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Am Fam Physician. 2020;102(7):411-417

Related letter: Oral and Dental Injury Prevention in Children and Adolescents

Patient information: See related handout on preventing accidental injuries in children, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

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).213

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 CExpert 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 CAmerican 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 BExpert 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 CClinical 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 BCluster 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 BCase-control studies, expert opinion, and policy recommendations
Children and family members should be counseled about the importance of consistent helmet use when bicycling.2 BSystematic review of case-control studies
Cause of injuryHigh-risk groupsPrevention strategies
BicyclingAll childrenHelmets should be worn at all times2
Bicycles should be checked regularly for brake malfunction or loose parts
DrowningAll childrenPool fences should completely enclose and isolate the pool from the home3
Swimming lessons are recommended for all children by four years of age and may be considered as early as one year of age4
All adults and caregivers should be trained in cardiopulmonary resuscitation5
Coast Guard–approved life jackets should be worn at all times while boating5
FallsInfants and toddlersChildren should be taught not to climb on objects6
Infant or toddler walkers should not be used7
Safety gates should be used, and stairs should be carpeted8
FiresChildren younger than five yearsSmoke detectors should be installed and maintained regularly9
Families should have a fire escape plan and conduct home fire drills9
Smoking should not be allowed in the home9
A fire extinguisher should be kept in the home9
GunsToddlers and teenagersGuns should be stored unloaded and in locked locations, with ammunition in a separate locked location10
Motor vehicle crashesAll childrenChildren should be restrained with age- and size-appropriate restraints and remain rear-facing until at least two years of age11
Children younger than 13 years should ride in the back seat of the vehicle11
PoisoningToddlers and teenagersPoison control or emergency services should be called for any potential ingestion or exposure12
Vomiting should not be induced (including with syrup of ipecac) if a potential ingestion is suspected12
Suffocation and strangulationInfantsInfants should sleep on their backs in a crib13
Infants should sleep on a mattress with a fitted sheet and no additional bedding or toys13
Infants should sleep in the same room as a caregiver for the first six to 12 months of life13

Motor Vehicle Crashes and Pedestrian Injuries

Motor vehicle crashes account for nearly 50% of all fatal injuries in children and adolescents.1 In the United States, an average of three children 14 years or younger are killed in traffic-related crashes each day.14 Child safety seats reduce mortality from motor vehicle crashes by 71% in infants younger than one year, 54% in children one to four years of age, and 45% in those five years and older.14 Figure 1 is an algorithm to guide implementation of child safety seat recommendations from the American Academy of Pediatrics (AAP) based on the child's age, height, and weight.11 Infants and toddlers should ride in a rear-facing seat for as long as the seat's manufacturer specifies, generally until at least 24 months of age.11 Children younger than 13 years should be properly restrained in the back seat.11 Unrestrained children are at much greater risk of death in a crash. Compliance with proper child safety restraints is reported to be 90%; however, 35% of children 12 years and younger who were killed in motor vehicle crashes in 2017 were unrestrained.14 Newborns born at or before 37 weeks' gestation should be directly observed in their car seat for 90 to 120 minutes before hospital discharge.15 The National Highway Traffic Safety Administration's website allows caregivers to register car seats so that they receive safety updates, as well as resources for safety technicians (including Spanish speakers) to evaluate for proper car seat installation (https://www.nhtsa.gov/equipment/car-seats-and-booster-seats).

Distracted driving is another significant cause of traffic-related injury. The risk of a crash or near-crash is increased in novice drivers (16 to 17 years of age) who are dialing a cell phone, sending or receiving text messages, or reaching for a phone or other object.16 Nearly 50% of teenagers report that they have texted while driving, and those who have are less likely to wear a seat belt and more likely to drink and drive or ride with a driver who has consumed alcohol.17 States with strict alcohol laws have lower rates of motor vehicle– related fatalities in children.18 The American Academy of Family Physicians (AAFP) recommends counseling teenagers about distracted driving during all preventive health care visits.19

The incidence of pedestrian injury is significantly higher in children vs. adults, and those who live in low-income urban areas are at greatest risk.20 The Safe Routes to School program allocates federal funds for improved sidewalks, signage, safe crossings, and bicycle lanes throughout the United States; one study found that this program reduced pedestrian injuries by 44% during school-travel hours in New York City.21

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