Prevention of Unintentional Childhood Injury
Am Fam Physician. 2020 Oct 1;102(7):411-417.
Patient information: See related handout on preventing accidental injuries in children, written by the authors of this article.
Author disclosure: No relevant financial affiliations.
Unintentional injury accounts for one-third of deaths in children and adolescents each year, primarily from motor vehicle crashes. Children younger than 13 years should be restrained in the back seat, and infants and toddlers should remain rear-facing until at least two years of age. Infants should be positioned on their backs in a crib, on a mattress with only a fitted sheet to avoid suffocation, and all items that could potentially entrap or entangle the child should be removed from the sleep environment. Fencing that isolates swimming pools from the house is effective in preventing drownings. Swimming lessons are recommended for all children by four years of age. Inducing vomiting after toxic ingestions is not recommended. Installing and maintaining smoke detectors, having a home escape plan, and teaching children how to respond during a fire are effective strategies for preventing fire-related injuries or death. The most effective way to prevent gun-related injuries in children and adolescents is the absence of guns from homes and communities. Family physicians should counsel patients with guns in the home to keep them locked, unloaded, and with ammunition stored in a separate locked location. Fall injuries can be reduced by avoiding walkers for infants and toddlers. Consistent helmet use while bicycling reduces head and brain injuries. Although direct counseling by physicians seems to improve some parental safety behaviors, its effect on reducing childhood injuries is unclear. Community-based interventions can be effective in high-risk populations.
Unintentional injury is the leading cause of death in children and adolescents one to 19 years of age, accounting for about one-third of deaths in this population each year.1 Motor vehicle crashes are the most common cause of fatal injuries, followed by drowning and poisoning. Unintentional injury is the fifth leading cause of death in children younger than one year; 85% of these deaths are due to suffocation.1 Boys are nearly twice as likely as girls to have fatal injuries,1 and there are also significant racial disparities. In 2017, Black and American Indian/Alaska Native children were 1.7 and 1.4 times, respectively, more likely than White children to die from unintentional injury, whereas Asian/Pacific Islander children were about half as likely as White children to have a fatal unintentional injury.1 Nonfatal injuries account for significant morbidity among children, with falls being the most common, followed by contact injuries (i.e., being struck by or against an object).1 Physicians have a pivotal role in preventing unintentional injuries in children. There are many evidence-based strategies that, when implemented, are proven to reduce morbidity and mortality from injuries (Table 1).2–13
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Expert opinion based on laboratory biomechanical testing
American Academy of Pediatrics recommendations based on good-quality patient-oriented evidence
Expert opinion and case-control studies with systematic review of observational data in the absence of data from clinical trials
Clinical review article and expert opinion
Cluster randomized controlled trial
Guns should not be kept in the home. If there are guns in the home, they should be stored locked and unloaded, with ammunition stored in a separate locked location. Physicians should consider contacting legislators if local gun laws are not in the best interest of children's safety.10,37,41
Case-control studies, expert opinion, and policy recommendations
Systematic review of case-control studies
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMME
Referencesshow all references
1. Centers for Disease Control and Prevention. Injury prevention and control: WISQARS injury statistics. October 25, 2019. Accessed December 4, 2019. https://www.cdc.gov/injury/wisqars/facts.html...
2. Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 2000;(2):CD001855.
3. Thompson DC, Rivara FP. Pool fencing for preventing drowning in children. Cochrane Database Syst Rev. 2000;(2):CD001047.
4. Denny SA, Quan L, Gilchrist J, et al.; Council on Injury, Violence, and Poison Prevention. Prevention of drowning. Pediatrics. 2019;143(5):e20190850.
5. American Academy of Family Physicians. Residential pool safety. Updated 2019. Accessed December 26, 2019. https://www.aafp.org/about/policies/all/residential-pool.html
6. Kendrick D, Maula A, Reading R, et al. Risk and protective factors for falls from furniture in young children: multicenter case-control study. JAMA Pediatr. 2015;169(2):145–153.
7. Khambalia A, Joshi P, Brussoni M, et al. Risk factors for unintentional injuries due to falls in children aged 0–6 years: a systematic review. Inj Prev. 2006;12(6):378–381.
8. Kendrick D, Zou K, Ablewhite J, et al. Risk and protective factors for falls on stairs in young children: multicentre case-control study. Arch Dis Child. 2016;101(10):909–916.
9. American Academy of Pediatrics. Fire safety: planning saves lives. Updated November 2, 2009. Accessed December 26, 2019. https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Fire-Safety-Planning-Saves-Lives.aspx
10. Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA. 2005;293(6):707–714.
11. Durbin DR, Hoffman BD; Council on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2018;142(5):e20182460.
12. McGregor T, Parkar M, Rao S. Evaluation and management of common childhood poisonings. Am Fam Physician. 2009;79(5):397–403. Accessed December 26, 2019. https://www.aafp.org/afp/2009/0301/p397.html
13. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162938.
14. National Highway Traffic Safety Administration. Traffic safety facts: 2017 data. May 2019. Accessed December 29, 2019. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812719
15. Bull MJ, Engle WA; Committee on Injury, Violence, and Poison Prevention; Committee on Fetus and Newborn; American Academy of Pediatrics. Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics. 2009;123(5):1424–1429.
16. Klauer SG, Guo F, Simons-Morton BG, et al. Distracted driving and risk of road crashes among novice and experienced drivers. N Engl J Med. 2014;370(1):54–59.
17. Olsen EO, Shults RA, Eaton DK. Texting while driving and other risky motor vehicle behaviors among US high school students. Pediatrics. 2013;131(6):e1708–e1715.
18. Hadland SE, Xuan Z, Sarda V, et al. Alcohol policies and alcohol-related motor vehicle crash fatalities among young people in the US. Pediatrics. 2017;139(3):e20163037.
19. American Academy of Family Physicians. Distracted driving. Updated 2018. Accessed December 29, 2019. https://www.aafp.org/about/policies/all/driver-distraction.html
20. Koopmans JM, Friedman L, Kwon S, et al. Urban crash-related child pedestrian injury incidence and characteristics associated with injury severity. Accid Anal Prev. 2015;77:127–136.
21. Dimaggio C, Li G. Effectiveness of a Safe Routes to School program in preventing school-aged pedestrian injury. Pediatrics. 2013;131(2):290–296.
22. Gao Y, Schwebel DC, Hu G. Infant mortality due to unintentional suffocation among infants younger than 1 year in the United States, 1999–2015. JAMA Pediatr. 2018;172(4):388–390.
23. Shapiro-Mendoza CK, Camperlengo L, Ludvigsen R, et al. Classification system for the Sudden Unexpected Infant Death Case Registry and its application. Pediatrics. 2014;134(1):e210–e219.
24. Erck Lambert AB, Parks SE, Cottengim C, et al. Sleep-related infant suffocation deaths attributable to soft bedding, overlay, and wedging. Pediatrics. 2019;143(5):e20183408.
25. Bombard JM, Kortsmit K, Warner L, et al. Vital signs: trends and disparities in infant safe sleep practices – United States, 2009–2015. MMWR Morb Mortal Wkly Rep. 2018;67(1):39–46.
26. Irwin CC, Irwin RL, Ryan TD, et al. Urban minority youth swimming (in) ability in the United States and associated demographic characteristics: toward a drowning prevention plan. Inj Prev. 2009;15(4):234–239.
27. Banks TL. Still drowning in segregation: limits of law in post–civil rights America. Law Inequality. 2014;32(2):215–255.
28. Tobin JM, Ramos WD, Pu Y, et al. Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation. 2017;115:39–43.
29. Gummin DD, Mowry JB, Spyker DA, et al. 2018 annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 36th annual report [published correction appears in Clin Toxicol (Phila). 2019;57(12):e1]. Clin Toxicol (Phila). 2019;57(12):1220–1413.
30. Lovegrove MC, Mathew J, Hampp C, et al. Emergency hospitalizations for unsupervised prescription medication ingestions by young children. Pediatrics. 2014;134(4):e1009–e1016.
31. American Association of Poison Control Centers. E-cigarettes and liquid nicotine. Accessed December 26, 2019. https://www.aapcc.org/track/ecigarettes-liquid-nicotine
32. Vigil DI, Van Dyke M, Hall KE, et al. Marijuana use and related health care encounters in Colorado before and after retail legalization. Int J Ment Health Addict. 2018;16(4):806–812.
33. U.S. Fire Administration. U.S. fire statistics. Accessed January 1, 2020. https://www.usfa.fema.gov/data/statistics
34. Runyan CW, Bangdiwala SI, Linzer MA, et al. Risk factors for fatal residential fires. N Engl J Med. 1992;327(12):859–863.
35. Clare J, Garis L, Plecas D, et al. Reduced frequency and severity of residential fires following delivery of fire prevention education by on-duty fire fighters: cluster randomized controlled study. J Safety Res. 2012;43(2):123–128.
36. Leventhal JM, Gaither JR, Sege R. Hospitalizations due to firearm injuries in children and adolescents. Pediatrics. 2014;133(2):219–225.
37. Dowd MD, Sege RD; Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416–e1423.
38. American Academy of Family Physicians. Gun violence, prevention of (position paper). 2008. Accessed July 4, 2020. https://www.aafp.org/about/policies/all/gun-violence.html
39. Santaella-Tenorio J, Cerdá M, Villaveces A, et al. What do we know about the association between firearm legislation and firearm-related injuries? [published correction appears in Epidemiol Rev. 2017;39(1):171–172]. Epidemiol Rev. 2016;38(1):140–157.
40. Morral AR, Ramchand R, Smart R, et al.; RAND Corporation. The science of gun policy: a critical synthesis of research evidence on the effects of gun policies in the United States. 2018. Accessed July 4, 2020. https://www.rand.org/pubs/research_reports/RR2088.html
41. Sexton SM, Lin KW, Weiss BD, et al. Preventing gun violence: the role of family physicians [editorial]. Am Fam Physician. 2018;98(9):560–568. Accessed December 26, 2019. https://www.aafp.org/afp/2018/1101/p560.html
42. Starr S. Window fall injuries common among young children. AAP News. 2013;34(8):25.
43. Embree TE, Romanow NTR, Djerboua MS, et al. Risk factors for bicycling injuries in children and adolescents: a systematic review. Pediatrics. 2016;138(5):e20160282.
44. Karkhaneh M, Rowe BH, Saunders LD, et al. Trends in head injuries associated with mandatory bicycle helmet legislation targeting children and adolescents. Accid Anal Prev. 2013;59:206–212.
45. Tuckel PS, Milczarski W, Silverman DG. Changing incidence and nature of injuries caused by falls from skateboards in the United States. Clin Pediatr (Phila). 2019;58(4):417–427.
46. Aizpuru M, Farley KX, Rojas JC, et al. Motorized scooter injuries in the era of scooter-shares: a review of the National Electronic Surveillance System. Am J Emerg Med. 2019;37(6):1133–1138.
47. American Academy of Family Physicians. Helmet laws. Updated 2019. Accessed April 20, 2020. https://www.aafp.org/about/policies/all/helmet-laws.html
48. Hammig B, Jozkowski K. Prevention counseling among pediatric patients presenting with unintentional injuries to physicians' offices in the United States. Prev Med. 2015;74:9–13.
49. Zonfrillo MR, Gittelman MA, Quinlan KP, et al. Outcomes after injury prevention counselling in a paediatric office setting: a 25-year review. BMJ Paediatr Open. 2018;2(1):e000300.
50. Kendrick D, Mulvaney CA, Ye L, et al. Parenting interventions for the prevention of unintentional injuries in childhood. Cochrane Database Syst Rev. 2013;(3):CD006020.
51. Shields WC, McDonald EM, McKenzie L, et al. Using the pediatric emergency department to deliver tailored safety messages: results of a randomized controlled trial. Pediatr Emerg Care. 2013;29(5):628–634.
52. Theurer WM, Bhavsar AK. Prevention of unintentional childhood injury. Am Fam Physician. 2013;87(7):502–509. Accessed July 4, 2020. https://www.aafp.org/afp/2013/0401/p502.html
53. Schnitzer PG. Prevention of unintentional childhood injuries. Am Fam Physician. 2006;74(11):1864–1869. Accessed July 4, 2020. https://www.aafp.org/afp/2006/1201/p1864.html
Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions