Injury Control

Mortality

In the United States, injuries cause 42% of deaths among 1-4 yr old children and 3.5 times more deaths than the next leading cause, congenital anomalies. For the rest of childhood and adolescence up to age 19 yr, 64% of deaths are a result of injuries, more than all other causes combined. In 2016, injuries caused 13,952 deaths (16.78 deaths per 100,000 population) among individuals ≤19 yr old in the United States, resulting in more years of potential life lost than any other cause. Unintentional injuries remained the leading cause of death among those <24 yr old in 2016 (see Table 13.1 and Fig. 13.1 ).

Motor vehicle injuries lead the list of injury deaths among school-age children and adolescents and are the 2nd leading cause of injury death for those age 1-4 yr. In children and adults, motor vehicle occupant injuries account for the majority of these deaths. During adolescence, occupant injuries are the leading cause of injury death, accounting for >50% of unintentional trauma mortality in this age-group.

Drowning ranks 2nd overall as a cause of unintentional injury deaths among those age 1-19 yr, with peaks in the preschool and later teenage years (see Chapter 91 ). In some areas of the United States, drowning is the leading cause of death from trauma for preschool-age children. The causes of drowning deaths vary with age and geographic area. In young children, bathtub and swimming pool drowning predominates, whereas in older children and adolescents, drowning occurs predominantly in natural bodies of water while the victim is swimming or boating.

Fire- and burn-related deaths account for 3% of all unintentional trauma deaths, with the highest rates among those <5 yr of age (see Chapter 92 ). Most deaths are a result of house fires and are caused by smoke inhalation or asphyxiation rather than severe burns. Children and elderly persons are at greatest risk for these deaths because of difficulty in escaping from burning buildings.

Suffocation accounts for approximately 87% of all unintentional deaths in children <1 yr old. Some cases result from choking on food items, such as hot dogs, candy, grapes, and nuts. Nonfood items that can cause choking include undersize infant pacifiers, small balls, and latex balloons. An increasing number of infant suffocation deaths represent sleep-related mortality in the presence of unsafe bedding, crib bumpers, or cosleeping with an impaired adult. In previous years these might have been classified as sudden infant death syndrome (see Chapter 402 ).

Homicide is the 3rd leading cause of injury death in children 1-4 yr old and the 3rd leading cause of injury death in adolescents (15-19 yr old) ( Fig. 13.2 ). Homicide in the pediatric age-group falls into 2 patterns: infant (child) and adolescent. Child homicide involves children <5 yr old and represents child abuse (see Chapter 16 ). The perpetrator is usually a caretaker; death is generally the result of blunt trauma to the head and/or abdomen. The adolescent pattern of homicide involves peers and acquaintances and is caused by firearms in 88% of cases. The majority of these deaths involve handguns. Children between these 2 age-groups experience homicides of both types.

Suicide is rare in children <10 yr old; only 1% of all suicides occur in children <15 yr. The suicide rate increases greatly after age 10 yr, with the result that suicide is now the 2nd leading cause of death for 15-19 yr olds. Native American teenagers are at the highest risk, followed by white males; black females have the lowest rate of suicide in this age-group. Approximately 40% of teenage suicides involve firearms (see Chapter 40 ).

There has been a sharp and substantial increase in unintentional poisoning deaths among teens and young adults. In 2016, unintentional poisonings were the 2nd leading cause of injury deaths among 15-24 yr olds. Many of these were from prescription analgesic and opioid medications such as fentanyl.

Nonfatal Injuries

Most childhood injuries do not result in death. Approximately 12% of children and adolescents receive medical care for an injury each year in hospital EDs, and at least as many are treated in physicians’ offices. Of these, 2% require inpatient care, and 55% have at least short-term temporary disability as a result of their injuries.

The distribution of nonfatal injuries is very different from that of fatal trauma ( Fig. 13.3 ). Falls are the leading cause of both ED visits and hospitalizations. Bicycle-related trauma is the most common type of sports and recreational injury, accounting for approximately 300,000 ED visits annually. Nonfatal injuries , such as anoxic encephalopathy from near-drowning, scarring and disfigurement from burns, and persistent neurologic deficits from head injury, may be associated with severe morbidity, leading to substantial changes in the quality of life for victims and their families. In 2010, nonfatal injuries to U.S. children <19 yr old resulted in >$32 billion in direct medical and lifetime work loss costs.

Global Child Injuries

Child injuries are a global public health issue, and prevention efforts are necessary in low-, middle-, and high-income countries. Between 1990 and 2010 there was a 53% decrease in mortality of people of all ages from communicable, maternal, neonatal, and nutritional disorders, while injury mortality decreased by only 16% ( Fig. 13.4 ).

Worldwide, almost 1 million children and adolescents die from injuries and violence each year, and >90% of these deaths are in low- and middle-income countries. As child mortality undergoes an epidemiologic transition because of better control of infectious diseases and malnutrition, injuries have and will increasingly become the leading cause of death for children in the developing world, as it now is in all industrialized countries. Drowning is the 5th most common cause of death for 5-9 yr old children globally, and in some countries, such as Bangladesh, it is the leading cause of death among children beyond the 1st yr of life, with a rate 22 times greater than that in the Americas. An estimated 1 billion people do not currently have immediate access to roads; as industrialization and motorization spreads, the incidence of motor vehicle crashes, injuries, and fatalities will climb. The rate of child injury death in low- and middle-income countries is 3-fold higher than that in high-income countries and reflects both a higher incidence of many types of injuries and a much higher case fatality rate in those injured because of a lack of access to emergency and surgical care. As in high-income countries, prevention of child injuries and consequent morbidity and mortality is feasible with multifaceted approaches, many of which are low cost and of proven effectiveness.