Demographic risk factors for injury among Hispanic and non-Hispanic white children: an ecologic analysis

Objectives—To determine the effects of neighborhood levels of poverty, household crowding, and acculturation on the rate of injury to Hispanic and non-Hispanic white children.

Setting—Orange County, California.

Methods—An ecologic study design was used with census block groups as the unit of analysis. Measures of neighborhood poverty, household crowding, and acculturation were specific to each ethnic group. Poisson regression was used to calculate mutually adjusted incidence rate ratios (IRRs) corresponding to a 20% difference in census variables.

Results—Among non-Hispanic white children, injury rates were more closely associated with neighborhood levels of household crowding (adjusted IRR 2.36, 95% confidence interval (CI) 1.22 to 4.57) than with neighborhood poverty (adjusted IRR 1.06, 95% CI 0.89 to 1.26). For Hispanic children, the strongest risk factors were the proportion of Hispanic adults who spoke only some English (compared with the proportion who spoke little or no English, adjusted IRR 1.26, 95% CI 1.04 to 1.53) and the proportion who were US residents for <5 years (adjusted IRR 1.20, 95% CI 1.001 to 1.43). Neighborhood levels of household crowding were not related to injury among Hispanic children (adjusted IRR 0.98, 95% CI 0.89 to 1.08), but surprisingly, neighborhood poverty was associated with lower injury rates (adjusted IRR 0.89, 95% CI 0.81 to 0.97).

Conclusions—Cultural and geographic transitions, as well as socioeconomic differences, appear to contribute to differences in childhood injury rates between ethnic groups.

     

A case-control study of risk factors for playground injuries among children in Kingston and area

Objective—To determine the risk for injury associated with environmental hazards in public playgrounds.

Setting—One hundred and seventeen playgrounds operated by municipalities or school boards in and around Kingston, Ontario, Canada.

Methods—A regional surveillance database was used to identify children presenting to emergency departments who were injured on public playgrounds; each case was individually matched (by sex, age, and month of occurrence) with two controls—one non-playground injury control, and one child seen for non-injury emergency medical care. Exposure data were obtained from an audit of playgrounds conducted using Canadian and US safety guidelines. Exposure variables included the nature of playground hazards, number of hazards, frequency of play, and total family income. No difference in odds ratios (ORs) were found using the two sets of controls, which were therefore combined for subsequent analysis.

Results—Multivariate analysis showed strong associations between injuries and the use of inappropriate surface materials under and around equipment (OR 21.0, 95% confidence interval (CI) 3.4 to 128.1), appropriate materials with insufficient depth (OR 18.2, 95% CI 3.3 to 99.9), and inadequate handrails or guardrails (OR 6.7, 95% CI 2.6 to 17.5).

Conclusion—This study confirms the validity of guidelines for playground safety relating to the type and depth of surface materials and the provision of handrails and guardrails. Compliance with these guidelines is an important means of preventing injury in childhood.

     

School based bicycle safety education and bicycle injuries in children: a case-control study

Objectives—To evaluate possible benefits of a school based bicycle safety education program ("Bike Ed") on the risk of bicycle injury in children.

Methods—A population based case-control study was undertaken in a region of Melbourne, Australia. Cases were children presenting at hospital emergency departments with injuries received while riding bicycles. Controls were recruited by calling randomly selected telephone numbers. Data were collected by personal interview.

Results—Analysis, based on 148 cases and 130 controls aged 9 to 14 years, showed no evidence of a protective effect and suggested a possible harmful effect of exposure to the bicycle safety course (odds ratio (OR) 1.64, 95% confidence interval (CI) 0.98 to 2.75). This association was not substantially altered by adjustment for sex, age, socioeconomic status, and exposure, measured as time or distance travelled. Subgroup analysis indicated that the association was strongest in boys (OR 2.0, 95% CI 1.1 to 3.8), younger children, children from families with lower parental education levels, and children lacking other family members who bicycle.

Conclusions—It is concluded that this educational intervention does not reduce the risk of bicycle injury in children and may possibly produce harmful effects in some children, perhaps due to inadvertent encouragement of risk taking or of bicycling with inadequate supervision.

     

Characteristics of a gun exchange program, and an assessment of potential benefits

Objectives—To describe a gun exchange program and assess potential benefits for participants and host communities.

Methods—Mail survey of participants in a Sacramento, California gun exchange program, August 1993; the response rate was 79%. Comparative data were obtained from nationwide polls of gun owners.

Results—Most (62%) respondents were men; 40% were more than 55 years old; none was less than 25. Concern that children might find and use the gun was the most frequently cited reason for participating (46% of respondents). Of 141 firearms exchanged, 72% were handguns; 23% of respondents indicated that the guns they turned in were not in working order. Of respondents who owned a gun at the time of the program (rather than those who owned no guns and turned in a gun owned by someone else), 41% owned no guns after participating; the prevalence of handgun ownership declined from 79% to 32%. Those who continued to own guns were as likely as gun owners nationwide to keep a gun loaded in the house (odds ratio (OR) 0.9, 95% confidence interval (CI) 0.4 to 1.7) or to carry a gun with them (OR 1.5, 95% CI 0.6 to 3.8).

Conclusions—Gun exchange programs may reduce risk for firearm violence among some participants, but a number of factors limit their overall benefits to host communities.

     

Fractures among children: incidence and impact on daily activities

Objectives—The study's objective was to examine incidence of fractures and associated activity restriction among children aged 0–12 years.

Design—Injuries were prospectively recorded over the four year period from 1992–95 in a cohort of children aged 0–12 years, representing 193 540 children years. Information about length and extent of activity restriction was collected from parents by a mailed questionnaire for a subsample of 192 children with a fracture.

Results—A total of 2477 fractures occurred in the study population (128 per 10 000 children annually). The incidence increased linearly with age, by 14 cases per 10 000 children year for each year of age. Boys and girls showed similar patterns of fracture occurrence. There was a significant difference in length of activity restrictions for different types of fractures. The mean and 95% confidence interval (CI) of activity restricted days for leg fractures were 26 (95% CI 7 to 45) days, for arm fractures, 14 (95% CI 8 to 20) days, and for other fractures, 5 (95% CI 1 to 8) days. Arm fractures represented 66% of the cases and 62% of the activity restricted days; leg fractures 19% of cases and 33% of all activity restricted days; and other fractures 16% of the cases but only 5% of the activity restricted days in this population.

Conclusion—The incidence of fractures increases in childhood. Different types of fractures among children cause different amounts of activity restriction.

     

An observational study of protective equipment use among in-line skaters

Objectives—To describe the patterns of protective equipment use by in-line skaters in Winnipeg, Manitoba and nearby rural communities.

Methods—In-line skaters were observed for three months in 1996 at 190 urban and 30 rural sites selected using a formal sampling scheme. Age, gender, protective equipment use, skating companions, correct helmet use, and use of headphones were recorded.

Results—Altogether 123 in-line skaters were observed at 61 sites, including one rural site. No skaters were observed at the remaining sites. There were 37 adults and 86 children; 56% were male. Helmet use was 12.2% (95% confidence interval (CI ) = 6.4% to 18.0%), wrist guard use was 16.3% (95% CI = 9.7% to 22.8%), knee pad use was 9.8% (95% CI = 5.2% to 16.4%), and elbow pad use was 7.3% (95% CI = 3.4% to 13.4%). Children were more likely to wear a helmet than teens 12–19 years of age (relative risk (RR) = 30, 95% CI = 4.01 to 225). Adults were more likely to wear wrist guards than children (RR = 4.32, 95% CI = 1.87 to 9.94). No gender differences were found. Incorrect helmet use was documented in four skaters; three skaters were wearing headphones.

Conclusions—Low rates of protective equipment use were documented in our region, significantly lower than those reported in the literature. Barriers to equipment use are not known, and should be examined by further study. In-line skating safety programs should be developed, promoted, and evaluated. Teens should be targeted for future preventive efforts.

     

All terrain vehicle ownership, use, and self reported safety behaviours in rural children

Objectives—To describe all terrain vehicle (ATV) ownership, access, use, and safety behaviours in rural Manitoba children.

Methods—Questionnaire administered to a convenience sample of grade 6 students attending an agricultural fair.

Results—162 grade 6 children participated. The mean age was 11.4 years, and 46% were male. 125 students (77%) reported having access to ATVs, including 69 four wheeled, 24 three wheeled, and four both three and four wheeled ATVs. ATV experience was reported in 95 students, significantly more often in males and among those with a family owned ATV, with no difference between children living on a farm and in a town. Use of helmets and protective clothing was inadequate (10–40%), and dangerous riding habits common, with males and children living on a farm reporting significantly fewer desirable behaviours.

Conclusions—ATVs are commonly used by children in rural Manitoba, with inadequate protective gear and dangerous riding habits. Mandatory rider training, consumer and dealer education, and legislation enforcement could improve ATV safety in this population.

     

Harstad injury prevention study: prevention of burns in young children by community based intervention

Objective—To describe the long term effectiveness of a community based program targeting prevention of burns in young children.

Design—Quasiexperimental.

Setting—The Norwegian city of Harstad (main intervention), six surrounding municipalities (intervention diffusion), and Trondheim (reference).

Participants—Children under age 5 years in the three study populations.

Methods—Outpatient and inpatient hospital data were coded according to the Nordic system, and collected as part of a national injury surveillance system. Burn data collection started in May 1985. The first 19.5 months of the study provided baseline data, while the last 10 years involved community based intervention, using a mix of passive and active interventions.

Results—The mean burn injury rate decreased by 51.5% after the implementation of the intervention in Harstad (p<0.05) and by 40.1% in the six municipalities (not significant). Rates in the reference city, Trondheim, increased 18.1% (not significant). In Harstad and the six surrounding municipalities there was a considerable reduction in hospital admissions, operations, and bed days. Interventions with passive strategies were more effective, stove and tap water burns being eliminated in the last four years, while active strategies were less effective.

Conclusions—A program targeting burns in children can be effective and sustainable. Local injury data provided the stimulus for community action.

     

Epidemiology of bicycle injury,head injury,and helmet use among children in British Columbia: a five year descriptive study

Objectives and methods—Data on 1462 injured bicyclists aged 1–19, obtained over a period of five years from the British Columbia Children''s Hospital as part of a national emergency room based program in Canada, were analyzed to describe the epidemiology of injuries, helmet use, and the occurrence of head injuries before the enactment of a new mandatory helmet law. The odds ratio (OR) and 95% confidence interval (CI) were calculated for non-users compared with helmet users. Results—Bicycle injuries comprised 4% of all injuries seen in the five year study period. The proportion of admissions was 12.7% among bicyclists, significantly higher than the 7.9% admissions of all 35 323 non-bicyclist children who were seen during the study period (OR = 1.96, CI = 1.44 to 1.99). Boys were injured more often than girls. The proportion of admissions for boys was 13.8% compared with 10.2% among girls (OR = 1.41, CI = 0.97 to 2.05). More than 70% of injured bicyclists reported no helmet use. The proportion of admissions of injured bicyclists who did not use helmets was always higher than the proportion of admissions of those who used helmets (OR = 2.23, CI = 1.39 to 3.62). Head and face injuries occurred more often among those who did not use helmets (OR = 1.55, CI= 1.18 to 2.04 ). However, there was no excess of minor head injuries among non-users (OR = 1.10, CI = 0.60 to 2.06). Of the 62 concussions, 57 occurred to non-helmet users (OR = 4.04, CI = 1.55 to 11.47). Most injuries occurred in the upper (46.4%) or lower extremities (32.4%). Dental injuries occurred slightly more often among helmet users compared with non-users but this excess was not statistically significant (OR = 1.29, CI = 0.76 to 2.20). Conclusion—The data indicate the need to control injuries by using helmets. A decrease in the number of head injuries and their severity is expected when bicycle helmet use becomes law in British Columbia.     

Pacifier use and sudden infant death syndrome: results from the CESDI/SUDI case control study

OBJECTIVES—To investigate the relation between pacifier use and sudden infant death syndrome (SIDS).
DESIGN—Three year population based, case control study with parental interviews for each death and four age matched controls.
SETTING—Five regions in England (population > 17 million).
SUBJECTS—325 infants who had died from SIDS and 1300 control infants.
RESULTS—Significantly fewer SIDS infants (40%) than controls (51%) used a pacifier for the last/reference sleep (univariate odds ratio (OR), 0.62; 95% confidence interval (CI), 0.46 to 0.83) and the difference increased when controlled for other factors (multivariate OR, 0.41; 95% CI, 0.22 to 0.77). However, the proportion of infants who had ever used a pacifier for day (66% SIDS v 66% controls) or night sleeps (61% SIDS v 61% controls) was identical. The association of a risk for SIDS infants who routinely used a pacifier but did not do so for the last sleep became non-significant when controlled for socioeconomic status (bivariate OR, 1.39 (0.93 to 2.07)).
CONCLUSIONS—Further epidemiological evidence and physiological studies are needed before pacifier use can be recommended as a measure to reduce the risk of SIDS.
     

Trends in injury mortality among adolescents in Taiwan, 1965–94

Objectives—To describe trends in injury mortality among adolescents in Taiwan for prioritising preventive interventions.

Methods—Adolescent injury mortality data for Taiwan were derived from official publications of vital statistics from 1965 to 1994 to determine trends by sex and cause of death. Simple linear regression was used to test the trends.

Results—The number of deaths due to injury among adolescents aged 10–19 years in Taiwan increased from 983 in 1965 to 1783 in 1994, an 81% increase. The injury mortality rate increased 42%, from 32.2 per 100 000 in 1965 to 45.6 per 100 000 in 1994. The proportion of injury deaths also increased, from 45.3% in 1965 to 72.8% in 1994. The trends in mortality from motor vehicle injury (MVI) among four demographic groups were all significantly positive (p<0.001). The proportion of deaths due to MVI among injury was 14% in 1965 and increased to 63% in 1994.

Conclusions—The increase in injury mortality rates among adolescents over the past three decades appears to be due largely to the increase in MVI mortality rates with males aged 15–19 years accounting for most of this increase. Priorities for adolescents in Taiwan are MVI (especially motorcyclists) and drownings.

     

Unintentional injury mortality in children: a priority for middle income countries in the advanced stage of epidemiological transition

Objectives—To examine the relationship between the magnitude, and the relative importance of unintentional child injury mortality with socioeconomic development, and to conceptualise the dynamic changes in injury mortality within the framework of epidemiological transition.

Design—Ecological cross sectional study using data on 51 countries.

Main outcome measures—The relationship between total mortality rates, unintentional injury mortality rates, and percentage in children 1–14 years of age with gross national product (GNP) per capita.

Results—Unintentional injury mortality rates in children were negatively correlated with GNP per capita. However, by categorising the data, we found some areas of non-correlation: in children 5–14 years in low income versus lower middle income countries, and in all age and gender groups in lower high income versus higher high income countries. A high percentage of total deaths due to injuries was clearest in the lower middle income countries in all age and gender groups.

Conclusions—The changes in child injury mortality in relation to socioeconomic development could be conceptualised as three stages: a stage of high magnitude; a stage of high priority; and a stage of improvement. Most middle income countries are in the high priority stage where both injury mortality rates and injury percentage of total deaths are high.

     

Bicycle helmet promotion among low income preschool children

Objective—To evaluate the effectiveness of a multifaceted bicycle helmet promotion program for low income children attending preschool enrichment programs throughout Washington State.

Study sample—Preschool Head Start programs that conducted routine home visits among their enrolled families at least five times during the school year were eligible. Eighteen sites and 880 children met this criterion and were able and willing to carry out evaluation activities. Two hundred children were from control sites where no helmet promotion activities were carried out.

Intervention—Classroom activities with children, education of parents during school meetings and home visits, fitting and distribution of helmets, a bicycle skills and safety "rodeo" event, and requiring children to wear helmets while riding on school grounds.

Evaluation methods—Regularly scheduled home visits were used to observe helmet use of enrolled preschool children before and after the promotion program. Home visitors requested parental permission for enrolled children to ride, and then noted whether the child wore a helmet.

Results—Helmet use in the intervention group more than doubled, from 43% to 89%, while use in the control group increased from 42% to 60% (p<0.05 for intervention group changes v control group changes).

Conclusions—This multifaceted helmet promotion program successfully increased helmet use. Similar home visit protocols may be useful to evaluate the impact of other injury intervention programs.

     

Systematic review of the treatment of upper respiratory tract infection

OBJECTIVES—To assess the risks and benefits of antibiotic treatment in children with symptoms of upper respiratory tract infection (URTI).
DESIGN—Quantitative systematic review of randomised trials that compare antibiotic treatment with placebo.
DATA SOURCES—Twelve trials retrieved from a systematic search (electronic databases, contact with authors, contact with drug manufacturers, reference lists); no restriction on language.
MAIN OUTCOME MEASURES—The proportion of children in whom the clinical outcome was worse or unchanged; the proportion of children who suffered complications or progression of illness; the proportion of children who had side effects.
RESULTS—1699 children were randomised in six trials that contributed to the meta-analysis. Six trials were not used in the meta-analysis because of different outcomes or incomplete data. Clinical outcome was not improved by antibiotic treatment (relative risk 1.01,95% confidence interval (CI) 0.90 to 1.13), neither was the proportion of children suffering from complications or progression of illness (relative risk 0.71, 95% CI 0.45 to 1.12). Complications from URTI in the five trials that reported this outcome was low (range 2-15%). Antibiotic treatment was not associated with an increase in side effects compared with placebo (relative risk 0.8, 95% CI 0.54 to 1.21).
CONCLUSIONS—In view of the lack of efficacy and low complication rates, antibiotic treatment of children with URTI is not supported by current evidence from randomised trials.

     

Double blind placebo controlled trial of nebulised budesonide for croup

Accepted 28 August 1996
AIMS—To determine whether nebulised budesonide improves the symptoms or shortens the duration of stay of children admitted to hospital with a clinical diagnosis of croup.
METHODS—A prospective, randomised, double blind placebo controlled trial. Patients received either nebulised budesonide or placebo every 12 hours. The main outcome measures were duration of inpatient stay and croup scores at 30 minutes, one, two, four, 12, and 24hours.
RESULTS—87 patients (89 admissions) aged 7-116 months entered the trial. Nebulised budesonide was associated with a significant improvement in symptoms at 12 hours (95% confidence interval (CI) 1 to 3) and 24 hours (95% CI 0 to 3). Patients with an initial croup score above 3 demonstrated a significant improvement in symptoms at two hours (95% CI 1 to 3). Nebulised budesonide was also associated with a 33% reduction in the length of stay (95% CI 2% to 63%) when the confounding variables of age, initial croup score, and coryzal symptoms were taken into consideration.
CONCLUSIONS—Nebulised budesonide is an effective treatment for children admitted to hospital with a clinical diagnosis of croup.

     

Family characteristics and pedestrian injury risk in Mexican children

BACKGROUND: Family characteristics have been described as risk factors for child pedestrian and motor vehicle collision. Research results come mainly from developed countries, where family relationships could be different than in developing ones. OBJECTIVE: To examine family characteristics as risk factors for pedestrian injury in children living in Guadalajara City, Mexico. METHODS: Case-control study of injuries among children 1-14 years of age involved in pedestrian-motor vehicle collisions. Cases resulting in death or injuries that required hospitalization or medical attention were included and identified through police reports and/or emergency room registries. Two neighborhood matched controls were selected randomly and compared with cases to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Significant risk factors were: male (OR 2.3, 95% CI 1.2 to 4.4), number of siblings in household (two siblings, OR 3.2, 95% CI 1.4 to 6.6; three siblings, OR 4.5, 95% CI 1.9 to 11.0; four or more siblings, OR 3.7, 95% CI 1.1 to 12.9), and number of non-siblings/non-parents in household (four or more, OR 6.2, 95% CI 1.5 to 26.6). Children of a sole mother, working mother, or grandmother living in house did not show increased risk after adjusting for socioeconomic conditions. CONCLUSION: Household size has implications for child pedestrian and motor vehicle collision prevention efforts and is relatively easy to identify. Also, the lack of risk association with working mothers may indicate that grandmothers are not part of the social support network that cares for children of working mothers.     

Reported incidence of injuries caused by street glass among urban children in Philadelphia

Setting—Children (18 years of age or younger) in the Ludlow community of Philadelphia.

Methods—A retrospective analysis of lacerations sustained while walking outdoors. A personal survey was conducted with 241 children on a door to door basis. Glass litter was measured by visual inspection of individual streets.

Results—Of 241 children, 83 (34%) had been cut at least once while walking outdoors. Of the 83, 62 were not wearing footwear at the time of injury. The majority of lacerations (86%) were caused by broken glass. Thirty nine of the 83 children received professional medical care for the laceration. Broken glass was estimated to be present on 30% of the outdoor walking area.

Conclusions—Broken glass is a significant health problem on littered urban streets. Preventive measures such as street cleaning, footwear education, and glass recycling incentives are needed to address this public health hazard.

     

Systemic availability and pharmacokinetics of nebulised budesonide in preschool children

AIM—To evaluate the systemic availability and basic pharmacokinetic parameters of budesonide after nebulisation and intravenous administration in preschool children with chronic asthma.
METHODS—Plasma concentrations of budesonide were measured for three hours after an intravenous infusion of 125 µg budesonide. The children then inhaled a nominal dose of 1 mg budesonide through the mouthpiece of a Pari LC Jet Plus nebuliser connected to a Pari Master compressor, and the plasma concentrations of budesonide were measured for another six hours. The amount of budesonide inhaled by the patient ("dose to subject") was determined by subtracting from the amount of budesonide put into the nebuliser, the amount remaining in the nebuliser after nebulisation, the amount emitted to the ambient air (filter), and the amount found in the mouth rinsing water.
RESULTS—Ten patients aged 3 to 6 years completed both the intravenous and the inhaled treatment. The mean dose to subject was 23% of the nominal dose. The systemic availability of budesonide was estimated to be 6.1% of the nominal dose (95% confidence intervals (CI), 4.6% to 8.1%) or 26.3% of the dose to subject (95% CI, 20.3% to 34.1%). Budesonide clearance was 0.54 l/min (95% CI, 0.46 to 0.62), steady state volume of distribution 55 litres (95% CI, 45 to 68), and the terminal half life was 2.3 hours (95% CI, 2.0to 2.6).
CONCLUSIONS—Approximately 6% of the nominal dose (26% of the dose to subject) reached the systemic circulation of young children after inhalation of nebulised budesonide. This is about half the systemic availability found in healthy adults using the same nebuliser.

     

Seating positions and children's risk of dying in motor vehicle crashes

Objectives—To determine the effects of seating position, combined with restraint use and airbag status, on children's risk of dying in crashes.

Methods—Using 1988–95 data from the United States Fatality Analysis Reporting System, risk of death was compared among front and rear seated passengers aged 12 and younger who were involved in fatal crashes for different categories of restraint use and in vehicles with and without passenger airbags.

Results—Restrained children in rear seats had the lowest risk of dying in fatal crashes. Among children seated in the rear, risk of death was reduced 35% in vehicles without any airbags, 31% in vehicles equipped only with driver airbags, and 46% in vehicles with passenger airbags. Both restrained and unrestrained children aged 0–12 were at lower risk of dying in rear seats. Rear seats also afforded additional protection to children aged 5–12 restrained only with lap belts compared with lap/shoulder belted children in front seats. Children were about 10–20% less likely to die in rear center than in rear outboard positions.

Conclusions—Parents and others who transport children should be strongly encouraged to place infants and children in rear seats whether or not vehicles have airbags. Existing laws requiring restraint use by children should be strengthened and actively enforced.