Differential ranking of causes of fatal versus non-fatal injuries among US children.

OBJECTIVE: Leading causes of fatal and non-fatal injury among US children aged <15 years were compared. METHOD: A descriptive study was conducted using nationally representative data on injury related deaths (National Vital Statistics System) and on non-fatal injury related emergency department visits (IEDV; National Electronic Injury Surveillance System-All Injury Program). Data were accessed using a publicly available web based system. RESULTS: Annually, an estimated 7100000 pediatric IEDV and 7400 injury deaths occurred. The overall non-fatal to fatal ratio (NF:F) was 966 IEDV:1 death. Among deaths, the leading causes were motor vehicle traffic occupants (n = 1700; NF:F = 150:1), suffocations (n = 1037; NF:F = 14:1), and drownings (n = 971, NF:F = 6:1). Among non-fatal injuries, falls (estimated 2400000) and struck by/against (estimated 1800000) were the most common causes, but substantially less lethal (NF:F = 19000:1 and 15000:1, respectively). CONCLUSIONS: The leading causes of pediatric fatal and non-fatal injuries differed substantially. This study indicates the need for consideration of common causes of non-fatal injury, especially falls.

Effectiveness of a state law mandating use of bicycle helmets among children: an observational evaluation.

In spring 1999, the authors evaluated the effectiveness of a 1997 Florida law requiring helmet use by all bicyclists younger than age 16 years. Sixty-four counties in Florida had enacted the bicycle helmet-use law, while the other three counties had opted out. Using a cross-sectional study design, the authors conducted unobtrusive observations at bicycle racks at public elementary schools statewide. Florida children riding bicycles in counties where the state helmet-use law was in place were twice as likely to wear helmets as children in counties without the law. In counties where the state law was in place, 16,907 (79%) of 21,313 riders observed wore a helmet, compared with only 148 (33%) of 450 riders in counties where no such law was in place (crude prevalence ratio = 2.4, 95% confidence interval: 2.1, 2.8). Helmet use by children of all racial groups exceeded 60% under the law. No significant difference in use by gender was found. These data support the positive influence of a law on bicycle helmet use among children. The data reinforce the Healthy People 2010 objective that all 50 states adopt such a law for children in order to increase helmet use and consequently reduce brain injury.

Lawn mower-related injuries to children.

Lawn mower-related injuries to children are relatively common and can result in severe injury or death. Many amputations during childhood are caused by power mowers. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries.

Measuring community bicycle helmet use among children.

Bicycling is a popular recreational activity and a principal mode of transportation for children in the United States, yet about 300 children die and 430,000 are injured annually. Wearing a bicycle helmet is an important countermeasure, since it reduces the risk of serious brain injury by up to 85%. The Centers for Disease Control and Prevention (CDC) have funded state health departments to conduct bicycle helmet programs, and their effectiveness has been evaluated by monitoring community bicycle helmet use. Although it would appear that measuring bicycle helmet use is easy, it is actually neither simple nor straightforward. The authors describe what they have learned about assessing helmet use and what methods have been most useful. They also detail several key practical decisions that define the current CDC position regarding helmet use assessment. Although important enough in their own right, the lessons learned in the CDC's bicycle helmet evaluation may serve as a model for evaluating other injury prevention and public health programs.

Legislative and regulatory strategies to reduce childhood unintentional injuries.

Laws and regulations are among the most effective mechanisms for getting large segments of the population to adopt safety behaviors. These have been applied at both the state and federal levels for diverse injury issues. Certain legal actions are taken to prevent the occurrence of an otherwise injury-producing event, while other legal actions are designed to prevent injury once an event has occurred. At the federal level, effective laws and regulations have been directed at dangers posed by unsafe manufactured products or motor vehicle design. At the state level, effective safety laws and regulations have been directed at encouraging safety behaviors and regulating the use of motor vehicles or other forms of transportation. In this article, six legislative efforts are described to point out pros and cons of the legislative approach to promoting safety. Three such efforts are aimed at preventing injury-producing events from occurring: mandating child-resistant packaging for prescription drugs and other hazardous substances, regulating tap water temperature by presetting a safe hot-water heater temperature at the factory, and graduated licensing. Three other examples illustrate the value and complexities of laws designed to prevent injuries once an injury-producing event does occur: mandatory bicycle helmet use, sleep-wear standards, and child safety seat use. This article concludes with specific recommendations, which include assessing the value of laws and regulations, preventing the rescission of laws and regulations known to work, refining existing laws to eliminate gaps in coverage, developing regulations to adapt to changing technology, exploring new legal means to encourage safe behavior, and increasing funding for basic and applied research and community programs. Further reductions in childhood injury rates will require that leaders working in the field of injury prevention together provide the creativity to devise new safety devices and programs, incentives to persuade the public to adopt a "culture of safety" as a social norm, training and education to develop new leaders and workers, and the political will to challenge the status quo and engage the public interest.

Police enforcement as part of a comprehensive bicycle helmet program.

BACKGROUND: Bicycle-related head injuries cause >150 deaths and 45 000 nonfatal injuries among children in the United States annually. Although bicycle helmets are highly effective against head injury, only 24% of US children regularly wear one. Georgia mandated bicycle helmet use for children, effective July 1993. During that summer, 1 rural Georgia community passed an ordinance instructing police officers to impound the bicycle of any unhelmeted child. We evaluated the effect of active police enforcement of this ordinance, combined with a helmet giveaway and education program. METHODS: During April 1997, approximately 580 children in kindergarten through grade 7 received free helmets, fitting instructions, and safety education. Police then began impounding bicycles of unhelmeted children. We conducted an observational study, unobtrusively observing helmet use just before helmet distribution, several times during the next 5 months, and once 2 years later. RESULTS: Before the program began, none of 97 observed riders wore a helmet. During the next 5 months, helmet use among 358 observed children averaged 45% (range: 30%-71%), a significant increase in all race and gender groups. In contrast, adult use did not change significantly. Police impounded 167 bicycles during the study, an average of 1 per day. Two years after program initiation, 21 of 39 child riders (54%) were observed wearing a helmet. CONCLUSIONS: Without enforcement, the state and local laws did not prompt helmet use in this community, yet active police enforcement, coupled with helmet giveaways and education, was effective and lasting.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge.

All hospitals should set policies that require the discharge of every newborn in a car safety seat that is appropriate for the infant's maturity and medical condition. Discharge policies for newborns should include a parent education component, regular review of educational materials, and periodic in-service education for responsible staff. Appropriate child restraint systems should become a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Transporting children with special health care needs.

Children with special health care needs should have access to proper resources for safe transportation. This statement reviews important considerations for transporting children with special health care needs and provides current guidelines for the protection of children with specific health care needs, including those with a tracheostomy, a spica cast, challenging behaviors, or muscle tone abnormalities as well as those transported in wheelchairs.

Motor vehicle related injuries among American Indian and Alaskan Native youth, 1981-92: analysis of a national hospital discharge database.

OBJECTIVE: To describe national trends in hospitalizations for motor vehicle related injuries among children and youth (0-24 years) of the United States Indian Health Service (IHS) from 1981-92. DESIGN: Descriptive epidemiologic study of the E coded national hospital discharge database of the IHS. RESULTS: From 1981 to 1992, the age standardized annual incidence of motor vehicle related injury hospitalizations (per 100,000 population) among American Indian and Alaskan Native (AI/AN) youth decreased more than 65% from 269 to 93. Substantial declines in hospitalization rates for all age and sex groups, all IHS areas, and most injury types were seen over this time. Injuries to vehicle occupants accounted for 78% of all motor vehicle related injury hospitalizations. The annual incidence of hospitalization (per 100,000 population) ranged from 291 in the Billings (Wyoming/Montana) and Aberdeen (the Dakotas) areas to 38 in the Portland area (Pacific Northwest). CONCLUSIONS: National motor vehicle related injury hospitalization rates of AI/AN children and youth decreased significantly from 1981-92. This may be due to a reduction in the incidence of severe motor vehicle related trauma, changing patterns of medical practice, and changes in the use of services. Additional measures, such as passage and enforcement of tribal laws requiring the use of occupant restraints and stronger laws to prevent alcohol impaired driving, might further reduce the incidence of serious motor vehicle related injuries in this high risk population.

Preventing non-family child abductions: are children aware they are being followed?

Australia, the United States, and other developed countries, offer elementary school programs that heighten childrens' awareness about the possibility of abduction. To examine the effectiveness of such programs, an investigation was conducted of the proportion of elementary school children previously taught about "stranger" abduction and who detected they were being followed. Fifteen children were observed on four separate occasions during a seven-month period. Only 3% of the observations were detected by children. Several reasons are proposed for the poor detection rate, and recommendations for elementary school programs are made.

Risk factors for injuries from in-line skating and the effectiveness of safety gear.

BACKGROUND: Of the estimated 22.5 million people participating in in-line skating in the United States in 1995, about 100,000 were sufficiently injured so as to require emergency department care. We investigated the effectiveness of wrist guards, elbow pads, knee pads, and helmets in preventing skating injuries. METHODS: We used data from the 91 hospital emergency departments participating in the National Electronic Injury Surveillance System, a national probability sample of randomly selected hospitals with 24-hour emergency departments. Injured in-line skaters who sought medical attention between December 1992 and July 1993 were interviewed by telephone. We conducted a case-control study of skaters who injured their wrists, elbows, knees, or heads as compared with skaters with injuries to other parts of their bodies. RESULTS: Of 206 eligible injured subjects, 161 (78 percent) were interviewed. Wrist injuries were the most common (32 percent); 25 percent of all injuries were wrist fractures. Seven percent of injured skaters wore all the types of safety gear; 46 percent wore none. Forty-five percent wore knee pads, 33 percent wrist guards, 28 percent elbow pads, and 20 percent helmets. The odds ratio for wrist injury, adjusted for age and sex, for those who did not wear wrist guards, as compared with those who did, was 10.4 (95 percent confidence interval, 2.9 to 36.9). The odds ratio for elbow injury, adjusted for the number of lessons skaters had had and whether or not they performed trick skating, was 9.5 (95 percent confidence interval, 2.6 to 34.4) for those who did not wear elbow pads. Non-use of knee pads was associated with a nonsignificant increase in the risk of knee injury (crude odds ratio, 2.2; 95 percent confidence interval, 0.7 to 7.2). The effectiveness of helmets could not be assessed. CONCLUSIONS: Wrist guards and elbow pads are effective in protecting in-line skaters against injuries.

Effect of a state law on reported bicycle helmet ownership and use.

OBJECTIVE: To evaluate the effect of a state law on reported bicycle helmet ownership and use. DESIGN: Multistage cluster random-digit-dialing telephone survey. SETTING: Georgia, June through November 1993. PARTICIPANTS: Adults who reported the behavior of bicyclists 4 through 15 years old. INTERVENTION: State law mandating helmet use after July 1, 1993, for all bicyclists aged younger than 16 years. MAIN OUTCOME MEASURES: Bicycle helmet ownership and use. RESULTS: Reported helmet ownership increased from 39% before the law took effect to 57% afterward (+ 46%, P = .06). Reported use increased from 33% before to 52% afterward (+ 58%, P < .05). About 7% of riders changed from "never-wearing" to "always-wearing" behavior. After the law took effect, in those households in which the law was known, 69% of riders owned and 64% used a helmet. By comparison, in those households in which the law was not known, only 30% owned and 25% used a helmet (P < .01). Reported ownership and use were 93% concordant, inversely related to rider age, and directly related to household income. Multivariable analysis indicated that race was an effect modifier of reported helmet ownership and use. In black riders, knowledge of the law appeared to be highly associated with both reported helmet ownership and use but was not significant in white riders. In white riders, though age and income were significantly associated with reported helmet ownership and use. CONCLUSIONS: This law appeared important in increasing reported helmet ownership and use, particularly in black riders. Since knowledge of the law was associated with increased ownership and use, additional publicity about the law might further increase helmet use. Because most riders who owned helmets used them, give-away programs targeting areas of low ownership may also increase use.

Self-efficacy in pediatric resuscitation: implications for education and performance.

OBJECTIVE: This article examines the relevance of self-efficacy--a cognitive process indicating people's confidence in their ability to effect a given behavior--to training and performance of pediatric resuscitation. The case is made that self-efficacy is likely to influence the development of and real-time access to cognitive, affective, psychomotor, and social aspects of resuscitation proficiency. METHODS: Comprehensive literature reviews were conducted on relevant topic areas, including self-efficacy theory and empirical investigations of self-efficacy in clinical practice. Three case studies are used to illustrate the influence of self-efficacy on resuscitation practice. RESULTS: The limited empirical evidence on the role of self-efficacy in clinical practice is consistent with self-efficacy theory: clinicians are less likely to initiate and sustain behaviors for which they lack confidence. This performance-based confidence can be distinguished from both knowledge and skills necessary to perform the behavior. CONCLUSIONS: Even clinicians who are knowledgeable and skilled in resuscitation techniques may fail to apply them successfully unless they have an adequately strong belief in their capability. General guidelines for promoting self-efficacy are presented, and specific recommendations are made for enhancing resuscitation self-efficacy during resuscitation training and postresuscitation procedures.

In-line skating injuries. Epidemiology and recommendations for prevention.

In 1993 there was an estimated 12.6 million in-line skaters in the US. In-line skating is popular because of its affordability and its exercise and recreational value. The main risk factors for injury include speed, obstacles and hard surfaces. Using the National Electronic Injury Surveillance System in US hospitals, 31,000 skaters were reported injured over a 12 month period. Fractures, dislocations, sprains, strains and avulsion made up 67% of all injuries. It is recommended that skaters wear protection equipment including, helmet, wrist guards, knee-pads and elbow-pads. Although head injuries from skating appear low in numbers, helmet protection is also recommended. Further studies are required that assess risk factors for injury and environmental and behavioural aspects.

Comparison of in-line skating injuries with rollerskating and skateboarding injuries.

OBJECTIVE: To describe the estimated relative frequency, types of injuries, and demographic features of people injured while in-line skating, rollerskating, and skateboarding in the United States. DESIGN: Case series. SETTING: Emergency department visits to hospitals participating in the National Electronic Injury Surveillance System. PARTICIPANTS: All persons treated for a product-related injury involving in-line skates, rollerskates, or a skateboard between July 1, 1992, and June 30, 1993. RESULTS: Approximately 30,863 persons (95% confidence interval, 23,073 to 38,653) were treated for in-line skating injuries during the study period. For every in-line skating injury, approximately 3.3 rollerskating and 1.2 skateboarding injuries occurred (P < .0001). The median age of those injured in these three sports was 15, 12, and 13 years, respectively (P < .0001). Sixty-three percent of injured in-line skaters had a musculoskeletal injury, including 37% with a wrist injury, of which two thirds were fractures and/or dislocations. Five percent of all injured in-line skaters had head injury and 3.5% of the injured in-line skaters required hospitalization. CONCLUSIONS: In-line skating and skateboarding injuries resulted in a similar number of emergency department visits, but fewer than that for rollerskating injuries. Because wrist fractures were the most common type of injury in all three sports, wrist protection is needed. Head protection by helmets is recommended.