Injury is defined as "unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen" (National Committee for Injury Prevention and Control, 1989). Examples include damage caused by falls, motor-vehicle crashes (e.g., to pedestrians, cyclists, occupants), poisoning, suicide, fire, drowning, suffocation, and homicide. Many of these events were once considered "accidents," or random unavoidable events. Today, injury events, like diseases, are considered predictable, preventable, and controllable using a public health approach that includes surveillance, risk-factor identification, intervention development and implementation, and evaluation and dissemination.
EPIDEMIOLOGY OF CHILDHOOD INJURY
Injuries are the leading cause of the death of children, accounting for 48 percent of mortality in children one to fourteen years of age in the United States. In every industrialized country, injury is the leading killer of children, accounting for almost 40 percent of all deaths in this age group.
About twenty children die every day in the United States from a preventable injury: more than die from all other diseases combined. Motor-vehicle crashes result in the most deaths in every age bracket past age one (see Figure 1). One in four children annually will be injured severely enough to miss school or require medical attention or bed rest, and for every injury-related death, there are approximately 19 hospitalizations, 233 hospital emergency-department visits, and 450 physician visits.
The most serious injuries to children are traumatic brain injuries and injuries from residential fires, which are particularly lethal, disabling, disfiguring, and the most costly to treat. Traumatic brain injuries account for 39 percent of all injury-related death in those under twenty years of age, or about 5,000 deaths per year in the United States. Residential fires result in about 900 deaths to this age group each year.
Death rates are higher for unintentional injuries than for violence at every age, but violence is a growing problem among children. In 1997, homicide was the third leading cause of death for children ages five to fourteen, and children who witness violence are more likely to have social, emotional, and academic problems later in life.
Many socioeconomic and demographic factors influence childhood injury risks. Among those under age fifteen, African-American and Native-American children have injury rates that are twice
Nonfatal injuries in children under fifteen result in 25 percent of all hospital emergency-department (ED) visits. An estimated 4.6 million males and 2.9 million females under age fifteen were treated for injuries in U.S. hospital EDs in 2000. Unintentional injuries accounted for 97 percent of the visits, while violence accounted for 3 percent. Nonfatal injury rates were 33 percent higher in males than females younger than five, 41 percent higher in ages five through nine, and 68 percent higher in ages ten through fourteen. Assault and sexual assault account for the greatest number of violence-related visits. Falls; being struck by, or against, something; cycling; and bites and stings were the leading causes of unintentional injury visits to EDs.
THE COSTS OF INJURY
The cost of injury and violence in the United States is estimated at more than $224 billion per year, an increase of 42 percent between 1990 and 2000. Injury is also one of the most costly afflictions to children. Childhood injuries are estimated to cost $12 billion in medical-care expenses, representing 14 percent of all medical-care expenses for children. Emergency visits for child and adolescent injury cost an estimated $4 billion per year. Yet, it is estimated that for every dollar spent on a bike helmet, society can save between $17 and $44; a dollar spent on a child safety seat saves between $18 and $30; a dollar spent on smoke alarms saves $27; a dollar spent on pediatric counseling can save $10; and a dollar spent on poison-control telephone services can save $7.
Childhood injury prevention encompasses prevention of both violence and unintentional injury. Unintentional injury deaths to children declined about 40 percent between 1980 and 2000, and 2000 overall homicide rates were at their lowest level in three decades.
Prevention of childhood injuries has been successful due to three highly interdependent strategies: (1) education and behavior change, (2) technology and engineering, and (3) legislation and enforcement.
Education and behavior-change strategies are designed to reduce risky behaviors, provide early detection of potential harm, and eliminate exposure to environmental hazards. Efforts are usually directed to adult caregivers, parents, and the child, but can also target legislators and engineers, with the goal of improving environmental and product safety. Office-based pediatric injury counseling conducted by pediatricians or their staff and the use of behavior-modification strategies with children have demonstrated effectiveness in reducing injury risk behaviors.
Legislation and enforcement have been very effective in reducing childhood injury. Examples include legislation requiring child safety seats, child-resistant closures on medications and household cleaning agents, fire-retardant clothing, and the use of bicycle helmets. The effectiveness of these laws is related to a motivated public, informed and willing legislators, and strong enforcement programs; however, laws may not be appropriate to address all types of injuries (e.g., falls).
Technology and engineering contribute to the safety of consumer goods, residential homes, neighborhoods, playgrounds, and automobiles. Better product design and performance can prevent many injuries. For example, fire deaths associated with children playing with lighters dropped 43 percent after implementation of a standard requiring cigarette lighters to be child-resistant. Ten-year lithium-powered smoke alarms and automatic sprinkler systems could prevent most fire-related deaths. New products such as airbags, scooters, snowboards, and in-line skates have created new patterns of injuries, often stimulating the development of new protection technology (e.g., smart airbags, lightweight knee and elbow pads, wristguards).
The use of a combination of these and other health-promotion strategies can reduce injuries. It is not a matter of allegiance to one or another type of intervention, but the need for flexibility in combining strategies to arrive at the most effective mix.
Prevention strategies include installing and maintaining smoke alarms properly; correctly using child safety seats, booster seats, and safety belts; reducing hot-water temperatures; and installing four-sided fencing around residential pools. Improving the safety of toys, installing window guards and stair gates, increasing the use of bicycle helmets and sports protection devices, slowing traffic speeds in areas where children walk and play, and reducing bullying will all prevent injuries. Supervising children at play, training children to evacuate in a fire, building safe walking paths, enforcing child-protection laws, packaging medications in child-resistant containers, and reducing access to lethal weapons would also help reduce injuries in children. Some claim that implementing proven and effective environmental interventions alone could reduce childhood injury deaths by as much as one-third.
Organized community-based injury-control programs, such as those in Sweden, have demonstrated that health-promotion approaches to injury prevention can be both cost-effective and popular with the public. If the United States had injury death rates as low as Sweden's, 4,700 excess child-injury deaths a year would be prevented.
DAVID A. SLEET
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