Prevention of Unintentional Childhood Injury


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).213

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Clinical recommendationEvidence ratingComments

All children younger than 13 years should be properly restrained in the back seat of motor vehicles. Children should sit in rear-facing seats until at least two years of age.11


Expert opinion based on laboratory biomechanical testing

Infants should be placed on their backs in a crib in the same room as a caregiver for the first six to 12 months of life, without any soft bedding or toys.13


American Academy of Pediatrics recommendations based on good-quality patient-oriented evidence

All children should have swimming lessons by four years of age, starting as early as one year. Fencing should completely enclose pools and separate them from the house and yard.3,4


Expert opinion and case-control studies with systematic review of observational data in the absence of data from clinical trials

Caregivers should be counseled to contact poison control or emergency services immediately after a potential poisoning. Inducing vomiting with or without ipecac is not recommended.12


Clinical review article and expert opinion

Parents should be encouraged to maintain functional smoke detectors and to educate children about what to do in the event of a fire.9


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

Children and family members should be counseled about the importance of consistent helmet use when bicycling.2


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


The Authors

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KATHARINE CLAIRE DeGEORGE, MD, MS, is an associate professor of family medicine, associate director of the Family Medicine Residency Program, and associate director of the Faculty Development Fellowship at the University of Virginia Department of Family Medicine, Charlottesville....

CAITLYN EASTERLING NELTNER, MD, is a third-year resident at the University of Virginia Department of Pediatrics.

BENJAMIN THOMAS NELTNER, MD, is a third-year resident at the University of Virginia Department of Family Medicine.

Address correspondence to Katharine Claire DeGeorge, MD, MS, University of Virginia School of Medicine, P.O. Box 800729, Charlottesville, VA 22908 (email: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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