Where children drown, United States, 1995.

CONTEXT: Drowning is the second leading cause of unintentional injury death among children ages 1 to 19 years. Details about the specific site of submersion are important for implementation of primary prevention efforts, but are not routinely available from national data. OBJECTIVES: To provide national data about the specific sites of drowning among US children and to examine site-specific drowning rates by age, race, and gender. SETTING: United States, 1995. DESIGN: Information was abstracted from death certificates for unintentional drownings among children <20 years of age. The site of drowning was coded from free text on death certificates. Proportional distributions of the site of drowning by age, region, gender, and race were examined. Site-specific drowning rates were calculated by age, race, and gender. Denominators were based on US Census Bureau, June 1995 estimates of the US population. RESULTS: For 1995, death certificates were obtained for 1420 unintentional drownings among children <20 years of age, 98% of the number of drowning deaths reported by the National Center for Health Statistics for the same year. Site of drowning was specified on 1308 (92%) death certificates. Fifty-five percent of infant drownings were in bathtubs. Among children between the ages of 1 to 4 years, 56% of drownings were in artificial pools and 26% were in other bodies of freshwater. Among older children, 63% of drownings were in natural bodies of freshwater. Site-specific drowning rates varied by race. Importantly, after the age of 5 years, the risk of drowning in a swimming pool was greater among black males compared with white males with rate ratios of 15.1 (95% confidence interval: 6.7-38.5) among 10- to 14-year-olds and 12.8 (95% confidence interval: 6.5-26.9) among 15- to 19-year-olds. CONCLUSION: The variety of sites in which children drown, even within specific age groups, emphasizes the need for a multifaceted approach to prevention. Reductions in the relatively high rates of drowning among black adolescent males will require targeted interventions to prevent swimming pool drownings among this group.

Birth weight for gestational age of Mexican American infants born in the United States.

OBJECTIVE: To develop a reference for birth weight for gestational age to identify Mexican American infants born in the United States who are small or large for gestational age. METHODS: Reference percentiles were developed for Mexican American and non-Hispanic white births, using national vital statistics from 1992-1994 for Mexican Americans (n = 1,197,916) and 1994 for non-Hispanic whites (n = 2,238,457). Birth weights and gestation from the last menstrual period were taken from birth certificates. Smoothed curves were fit, using unweighted fourth-degree polynomial equations, for the tenth, 50th, and 90th percentiles by gender and parity. RESULTS: Mexican American infants were heavier than non-Hispanic white infants between 30 and 37 weeks' gestation for all parities and both genders. However, at term there was consistent crossover. Non-Hispanic white infants were heavier at or after 37 through 42 weeks' gestation, whereas the growth of Mexican American infants appeared to slow. Beginning at 37 weeks, the differences in weights of infants of primiparas increased to more than 100 g by 40 weeks; the differences were only slightly less for infants of multiparas. CONCLUSION: Given differences in distribution of birth weights for gestational age between Mexican Americans and non-Hispanic whites, the ability to recognize fetal growth restriction (FGR) or excessive growth is questionable. These data provide a reference for Mexican Americans for clinical use and for future studies in identifying infants at risk for FGR or overgrowth.

Deaths attributable to injuries in infants, United States, 1983-1991.

OBJECTIVE: To describe risk factors for injury death among infants in the United States by the specific external cause of death. METHODS: Data were analyzed from the US-linked birth/infant death files for the years 1983-1991. Potential risk factors for injury death were identified from birth certificate data and included both maternal and infant factors. Injury rates were calculated by external cause of death. Characteristics of infants who died from an injury were compared with those of the entire birth cohort. The independent effect of potential risk factors was assessed in multivariate analyses using a case-control study design. RESULTS: A total of 10 370 injury deaths were identified over the 9-year study period (29. 72/100 000 live births). The leading causes of death were homicide, suffocation, motor vehicle crashes, and choking (inhalation of food or objects). There was no significant temporal trend in the overall rate of injury death; however, this was because significant increases in the rates of death from homicide (6.4%/year) and mechanical suffocation (3.7%/year) were offset by decreases in rates of death from fires (-4.7%/year) and choking (-4.6%/year). In adjusted analyses, infants born to mothers with no prenatal care, <12 years of education, two or more previous live births, Native American race, or <20 years of age were at twice the risk of injury death compared with the lowest risk groups (initiation of prenatal care in the first trimester, >/=16 years of education, no previous live births, white, or >/=25 years of age). When analyzed by the specific cause of death, the factors that were associated most strongly with death varied. For example, Native Americans were at greatest risk of a motor vehicle related death (compared with whites: OR: 3.6; 95% CI: 1.8-7.1), and infants with birth weights of <1500 g were at greatest risk of death attributable to inhalation of food (compared with >/=2500 g: OR: 9.6; 95% CI: 3.3-28.0) or objects (OR: 11.8; 95% CI: 4.5-30.5). CONCLUSION: A number of sociodemographic characteristics are associated with an increased risk of injury-related death in infants. The strength of associations between specific risk factors and death varies with the external cause of death, thus identifying high-risk subgroups for targeting of cause-specific interventions and simultaneously increasing our understanding of the individual and societal mechanisms underlying these tragedies.

Infant injury deaths with unknown intent: what else do we know?

OBJECTIVES: Strong evidence based on case record reviews indicates that the incidence of child homicide reported from death certificates is under ascertained. The characteristics of infant injury fatalities with undetermined, but suspicious, intent were compared for the probability that they should be considered homicides. METHODS: Using linked birth and death certificates for all birth cohorts in the US from 1983-91, 2345 injury fatalities reported as intentional, 7594 as unintentional, and 431 as undetermined intent were identified. Maternal and infant variables potentially predictive of injury fatalities were selected based on increased bivariate associations. Relative risks of injury death by intentional, unintentional, and undetermined intent were assessed for maternal and infant characteristics. RESULTS: Relative risks were consistently higher across all intent categories for infants of mothers with the least education, no prenatal care, young maternal age, and single marital status, as well as for infants who are second or later born, preterm, black, or American Indian. Fatalities with undetermined intent have larger relative risks in the highest risk categories than either intentional or unintentional injuries. Deaths with undetermined intent have risk profiles that more closely resemble profiles for intentional deaths than unintentional. CONCLUSIONS: Injury homicide rates would be almost 20% greater than official classifications indicate if deaths with undetermined intent were included. In analyses of infant homicide, excluding deaths of undetermined intent may lead to an underestimation of the magnitude of the public health problem of intentional injuries among infants. Other studies based on record reviews from multiple sources indicate that misclassification and under ascertainment of homicides may be even greater.

Risk factors for infant homicide in the United States.

BACKGROUND: Homicide is the leading cause of infant deaths due to injury. More than 80 percent of infant homicides are considered to be fatal child abuse. This study assessed the timing of deaths and risk factors for infant homicide. METHODS: Using linked birth and death certificates for all births in the U.S. between 1983 and 1991, we identified 2776 homicides occurring during the first year of life. Birth-certificate variables were reviewed in both bivariate and multivariate stratified analyses. Variables potentially predictive of homicide were selected on the basis of increased relative risks among subcategories with adequate numbers for stable estimates. RESULTS: Half the homicides occurred by the fourth month of life. The most important risk factors were a second or subsequent infant born to a mother less than 17 years old (relative risk, 10.9) or 17 to 19 years old (relative risk, 9.3), as compared with a first infant born to a mother 25 years old or older; a maternal age of less than 15 years, as compared with an age of at least 25 years (relative risk, 6.8); no prenatal care as compared with early prenatal care (relative risk, 10.4); and less than 12 years of education among mothers who were at least 17 years old (relative risk, 8.0), as compared with 16 or more years of education. CONCLUSIONS: Childbearing at an early age was strongly associated with infant homicide, particularly if the mother had given birth previously. Our findings may have implications for prevention.

Socioeconomic and racial/ethnic factors affecting non-fatal medically attended injury rates in US children.

OBJECTIVE: Using a representative survey of US children, the purpose was to evaluate separate effects of socioeconomic and racial/ethnic factors, including access to care, on medically attended non-fatal injury rates. METHODS: Multivariate linear regression models were used to determine associations between injuries and health care coverage (insurance or Medicaid), having a place to go for care, race/ethnicity, maternal education, number of adults and children in the household, poverty, and urbanicity. The 1988 Child Health Supplement to the National Health Interview Survey included questions on medically attended injuries, and their cause, location, and effects on the child. Injury categories included total, consequential, occurrence at home or school, falls, and being struck or cut. RESULTS: Lack of health care coverage was consistently associated with lower medically attended injury rates in non-Hispanic blacks or whites and Mexican-Americans, but affected total rates for each group differently due to unequal distribution of health care coverage. Injuries occurred about 40% more frequently to children and adolescents living in single adult households compared with two adult homes for all injury categories except for injuries occurring at school. CONCLUSIONS: Preventive interventions targeted to specific populations based on assumptions that poverty, lack of education, or minority status result in greater risks for injuries require a closer look. Efficient targeting should address underlying factors such as differences in exposures and environments associated with single adult homes or recreational activities. Data sources used to target high risk populations for interventions need to address bias due to access to care.

The epidemiology of nonfatal injuries among US children and youth.

OBJECTIVES: National data are not routinely available regarding the incidence of and associated risk factors for nonfatal injuries in children and youth. The Child Health Supplement to the 1988 National Health Interview Survey provided an opportunity to determine accurate national estimates of childhood injury morbidity by demographic factors, location, external cause, nature of injury, and other factors. METHODS: The closest adult for 17,110 sampled children was asked whether the child had had an injury, accident, or poisoning during the preceding 12 months and about the cause, location, and consequences of the event. An analysis for potential underreporting from 12 months of recall provided adjustments of annual rates to those for a 1-month recall period. RESULTS: On the basis of 2772 reported injuries, the national estimated annual rate for children 0 to 17 years of age was 27 per 100 children after adjustment to 1-month recall. Boys experienced significantly higher rates than girls (risk ratio [RR] = 1.52, 95% confidence interval [CI] = 1.37, 1.68), and adolescents experienced the highest overall rate (38 per 100 children) and proportion of serious injuries. CONCLUSIONS: Approximately one fourth of US children experience a medically attended injury each year, but the risks vary considerably depending on the characteristics of subgroups and the injury cause.

The effects of recall on estimating annual nonfatal injury rates for children and adolescents.

OBJECTIVES: This study used a recent national population survey on childhood and adolescent non-fatal injuries to investigate the effects of recall bias on estimating annual injury rates. Strategies to adjust for recall bias are recommended. METHODS: The 1988 Child Health Supplement to the National Health Interview Survey collected 12-month recall information on injuries that occurred to a national sample of 17,110 children aged 0 through 17 years. Using information on timing of interviews and reported injuries, estimated annual injury rates were calculated for 12 accumulative recall periods (from 1 to 12 months). RESULTS: The data show significantly declining rates, from 24.4 per 100 for a 1-month recall period to 14.7 per 100 for a 12-month recall period. The largest declines were found for the 0- through 4-year-old age group and for minor injuries. Rates of injuries that caused a school loss day, a bed day, surgery, or hospitalization showed higher stability throughout recall periods. CONCLUSIONS: Varying recall periods have profound effects on the patterns of childhood injury epidemiology that emerge from the data. Recall periods of between 1 and 3 months are recommended for use in similar survey settings.

Diet and the risk of in situ cervical cancer among white women in the United States.

A case-control study of women with incident in situ and invasive cervical cancer was conducted during 1982-83 in five US areas reporting to the Comprehensive Cancer Patient Data System: Birmingham, AL; Chicago, IL; Denver, CO; Miami, FL; and Philadelphia, PA. Controls were selected by random-digit dialing and matched to invasive cases on age, race, and telephone exchange. Of the white non-Hispanic in situ cases and controls identified, 229 (78 percent) and 502 (74 percent) were successfully interviewed. Diet was assessed by asking about the usual adult frequency of consumption of 75 food items and the use of vitamin supplements. Included were the major sources of the four micronutrients postulated to reduce the risk of cervical cancer: carotenoids, vitamin A, vitamin C, and folate. Weak inverse associations between risk of in situ disease and intake of carotenoids, vitamin C, folate, fruit, and vegetables/fruits were noted but, with further analysis, these seemed attributable to residual confounding by the multiple lifestyle-related risk factors for this disease and possibly to selection bias. Vitamin A and vegetable intake were unrelated to risk. Dark yellow-orange vegetable consumption and duration of multivitamin use were each strongly related to reduced risk of in situ disease (P for trend = 0.02 and 0.002, respectively) and need to be evaluated in other studies. The absence of persuasive protective effects for the four micronutrients and the similar findings from our analysis of invasive cervical cancer do not concur with other epidemiologic studies and suggest that the role of diet and nutrition in the etiology of cervical cancer is not yet resolved.

Diet and the risk of invasive cervical cancer among white women in the United States.

A case-control study of incident invasive cervical cancer was conducted in Birmingham, Alabama; Chicago, Illinois; Denver, Colorado; Miami, Florida; and Philadelphia, Pennsylvania, during 1982-1983. Controls were selected by random-digit dialing and were matched to cases by age, race, and telephone exchange. Of the white, non-Hispanic cases and controls identified, 271 (73%) and 502 (74%), respectively, were successfully interviewed. Diet was assessed by asking about the usual adult frequency of consumption of 75 food items and the use of vitamin supplements. Included were the major sources of the four micronutrients believed to reduce the risk of cervical cancer: carotenoids, vitamin A, vitamin C, and folate. Women in the highest quartiles of intake of each of these micronutrients had adjusted relative risks of invasive squamous cell cervical cancer comparable to those of women in the lowest quartiles, although their micronutrient intake was estimated to be 3-4 times as high. Risk was not affected by increased consumption of vegetables, dark green vegetables, dark yellow-orange vegetables, fruits, or legumes, or by high intake of the basic food groups. These generally negative findings stand in contrast to findings in previous epidemiologic studies, and the discrepancy is not readily explained by bias, uncontrolled confounding, or inadequate power. The question of the role of diet and nutrition in the etiology of cervical cancer is not yet resolved.