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.

Social learning approaches to health education: utilization of infant auto restraint devices.

There has been little critical evaluation of which methods achieve the desired results in health education. Using purchase of proper infant auto restraint devices as an objective, we assessed the effectiveness of three educational approaches. Only 37% of control families had purchased an acceptable car seat, compared to 54% of those who received descriptive literature alone, 71% of those that received literature and had been shown a descriptive film, and 60% of those who were given literature, shown the film, and been provided with a demonstration of the seat. Purchase of car seats was positively correlated with social class and knowledge of auto safety, but not with a history of auto accidents. Utilization of auto restraint devices is an example of how social learning theory can be applied in health education.

Relationship of passive cigarette-smoking to sudden infant death syndrome.

The smoking habits of 56 families who lost babies to the sudden infant death syndrome (SIDS) were compared to those of 86 control families. A higher proportion of SIDS mothers smoked both during pregnancy (61% vs. 42%) and after their babies were born (59% vs. 37%). SIDS mother also smoked a significantly greater number of cigarettes than controls. Exposure to cigarette smoke ("passive smoking") appears to enhance the risk of SIDS for reasons not known.

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 "Retreat" for pediatric interns.

For the past two years, pediatric interns at the University of Washington have been relieved of their clinical duties for five days to participate in a "retreat". Their places were taken by pediatric practitioners as a continuing education experience. The chief benefit of the retreat was the coming together of the intern group and the subsequent support they were able to give to each other. The educational content was deemed less important than the fact that the retreat occurred.

Changing spectrum of serious child abuse.

To determine whether the spectrum of serious child abuse has changed over the past decade, hospital and medical examiner records in the Seattle area were reviewed for the years 1971 to 1973 and 1981 to 1983. Although the incidence of hospitalized cases was similar in the two time periods (81 v 93), the proportion of severe injuries that occurred increased significantly (from 32% to 54%). The large number of cases in which the perpetrator was unknown makes generalization difficult. However, changes in the sex distribution for known perpetrators suggest that child abuse, especially serious and fatal cases, may be occurring more frequently at the hands of men.

Predicting accident frequency in children.

The concept of "accident proneness" is frequently discussed and rarely documented. We predicted that children who take more risks as judged by their behavior in gym class, or who have more stressful life changes as determined by their score on a Social Readjustment Rating Questionnaire (SRRQ), would be more likely to injure themselves. 103 junior high school boys were rated for these factors, and then followed for injuries by weekly telephone calls for five months. Boys having high SRRQ scores had significantly more accidents than those with low scores; risk-taking levels were not predictive. In this study, children undergoing stressful changes in their lives were more susceptible to accidents.

Prevention of pedestrian injuries to children: effectiveness of a school training program.

Pedestrian injuries are a complex problem for which no single intervention will be completely effective. One component of a community-wide program, training of schoolchildren in street-crossing skills, is evaluated. The program targeted public school students in grades K through 4 with an eight-session training program by a single teacher, cross-age teaching, videotape feedback, and in 1990 parent-child activity workbooks. Children's street crossing was observed pretraining and posttraining and graded on four behaviors: WALKING on sidewalk/shoulder vs in the street; STOPPING at the curb; LOOKING L-R-L before crossing; KEEP LOOKING while crossing. Analysis was conducted on matched pairs in which observations pretraining were compared with those posttraining on same child. Observations were completed on 137 children in 1989 and 92 in 1990. Nearly all children walked on the side of the road; however, fewer than 50% of children STOPPED, 25% LOOKED, and fewer than 20% KEPT LOOKING before training. Training did not improve the performance on the first two behaviors in either year, significantly increased LOOKING in 1990, and increased KEEP LOOKING by twofold in 1989 and threefold in 1990. It is concluded that pedestrian skills of children can be improved but that such a program must be part of a broader effort if pedestrian injuries are to decrease.

Relationship between epidemiologic risk factors and clinicopathologic findings in the sudden infant death syndrome.

The risk of sudden infant death syndrome (SIDS) is said to be enhanced by factors such as prematurity, low birth weight, and perinatal distress. The significance of risk factors for SIDS research was questioned because the majority of SIDS victims seem to lack them. Therefore, postmortem records of 1144 infants who died suddenly and unexpectedly in King County, Washington, over a 25-year period were studied. Deaths were classified as "explained" if a cause was apparent, "classic" SIDS if the history and autopsy were unrevealing or, where the diagnosis of SIDS was doubtful, as "probable" or "possible" SIDS. The infants' birth certificates were compared with those of 3647 infants born during a similar period. Seventy-nine deaths (7%) were explained. The 1065 previously certified as SIDS were reclassified classic SIDS (82%), probable SIDS (13%), and possible SIDS (5%). Low birth weight, small size for gestational age, prematurity, and low 5-minute Apgar scores each form a "continuum"; the possible-SIDS group had the highest proportion of such infants, followed by the probable- and classic-SIDS groups, which exhibit extensive overlap with the control population. A 5-minute Apgar score of less than 7 and delayed postnatal growth rate are not risk factors for classic SIDS. Risk factors are more prevalent in SIDS infants where the diagnosis may be doubtful. The great majority of SIDS victims possess fewer risk factors. To avoid the bias of confounding variables, SIDS research should focus on as "pure" a SIDS population as is possible.

Advocacy training during pediatric residency.

Despite broad concerns about the welfare of children, most pediatric residents are not able to engage in child advocacy during their busy training years. Yet residency can provide an opportunity for young pediatricians to learn valuable advocacy skills by undertaking an independent project with an experienced mentor. We describe the University of Washington Pediatrics Residency Program's experience in training interested residents in child advocacy. Basic requirements are that advocacy projects must not interfere with clinical training, resident participation must be voluntary, and faculty with advocacy skills must be available to help guide the residents. Four resident projects are outlined and guidelines for instituting such programs are presented.

The Seattle children's bicycle helmet campaign: changes in helmet use and head injury admissions.

OBJECTIVE: To describe the impact of a community bicycle helmet campaign on helmet use and the incidence of bicycle-related head injuries. SETTING: Metropolitan community and a large health maintenance organization. INTERVENTIONS: Communitywide bicycle helmet campaign. OUTCOMES: Rate of observed bicycle helmet use in the community and incidence of bicycle-related injuries in an health maintenance organization population. RESULTS: Helmet use among school-aged children increased from 5.5% in 1987 to 40.2% in 1992. Bicycle-related head injuries decreased by 66.6% in 5- to 9-year-old and 67.6% in 10- to 14-year-old members of an health maintenance organization. CONCLUSIONS: Educational campaigns can increase helmet use and decrease the incidence of bicycle-related head injury.

Safe storage of handguns. What do the police recommend?

OBJECTIVE: To ascertain the specific suggestions that local police departments in the United States give to parents who ask for advice about methods to safely store handguns. METHODS: A cross-sectional, semistructured telephone survey was administered to a sample of 102 police departments in the United States in cities with populations of 10,000 or more, selected within blocks of cities of similar population size. An investigator, posing as a parent of 3-year-old and 10-year-old children, called departments seeking specific advice on how to safely store a handgun acquired for protection. RESULTS: Usable responses were generated for 93 (91%) of the departments sampled. Only 3 departments (3.2%) refused to give advice over the telephone. The most commonly suggested storage methods were trigger locks (55 departments [59%]), portable lockboxes for handguns (48 [52%]), and the separation of guns from ammunition (30 [32%]). Seven percent of departments suggested removing the gun from the household. Over half of those suggesting trigger locks and lockboxes considered these devices safe (35 [64%] for trigger locks and 27 [56%] for lockboxes) and yet rapidly accessible to an adult (36 [65%] for trigger locks and 36 [75%] for lockboxes). Responding police officers most commonly reported using the following storage methods at home: no storage method (31 [38%]), portable lockboxes (23 [28%]), out-of-reach location (11 [13%]), separation of gun and ammunition (10 [12%]), and trigger locks (5 [6%]). CONCLUSIONS: Trigger locks are frequently recommended but infrequently used by police themselves at home. Portable lockboxes are frequently recommended as well as used by police.

Computed tomography of the larynx.

The normal computed tomographic anatomy of the larynx and surrounding structures is illustrated and discussed. An attempt is made to distinguish various types of tissues in cross-sectional display. The advantages of computed tomography over other modalities used for imaging the laryngeal region include the capacity to depict structural relationships in cross-section, to better define cartilaginous involvement by adjacent neoplasms, and to identify vascular components with contrast enhancement. The clinical application of computed tomography with respect to radiation therapy treatment planning of laryngeal tumors in an important feature of this imaging technique.

Strategies of a successful campaign to promote the use of equestrian helmets.

Although the risk of serious head injury for horse riders is higher than for most other sports, few equestrians regularly wear protective headgear. This study indicates that riders are well informed about the need for helmets and that the main reason for nonuse is inadequate helmet design. In particular, riders perceive that existing helmets are uncomfortable, expensive, and inappropriate for some riding styles. Based on these findings, the authors developed strategies to increase usage and incorporated them into a successful program. These strategies included working with manufacturers to develop a low-cost, versatile helmet; efficiently distributing educational literature among the horse riding community; and encouraging individual clubs and equestrian organizations to mandate a helmet policy.

Cost estimates for statewide reporting of injuries by E coding hospital discharge abstract data base systems.

A key element in the study of trauma problems is the design and development of adequate and affordable surveillance systems. One proposed method is the use of data available from hospital discharge abstract data base systems. However, surveillance systems based on existing data bases usually do not include codes that can identify the external causes of injuries, a critical limitation of the ability to determine the mechanisms of injuries. One obstacle to adding external cause of injury codes, known as E codes under the International Classification of Diseases, to uniform hospital discharge abstract data base systems is the cost of such a change. This study provided an estimate of the type and size of the costs for one State, based upon a survey of hospitals, information system vendors, and medical records experts. Two categories of the costs involved in adding E codes to hospital discharge abstract data base systems were identified. One-time implementation costs, which include modification of the computerized data base and the coding guidelines used by medical record personnel, average $600 per hospital. Annual costs resulting from increased operating expenses to include E codes average about $600 per hospital, because of the increased workload of coding and entry of the additional data. Adding E codes to hospital discharge abstract data base systems appears to be financially feasible for statewide surveillance of serious injury.

Analysis of fatal pedestrian injuries in King County, WA, and prospects for prevention.

Pedestrian fatalities caused by motor vehicles in King County, WA, over a 12-month period were reviewed to examine the potential for prevention by various strategies. Cases were identified through the King County Medical Examiner's Office. Between April 1, 1985, and March 31, 1986, a total of 38 pedestrians died of motor vehicle injuries. The victims were generally children (N = 11), the elderly (N = 13), or intoxicated adults (N = 9). Supervision of the child was inadequate in 64 percent of the children's deaths. The driver was at fault in deaths of seven children, five adults, and three elderly persons. None of the children and only one of the elderly victims was injured at night. The majority of injuries occurred on major thorough-fares; only 16 percent occurred on residential streets. Possible strategies for prevention appear to include improved enforcement of pedestrian right-of-way laws, changes in vehicle design, modification of the environment (particularly in urban areas), and improved training programs for children.

Elderly persons' attitudes towards footwear--a factor in preventing falls.

Injuries from falls are the main cause of trauma morbidity that leads to mortality among the elderly. One prevention strategy is to wear sturdy shoes. This study was undertaken to determine the attitudes towards and use of sturdy shoes among older adults. A random sample of persons ages 65 years and older was contacted by phone; 652 completed interviews. Sturdy shoes were worn by 26 percent of persons at the time of the call; more than two-thirds reported wearing such shoes at some time. Barriers to use of sturdy shoes included foot problems, difficulty putting them on, expense, style, and lack of knowledge about their importance. There was no difference in shoe use by the respondents' history of previous falls. The results provide information useful in the development of a program to increase the use of sturdy shoes by this population.

Iron-fortified formulas. Pediatricians' prescribing practices.

Primary care pediatricians in Washington State were surveyed regarding their attitudes about iron-fortified formula. Of the 210 responding physicians who stated an opinion 70 (33%) feel that there are definite indications for non-fortified formula, and 33 (16%) routinely recommend formula without added iron. Despite evidence that adding iron to formula has helped reduce the prevalence of anemia in children and does not cause gastrointestinal symptoms, iron-fortified formula is not universally recommended by pediatricians.

Toxic epidermal necrolysis. A comprehensive approach. Multidisciplinary management in a burn center.

Toxic Epidermal Necrolysis (TEN) is a life-threatening disorder with reported mortality rates of 25-60 percent in pediatric patients. The authors report on their experience in managing six children using a standardized treatment protocol in the intensive care unit of a regional burn center. Areas of sloughed skin were covered with porcine xenograft (pig skin) until reepithelialization was complete. There was one death in the series, and one child had ophthalmologic complications. Treatment in a multidisciplinary burn center is recommended for children with TEN.