Neonatal abstinence syndrome and early childhood morbidity and mortality in Washington state: a retrospective cohort study.

OBJECTIVE: The objective of the study was to evaluate the association between neonatal abstinence syndrome (NAS) and long-term childhood morbidity and infant mortality. STUDY DESIGN: We conducted a cohort study of infants born in Washington State during 1990 to 2008 who were diagnosed with NAS (n=1900) or were unexposed (n=12,283, frequency matched by birth year). 5-year hospital readmissions and infant mortality were ascertained. RESULTS: Children with history of NAS had increased risk of readmission during the first 5 years of life relative to unexposed children; this remained statistically significant after adjustment for maternal age, maternal education, gestational age and intrapartum smoking status (readmission rates: NAS=21.3%, unexposed=12.7%, adjusted relative risk (aRR) 1.54, 95% confidence interval (CI) 1.37 to 1.73). NAS was associated with increased unadjusted infant mortality risk, but this did not persist after adjustment (aRR 1.94, 95% CI 0.99 to 3.80). CONCLUSION: The observed increased risk for childhood hospital readmission following NAS diagnosis argues for development of early childhood interventions to prevent morbidity.Journal of Perinatology advance online publication,.

Risk factors for violent death of women in the home.

OBJECTIVES: To determine risk factors for violent death of women in the home, and particularly, to assess the strength and direction of any association between domestic violence or keeping firearms and homicide or suicide in the home. METHODS: Subgroup analysis of a large population-based case-control study database was performed, defining cases as all homicides and suicides occurring in the homes of female victims in 3 metropolitan counties: Shelby County, Tennessee; King County, Washington; and Cuyahoga County, Ohio. Randomly selected control subjects were matched to the victims by neighborhood, sex, race, and age range. Exposures to potential risk factors were ascertained by interviewing a proxy for the victim 3 to 6 weeks after the violent death occurred. These answers were compared with those obtained from controls using matched-pairs methods. RESULTS: All cases (n = 266) were identified in the 3-county area, including 143 homicides and 123 suicides, during a 5-year period. Matching controls (n = 266) were also identified. Firearms were involved in 46% of the homicides and 42% of the suicides. Independent risk factors for suicide in the home included a history of mental illness (odds ratio [OR], 258.8; 95% confidence interval [CI], 18.2-3679.8), living alone (OR, 13.4; 95% CI, 2.0-87.8), and having 1 or more guns in the home (OR, 4.6; 95% CI, 1.2-17.5). Independent risk factors for homicide included living alone (OR, 5.1; 95% CI, 2.0-13.2), illicit drug use by any member of the household (OR, 4.9; 95% CI, 1.3-15.9), prior domestic violence (OR, 4.0; 95% CI, 1.5-10.5), 1 or more guns in the home (OR, 3.4; 95% CI, 1.6-7.1), and previous arrest of any member of the household (OR, 3.0; 95% CI, 1.3-6.6). The increased risk of homicide associated with domestic violence, firearms, or illicit drugs was attributable to the homicides at the hands of a spouse, intimate acquaintance, or close relative. CONCLUSIONS: Among women, mental illness and living alone increase the risk of suicide in the home, and household use of illicit drugs and prior domestic violence increase the risk of homicide. Instead of conferring protection, keeping a gun in the home is associated with increased risk of both suicide and homicide of women. Household use of illicit drugs, domestic violence, and readily available firearms place women at particularly high risk of homicide at the hands of a spouse, an intimate acquaintance, or a close relative. Many factors place women at increased risk of violent death in the home. Community- and clinic-based interventions should target those with identifiable risk factors.

Traumatic deaths of children in the United States: currently available prevention strategies.

The causes of traumatic deaths of children 14 years of age and younger in the United States are presented. Available prevention strategies to decrease injury fatalities due to various causes are described, and the number of preventable deaths is calculated. With the implementation of only 12 currently available prevention strategies, childhood deaths from trauma could be reduced by 29% in the United States. The implications of these strategies are discussed, as well as the area for which no effective countermeasures exist and which require further epidemiologic and investigative research.

Fatal and nonfatal farm injuries to children and adolescents in the United States.

Agriculture is the second most dangerous occupation in the United States, and unlike other occupations, children make up a significant portion of the work force. This study presents national data on the morbidity and mortality due to farm injuries to children and adolescents less than or equal to 19 years of age. Data sources used were 1979 to 1981 mortality statistics from the National Center for Health Statistics, farm injuries treated in emergency rooms as reported to National Electronic Injury Surveillance System (1979 to 1983), farm deaths investigated by the Consumer Product Safety Commission, and the 1980 census. Nearly 300 children and adolescents die each year from farm injuries, and 23,500 suffer non-fatal trauma. The fatality rate increases with age of the child; the rate for 15- to 19-year-old boys is double that of young children and 26-fold higher than for girls. More than half (52.5%) die without ever reaching a physician; an additional 19.1% die in transit to a hospital, and only 7.4% live long enough to receive inpatient care. The most common cause of fatal and nonfatal injury is farm machinery. Tractors accounted for one half of these machinery-related deaths, followed by farm wagons, combines, and forklifts. Overall, 10% of children with nonfatal injuries require hospitalization, and one in 30 children younger than age of 5 years with a farm injury is hospitalized or dies. The magnitude of the problem requires the evaluation of a number of preventive strategies including legislation and improvement of emergency care in rural areas.

Demographic analysis of childhood pedestrian injuries.

Factors in a child's living environment and socioeconomic background that contribute to the risk of pedestrian injury were studied. In 1982, in the city of Memphis, there were 210 pedestrian injuries among children aged 0 to 14 years, a rate of 138/100,000 children. The injured child was most often male, with mean age of 7.3 years; the child was usually struck while crossing the street between intersections, most commonly during the hours from 2 to 7 PM. Pedestrian injuries occurred in 81 of the 142 census tracts in the city. Compared with census tracts without reported injuries, these tracts had twice the percentage of nonwhite population, lower household incomes, more children living in female-headed households, more families living below the poverty level, and greater household crowding (all differences significant at P less than .01). The single variable of crowded housing per acre best predicted the number of injuries per acre in multiple regression analysis. A group of children who are at high risk of pedestrian injury through increased exposure in the environment was identified. As with many other types of injuries, modification of external factors--in this case, traffic engineering modifications--seems to be the most practical solution.

Sweden's experience in reducing childhood injuries.

Why does Sweden have the lowest childhood injury rate of any country in the world? The answer lies in a combination of factors including the special characteristics of Swedish society and an energetic 35-year campaign. Contributing societal characteristics are a small, relatively homogeneous, health conscious, law-abiding population that values children. Key factors in the campaign have been support of trauma surveillance systems and injury prevention research, ensuring safer environments and products through legislation and regulation, and a broad-based safety education campaign using coalitions of existing groups. Emulating the strategies used in the Swedish campaign would markedly reduce the number of US children killed, injured, and disabled from trauma.

Schools and sex education: does it work?

The literature was critically reviewed to determine whether evidence exists to support sex education in the schools as a method of altering sexual behavior, contraception, and adolescent pregnancy. Five studies were identified in which the effects of sex education on these outcomes were evaluated. The available evidence indicates that there is little or no effect from school-based sex education on sexual activity, contraception, or teenage pregnancy.

Parents in jail.

OBJECTIVE: To determine the number of children in the United States with parents incarcerated in jail and to describe the characteristics of these parents and their criminal histories. SETTING: Inmates of local jails accounting for 36.5% of the incarcerated population of the US in 1989. PARTICIPANTS: Personal interviews with 5675 inmates randomly selected from 393,553 inmates of 3312 local jails in 1989. RESULTS: 44,263 (36%) inmates had children younger than the age of 15. Fathers outnumbered mothers 10-fold; the majority were in their 20s or 30s, unmarried, and poorly educated. The vast majority of parents had a record of prior offenses, and substance abuse accounted for one third of the incarcerations. Substance abuse was reported by 84% of inmates and 95% had sought prior treatment for alcohol, drug, or other mental health problems. CONCLUSIONS: Nearly 1 of 50 children in the US has a parent in jail. Parental imprisonment is not rare, is often chronic, and is strongly associated with other psychosocial and health problems in the family. Screening for parental imprisonment potentially should be included as part of a comprehensive biopsychosocial assessment.

Prevention of traumatic deaths to children in the United States: how far have we come and where do we need to go?

OBJECTIVE: To describe the changes in injury mortality from 1978 to 1991 and determine the number of preventable deaths with currently available intervention strategies. METHODS: Comparison of injury mortality data for children and adolescents 0 to 19 years in 1978 and 1991. Review of the literature to determine the effectiveness of currently available prevention strategies and application of these to deaths in 1991. RESULTS: The injury death rate declined by 26% over the 14-year period. Death rates of unintentional injuries decreased by 39%, with declines in all categories of unintentional injuries. Homicides increased by 67% and suicides by 17%; nearly all of this increase was in deaths from firearms. If currently available prevention strategies were fully used, 6640 deaths could have been prevented, a further 31% decrease. CONCLUSIONS: Although great studies have been made in preventing deaths from trauma, the application of currently available prevention strategies could save a large number of additional lives. However, the increasing problem of intentional injury will partly counterbalance the success in unintentional injury control.

Injuries to children younger than 1 year of age.

The circumstances and characteristics of emergency room-treated injuries in children younger than 1 year of age were studied and unintentional injuries were compared with those caused by abuse. Unintentional injuries were seen 15 times more frequently in an emergency room than injuries caused by abuse. The majority of unintentional injuries were minor, although skull fractures and fractures of the clavicle did occur. In contrast, injuries caused by abuse were commonly multiple and severe and were more likely to result in long-term disability. Results of this study indicate that unintentional injuries are rarely serious and that closed head injury, rib or lower extremity fractures, and abdominal injuries are usually indicative of abuse.

Injuries from fireworks.

In 1983, there were more than 8,200 victims of fireworks-related injuries treated in US emergency rooms. Half of those injured were children less than 15 years of age, and 11% of the injuries resulted in hospitalization. The eyes are the body part most often injured, followed by hands and fingers. Burns account for the majority of injuries. Every type of fireworks legally available has resulted in serious injury or death. Firecrackers, bottle rockets, and sparklers contribute to the most hospitalizations. States that allow a wide variety of fireworks to be sold for personal use have a rate of fireworks-related fires 50 times greater than states that strictly limit the availability of fireworks. The rate of fireworks-related injuries is more than seven times greater in the less restrictive states.

Children in car crashes: analysis of data for injury and use of restraints.

OBJECTIVE: To determine the effect of car restraints on motor vehicle injury rates for children aged 0 to 14 years. METHODS: A probability sample of all police-reported car crashes in the United States in 1990 and 1991 was analyzed for injury rates of passengers aged less than 15 years in relation to restraint usage, age, and seating position. RESULTS: Optimal restraint usage (defined as car seats for children 0 to 4 years old and lap shoulder belts for children 5 to 14 years old) was 40%. The use of the car seat was 76% for infants (0 to 12 months old) and 41% for toddlers (1 to 4 year olds). The non use of a restraint was highest for 10 to 14 year olds (43%). The rate of involvement in car crashes for all children was 21.4 (per 1000/yr). The highest rate was the 14 year olds with 29.6 followed by 2 year olds with 26.5. Injury rates were 4.76 (per 1000/yr) for all children. The lowest rate was 2.91 for infants but increased to 4.78 for 3 year olds. The single strongest risk factor for injury was the non use of a restraint. (Adjusted odds ratio 2.7; 95% CI 2.4 to 3.0.) The risk factor for injury for the front seat was 1.5 (95% CI 1.4 to 1.7). Use of the car seat reduced injuries by 60% for 0 to 4 year olds, whereas the lap shoulder harness was only 38% effective for 5 to 14 year olds (P < or = .001) Injury rates of unrestrained 0 to 4 and 5 to 14 year olds were similar. CONCLUSIONS: Greater involvement in car crashes and less use of car restraints explains the 64% higher rate of injury for 3 year olds than for infants. It is time to target the toddlers. Restraints designed for adults are not as effective for the school age child as car seats are for the preschool child. A better restraint for the school age child should be designed and evaluated. Meanwhile, increased usage of current restraints must be encouraged, as they substantially reduce injuries.

Parental attitudes and practices toward children as pedestrians.

Community programs to reduce the toll from pedestrian injuries in childhood must include parents as a key element. This study, consisting of a survey questionnaire, was undertaken to provide information concerning current parent attitudes and practices that could be used to guide prevention programs. The survey consisted of 2464 questionnaires from parents of children in grades kindergarten to four in a suburban school district. Although 94% of parents did not believe that 5- to 6-year-old children can reliably cross streets alone, one third of parents allowed kindergarten-aged children to cross residential streets alone and first-grade children to walk alone to school. The presence of speeding traffic or the lack of safe places to walk did not influence parents in limiting their children's crossings. Few (17%) parents believed that children should be taught not to cross alone; one half of parents, including 41% of parents of kindergarten-aged children believed that children should be taught to cross busy streets without traffic lights. According to results of the study, parent expectations for their children's pedestrian skills may be inappropriate and may be a fruitful target for injury-prevention programs.

A study of low socioeconomic status, black teenage fathers and their nonfather peers.

Demographic background, attitude and knowledge about pregnancy and contraception, and family characteristics and dynamics of 100 teenage fathers were studied and compared with those of 100 nonfather, age-matched peers. The subjects' age ranged from 14 to 19 years with a mean age of 17.5 years. Nearly all subjects were black and were from families of low socioeconomic status. There were no differences between the two groups for age at first sexual intercourse (mean 12.5 years) and frequency of intercourse in the last year. More control subjects than fathers perceived pregnancy as disruptive of their future plans for school, job, and marriage. Teenage fathers were more likely to have mothers who were teenage parents (77% v 53%, P = .0007). In both groups, one third of their brothers and 44% of their sisters were teenage parents. Both groups had poor knowledge about the risk of pregnancy and the effectiveness of contraceptives. In both groups, negative attitudes about contraceptives represent barriers to their use. Both groups of subjects became sexually active at young ages, had poor knowledge about pregnancy prevention, and often had unprotected intercourse. Although there were many similarities between the two groups, the teenage fathers, in particular, seemed to come from an environment in which teenage pregnancy was common, accepted, and perceived to be minimally disruptive of their lives now or in the future.

Extremity injuries in children: predictive value of clinical findings.

This study sought to identify clinical predictors of extremity fracture in children with trauma. There were 189 children 1 to 15 years of age with 209 extremity injuries seen during a 9-month period. Gross deformity and point tenderness were the best predictors of upper extremity fracture; these two findings correctly identified 81% of children with fractures and 82% of these without fractures. Gross deformity and pain on motion best predicted lower extremity fracture, with 97% of children with fractures correctly identified. The study showed that physical examination is predictive of fractures in extremity injuries of children, regardless of age. In the absence of the specific physical findings identified by the study, the probability of diagnosing a fracture by roentgenographic findings is low.

Injuries to children and adolescents: impact on physical health.

Disability resulting from injuries was examined in a health maintenance organization population of children and adolescents 0 through 19 years of age. The physical health status instrument from the Rand Health Insurance Study was used to evaluate functional outcome of patients seen in the emergency room and outpatient clinic. Overall, 55.1% of individuals had limitations in their usual activities during the week following injury; 16.4% and 3.8% were not yet back to full activities after 1 week and 1 month, respectively. Individuals 10 years of age and older had more functional impairment than did younger children. Restrictions were greatest for fractures/dislocations and sprains and for injuries due to sports, play/recreational activities, and falls.

Physician experience with pediatric inpatient care in Washington State.

OBJECTIVE: To determine the frequency with which pediatricians and family physicians in Washington State serve as attending physicians for pediatric inpatients. DESIGN: Retrospective review of statewide hospital discharge data. SUBJECTS: Attending physicians for all patients younger than 18 years of age with nonsurgical diagnoses discharged from civilian hospitals in Washington State during 1989 and 1990. RESULTS: Using medical rosters, the self-identified specialty of the attending physician was determined for 93% (n = 181,581) of discharges. Pediatricians and family physicians were listed as attending for 61% and 28%, respectively, of all eligible patients. Statewide, 97% (n = 555) of all pediatricians and 86% (n = 939) of all family physicians served as attending physicians for at least one inpatient, including healthy newborns, during the 2-year study period. The median annual number of discharges per physician was 78 for pediatricians and 14.5 for family physicians. Excluding healthy newborns, the median annual number of discharges was 25 for pediatricians and 3 for family physicians. Five percent of the physician attending group provided inpatient care for 50% of all children hospitalized with diagnoses other than healthy newborn; 50% of attending physicians cared for 95% of the patients. In rural hospitals, where family physicians served as attending physicians for 44% of pediatric inpatients, children were 3.3 times more likely to receive their care from family physicians than those hospitalized in urban centers. CONCLUSIONS: Most pediatricians and family physicians serve as inpatient attending physicians for hospitalized children only infrequently. These findings question whether the emphasis on inpatient care in many pediatric and family medicine training programs remains an appropriate goal.

Risk of injury to children less than 5 years of age in day care versus home care settings.

Recent studies have suggested that day care may be a relatively unsafe environment. In this population-based study, the incidence of injuries in day care and home care were evaluated based on the number of hours children were exposed to each environment. In this population, 43.6% of children less than 5 years of age spent part of the year in day care. The rate of injuries in day care was 2.50 per 100,000 child-hours of exposure compared with a rate of 4.88 per 100,000 child-hours of exposure in the home environment. There were no differences in overall severity of injuries in the two groups. It was concluded that children are at no greater risk of injury in day-care settings than in the home environment.

Population-based study of fall injuries in children and adolescents resulting in hospitalization or death.

OBJECTIVE: To determine the incidence and characteristics of fall-related injuries to children and adolescents. DESIGN: Population-based study. SETTING: All hospital discharges in Washington State for fall-related injuries in 1989 and 1990. POPULATION: Children and adolescents 19 years and younger. RESULTS: Falls accounted for nearly one third of all trauma admissions, and fall patients tended to be younger than those with other injuries. Falls from one level to another accounted for 40% of the total. One fourth of all patients and 42% of preschoolers sustained head injury. The annual cost of these injuries in Washington State was $4.5 million.

Behavior and parental expectations of child pedestrians.

Pedestrian injuries remain the most common cause of death from trauma for young school-age children. This study was based on the hypothesis that parents' abilities to accurately assess their children's street-crossing skills vary with the crossing test and age of the children, being less accurate for younger children. Children at three developmental levels (aged 5 through 6, 7 through 8, and 9 through 10 years) and their parents were evaluated on four street-crossing tests and a control vocabulary test. For each test, children's answers were compared to parents' estimates of their children's performance. Parents overestimated the abilities of their 5-through 6-year-olds on all four tests (P less than .01). Parents overestimated the abilities of 7- through 8-year-olds on two of the tests (P less than .05) and parents accurately assessed the abilities of the 9- through 10-year-olds. On the vocabulary test, parents overestimated their children's performance at all age levels (P less than .01). The results support the hypothesis and indicate that parents' expectations for their children's pedestrian skills are least accurate for 5- and 6-year-olds, with the mismatch decreasing as children get older. Inaccurate expectations of children's pedestrian skills may be fruitful target for injury prevention programs.