of injury prevention is the so-called three Es: education, enforcement of legislation and engineering (or environmental) measures (in reverse order of efficacy) (fig 1).

Figure 1

The three Es of injury prevention.

Education

Unless people are educated about safety, it is unreasonable to expect them to avoid injury through intuition or guesswork. Education may be directed at various groups – children, parents or carers, professionals and politicians – and may involve a range of methods to raise awareness, including media and advertising campaigns.

Enforcement

Passing legislation that is not enforced, for whatever reason, is pointless. Enforcement, however, is labour intensive and requires sustained commitment on the part of the statutory agencies such as the police and trading standards officers.

Engineering/environment

Advances in technology, building (including home design), road design, consumer product safety and other forms of engineering, in the broadest sense, all play a role in preventing injury. The wider environment – physical, social and emotional – is crucial to the generation or avoidance of injury risk. An important environmental dimension is poverty; the gradient of risk across children of different social classes is steeper for injury mortality than for many other causes of death in childhood,11 a phenomenon that may reflect the more hazardous environment of poorer localities.

Active and passive safety

The active approach to safety requires individuals to take positive actions or to change behaviour. The passive approach requires neither but creates the conditions where safety is promoted regardless of human judgement or behaviour. Examples of the former are avoiding drink driving, supervising children at play and using seat belts.

Examples of the latter are domestic water thermostats, automatic sprinklers attached to smoke detectors and impact absorbing playground surfaces. In general, passive approaches to injury prevention have been found to be more effective than active ones, presumably because they minimise the necessity for human decision-making. This finding has important implications for preventive policy making.

SUMMARY OF RESEARCH EVIDENCE ON THE EFFICACY OF INTERVENTIONS

Preventive measures are increasingly expected to conform to principles of evidence based practice, notably the integration of research findings and public perception with professional judgement. That in turn depends on the availability of robust research findings. The development and evaluation of injury prevention has been neglected by researchers but that appears to be changing. The evidence base for the efficacy of injury prevention measures has expanded substantially in recent years. A number of countermeasures, designed to reduce either unintentional injury incidence or risk, were cited in the Department of Health’s Accidental Injury Task Force (AITF) report3 and related documents (see below).

Recommendations of the UK Accidental Injury Task Force 2000–2002

Taking its cue from an earlier white paper on public health, the Department of Health established a multi-disciplinary Accidental Injury Task Force (AITF) in 2000. Its remit was to advise the Chief Medical Officer for England on the most important priorities for action to prevent unintentional injuries in the population. Its report3 contained several recommendations relating directly to children. A 1999 public health white paper16 set national targets for the reduction in injury death rates (by at least one fifth) and serious injury rates (by at least one tenth) in England by 2010. The AITF identified two population groups for priority attention – young people (children and young adults) and older people. Two parallel working groups were set up to consider what action was needed to protect these groups from accidental injury. They concluded that much could be done to address the major causes of injury – namely falls, road accidents and dwelling fires – across all age groups.

The AITF also identified the following 10 specific steps to help deliver successful local implementation:

  1. Use data collected in a common format to show where action is needed most.

  2. Adapt key interventions to specific local needs where they will have the greatest impact.

  3. Develop and disseminate good practice to show what can be done.

  4. Show how these interventions can help deliver other programmes and meet targets elsewhere.

  5. Involve all stakeholders in producing a local action plan.

  6. Develop a well-trained workforce with capacity to undertake injury prevention work.

  7. Recruit high-level support.

  8. Recruit support from the voluntary sector.

  9. Identify sources of additional funding.

  10. Identify indicators to monitor performance.

Recent research on injury prevention

Later publications from international sources, notably the European Child Safety Alliance,17 have reinforced and expanded the AITF’s recommendations. The findings of this more recent research into the efficacy of interventions may be summarised as follows.

Interventions that target road traffic injuries

  • Encourage universal bicycle/motorcycle helmet wearing

  • Encourage correct use of child restraints/seat belts

  • Encourage implementation of area wide urban safety measures

  • Promote traffic speed reduction and 20 mph speed limits in areas of higher pedestrian activity

  • Community based education/advocacy measures to protect pedestrians

  • Encourage participation in local child pedestrian training schemes and safe travel plans.

Interventions that target injuries at home

Fires
  • Encourage home risk assessments, safety checks and escape plans

  • Promote installation/upkeep of smoke alarms/sprinklers

  • Target deprived groups, particularly children in privately rented and temporary accommodation, and households in which people smoke

  • Promote the purchase and wearing of fire-resistant sleepwear.

Falls
  • Home safety checks by healthcare professionals

  • Installation/use of window bars/safety mechanisms

  • Installation/use of stair gates at tops of stairs

  • Discourage use of baby walkers.

Scalds
  • Thermostatic mixing valves for bath hot taps.

Poisoning
  • Promote use of child resistant closures and packaging

  • Promote the secure storage of medicines and poisons.

Drowning/submersion
  • Promote fencing of private swimming pools.

Interventions that target injuries during play/recreation

  • Promote use of playgrounds with impact absorbing surfaces

  • Promote use of playground equipment of appropriate height (1.5 m for young children)

  • Promote use of buoyancy aids/life-jackets for water recreation

  • Increase presence of trained lifeguards at pools and beaches.

Generic interventions

  • Promote parenting/early years interventions

  • Target poorest/high risk households.

Monitoring interventions

  • Establish local injury surveillance system

  • Undertake research, monitoring and evaluation.

IS THERE A ROLE FOR CLINICIANS IN PREVENTING UNINTENTIONAL INJURY?

Prevention in daily clinical practice

Although routine clinical work may offer limited opportunities for unintentional injury prevention, there is growing awareness that two principles – prevention and health promotion – are core professional responsibilities of all doctors in the UK; all good clinical management – especially in paediatrics and trauma care – is per se a form of prevention. Furthermore, doctors who observe the results of trauma are arguably best placed to initiate injury prevention activities.18

The evidence of the usefulness of clinical advice to parents and children for injury prevention is conflicting. The American Academy of Paediatrics (AAP) promotes a programme (see below) that appears to be highly effective and efficient – for each dollar invested, there may be a $13 return.19 UK researchers are more sceptical, arguing that environmental and legislative measures are likely to prove more effective.20 These two positions are not necessarily mutually exclusive.

Five principles of injury prevention in clinical paediatric practice (box 1) must be kept in mind:

  1. Although most parents want to keep their children safe at all times, a minority do not – and the distinction between unintentional and intentional injury (abuse or neglect) is sometimes blurred.

  2. Discussing child safety with parents need not be restricted to education in the narrow sense but can include offering practical advice about legislation (eg, on child car seat restraints) and environmental modification (eg, the installation of a thermostatic mixing valve).

  3. Adopt an evidence based approach as far as possible and avoid appealing to parental “common sense” as this can be misleading – many parents (wrongly) believe that cooker guards are useful and that baby walkers are safe.

  4. Promoting safety does not require “wrapping children in cotton wool” as that would delay normal development and restrict activity thereby increasing the risk of obesity. The aim should be to take reasonable precautions to ensure that the risk of injury to children is minimised.

  5. The nature of the risk of injury varies widely according to age and stage of development. As a rule of thumb, pre-school children are in greatest danger in the home while school age children face greatest risk on the roads or at play.

Box 1 Injury prevention: summary of opportunities for paediatricians

Clinically based:

  • Injury surveillance

  • Identifying and protecting children at risk of repeat injury

  • Providing evidence based information, advice and support to parents and carers

  • Encouraging the use and expansion of parenting interventions.

Non-clinically based:

  • Advocacy and awareness raising

  • Advising policy makers

  • Collaborating with the NHS, local authorities, voluntary organisations and relevant others

  • Promoting evidence based ethos beyond the NHS

  • Incorporating injury prevention into professional education, training, research and audit.

Clinical service development and exploitation

With a degree of imagination and initiative, paediatricians can develop and exploit existing clinical services in a way that enables them to contribute more effectively to injury prevention. Examples include:

  • Developing injury surveillance in A&E departments, in outpatient clinics and inpatient units

  • Identification of children at elevated risk of injury (eg, repeat attenders, substance misuse)

  • Encouraging the implementation or expansion of parenting interventions

  • Offering explicit evidence based advice and support to parents and carers.

Injury surveillance

Injury surveillance is the systematic ongoing collection, collation and analysis of injury data accompanied by the timely dissemination of the resultant information to those responsible for preventive action.21 There is a wide consensus in the injury prevention community that A&E based surveillance is important for local preventive practitioners including public health departments, and indeed for national policy making. Since the dissolution of the UK Home and Leisure Accident Surveillance System (HASS/LASS) in 2002, paediatricians and others have attempted to fill the void on an ad hoc basis with varying success.

Identification of children at risk

Children who suffer repeated injuries are often labelled “accident prone”, a concept that is highly problematic. Some children may be at higher risk because of poor neuromuscular co-ordination or other physiological factors, or due to a boisterous or hyperactive personality, or (more likely) through their constant exposure to a hazardous physical environment.22 The possibility must always be considered that such children are suffering from neglect or abuse. Paediatricians can deploy their unique diagnostic and therapeutic skills and experience to identify, manage and protect children at increased risk of injury.

Parenting interventions

Early intervention, in the form of multifaceted parent education and training programmes, has been shown to improve maternal psychological health, child behaviour and parenting practices. A recent Cochrane review23 of 15 studies (of which 11 were randomised controlled trials), has demonstrated that such interventions may be effective in reducing the risk and incidence of unintentional child injury. All the included studies provided the intervention to individual parents of young children and four worked with groups of parents. The mechanism of the apparent preventive effect of the interventions is unclear.

Advice and support to parents and carers

Injury prevention has been an integral part of primary care based paediatric practice in the USA for several decades. In 1983, the AAP launched The Injury Prevention Program (TIPP). This was initially aimed at pre-school children but has undergone several revisions and now covers the whole of childhood up to 12 years of age. It comprises several elements, including a safety-counselling schedule for paediatricians, age-specific safety surveys and educational materials for families. A major literature review of such counselling in primary care settings reported strong evidence of positive outcomes in the form of increased safety knowledge, improved safety behaviour and reduced injury incidence.24 Although the focus of TIPP is firmly on counselling, the AAP emphasises the wider role of the paediatrician who “should remain an active advocate to change social attitudes about childhood injuries”.25 This plea has global applicability and is independent of paediatricians’ national or local operating environments.

Advocacy

Advocacy is another important medium by which paediatricians can influence injury prevention.2628 This can take many forms including awareness-raising via clinical meetings, professional fora and the media, offering advice to policy makers during the consultation phases of white papers and other policy documents, and government lobbying. In the UK, paediatricians (notably Hugh Jackson) were instrumental in establishing the Child Accident Prevention Trust (CAPT) and have successfully advocated the use of child-resistant packaging and the building of safer home and play environments.27 29

Other opportunities for paediatricians to prevent injury

There are also numerous other opportunities for injury prevention that the alert paediatrician can explore. These include:

  • Collaboration with relevant NHS sectors (eg, public health departments) and others (eg, local authorities, the voluntary sector)

  • Promoting an evidence based ethos outside the NHS

  • Incorporating injury prevention into paediatric and other healthcare professional education, training, research and audit activities.

Role of the Royal College of Paediatrics and Child Health

The Royal College of Paediatrics and Child Health (RCPCH) has demonstrated its commitment to child safety and injury prevention over the years. A College injury prevention adviser (supported by a “virtual” committee of experts) was appointed 2003. The College has provided ad hoc responses to government policy documents, and has, wherever possible, offered support for CAPT and others in the field. All these activities will be facilitated if and when a new subspecialty of child public health is created, an idea currently being explored by a College working group.

There remain opportunities for the College to promote work and interest in injury prevention through, for example, the establishment of trauma fellowships, the creation of a database of injury prevention activities, and the undertaking of epidemiological studies by the British Paediatric Surveillance Unit.30

CONCLUSION

Injuries are a growing public health challenge. Paediatricians share a professional responsibility with others to strive to prevent them. While the evidence relating to the efficacy of some forms of paediatric clinical or counselling roles is unclear, there are numerous opportunities for making a worthwhile contribution. These include establishing injury surveillance systems, identifying and protecting children at risk, offering safety advice and information to parents and carers, promoting parenting interventions, advocacy, policy advice, collaborative working with others, promoting an evidence based ethos, education and training, research and audit, and service development. The RCPCH has a crucial and probably under-exploited role in many of these fields.

REFERENCES

Footnotes