Bronchiolitis-associated hospitalizations among American Indian and Alaska Native children

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract illness among infants and young children. Respiratory system diseases account for a large proportion of hospitalizations in American Indian and Alaska Native (AI/AN) children; however, aggregate estimates of RSV-associated hospitalizations among AI/AN children have not been made. METHODS: We used Indian Health Service hospitalization data from 1990 through 1995 to describe hospitalizations associated with bronchiolitis, the most characteristic clinical manifestation of RSV infection, among AI/AN children <5 years old. RESULTS: The overall bronchiolitis-associated hospitalization rate among AI/AN infants < 1 year old was considerably higher (61.8 per 1,000) than the 1995 estimated bronchiolitis hospitalization rate among all US infants (34.2 per 1,000). Hospitalization rates were higher among male infants (72.2 per 1,000) than among females infants (51.1 per 1,000). The highest infant hospitalization rate was noted in the Navajo Area (96.3 per 1,000). Hospitalizations peaked annually in January or February, consistent with national peaks for RSV detection. Bronchiolitis hospitalizations accounted for an increasing proportion of hospitalizations for lower respiratory tract illnesses. CONCLUSIONS: Bronchiolitis-associated hospitalization rates are substantially greater for AI/AN infants than those for all US infants. This difference may reflect an increased likelihood of severe RSV-associated disease or a decreased threshold for hospitalization among AI/AN infants with bronchiolitis compared with all US infants. AI/AN children would receive considerable benefit from lower respiratory tract illness prevention programs, including an RSV vaccine, if and when one becomes available.     

Diarrhea-associated hospitalizations and outpatient visits among American Indian and Alaska Native children younger than five years of age, 2000-2004

BACKGROUND: Diarrhea accounts for many hospitalizations and outpatient clinic visits among children. American Indian and Alaska Native (AI/AN) children have experienced a greater infectious disease burden compared with the general U.S. population of children, although diarrhea-associated hospitalization rates have declined among AI/AN children. METHODS: Hospital discharge and outpatient visit records with a diagnosis indicating a diarrhea-associated diagnosis were evaluated for AI/AN children <5 years of age, using the 2000-2004 Indian Health Service Direct and Contract Health Service Inpatient Data and outpatient visit data from the Indian Health Service National Patient Information Reporting System, and for the general U.S. population of children <5 years of age using the Kids' Inpatient Database for 2003 and National Ambulatory data for 2000-2004. RESULTS: For 2000-2004, the diarrhea-associated hospitalization rate was similar for AI/AN children and U.S. children <5 years of age (65.9 and 79.3 of 10,000, respectively), but the rate among AI/AN infants was nearly twice the rate among U.S. infants (262.6 and 154.7 of 10,000, respectively). The rate of diarrhea-associated outpatient visits among AI/AN children was higher than for U.S. children (2255.4 versus 1647.9 of 10,000, respectively), as a result of the high rate among AI/AN infants compared with U.S. infants (6103.5 and 2956.3 of 10,000, respectively). CONCLUSIONS: Although the diarrhea-associated hospitalization rate in AI/AN children <5 years old has declined to levels comparable with that of all U.S. children, the rate for AI/AN in infants remains higher than for U.S. infants. The diarrhea-associated outpatient visit rate for AI/AN children was higher than for U.S. children. Ongoing evaluation of hospitalization and outpatient data is important to understand the impact of rotavirus vaccine among AI/AN children.     

Asthma and bronchiolitis hospitalizations among American Indian children

OBJECTIVE: To compare asthma and bronchiolitis hospitalization rates in American Indian and Alaskan native (AI/AN) children and all children in Washington State. METHODS: A retrospective data analysis using Washington State hospitalization data for 1987 through 1996. Patients were included if asthma or bronchiolitis was the first-listed diagnosis. American Indian and Alaskan native children were identified by linking state hospitalization data with Indian Health Service enrollment data. RESULTS: Similar rates of asthma hospitalization were found for AI/AN children older than 1 year compared with all children. In AI/AN children younger than 1 year, hospitalization rates for asthma (528 per 100,000 population; 95% confidence interval [CI], 346-761) and bronchiolitis (2954 per 100,000 population; 95% CI, 2501-3456) were 2 to 3 times higher than the rates in all children (232 per 100,000 population [95% CI, 215-251] and 1190 per 100,000 population [95% CI, 1149-1232], respectively). Hospitalization rates for asthma and bronchiolitis increased 50% between 1987 and 1996 for all children younger than 1 year and almost doubled for AI/AN children younger than 1 year. CONCLUSIONS: American Indian and Alaskan native children have significantly higher rates of hospitalization for wheezing illnesses during the first year of life compared with children of other age groups and races. Furthermore, the disparities in rates have increased significantly over time. Future public health measures directed at managing asthma and bronchiolitis should target AI/AN infants.     

Kawasaki syndrome hospitalizations in Ireland, 1996 through 2000

OBJECTIVE: To describe the epidemiologic characteristics and estimate the incidence of Kawasaki syndrome (KS) among children in Ireland. METHODS: Hospital discharge records with a KS diagnosis among patients <18 years of age were examined using Ireland's Hospital In-Patient Enquiry database for 1996 through 2000. RESULTS: During the study period 265 hospitalizations associated with KS among children <18 years of age were recorded in Ireland. Of those, 194 (73%) occurred among children <5 years of age. The median age of patients at admission was 2 years. The average annual KS hospitalization rate for children <5 years of age was 15.2 per 100 000 children, and among that group the hospitalization rate was higher for infants <1 year of age than for children 1 to 4 years of age (19.7 and 16.0 per 100 000 children, respectively). Most KS hospitalizations occurred among children <5 years of age and among boys. The highest monthly number of hospitalizations occurred during the months of November through January. No deaths associated with KS were reported among hospitalized children. CONCLUSION: Hospital discharge data provide useful information on the epidemiology of KS in Ireland. The hospitalization rate for KS in Ireland is similar to rates in the United States and may be higher than those in other European countries, although the European studies differ in methodologies and time periods.     

Lower respiratory tract infections among american Indian and Alaska Native children and the general population of U.S. Children

BACKGROUND AND OBJECTIVE: Lower respiratory tract infections (LRTIs) cause substantial childhood morbidity. This study characterizes and compares LRTI-associated morbidity among American Indian/Alaska Native (AI/AN) children and the general population of U.S. children. METHODS: Hospitalization and outpatient records with a diagnosis indicating LRTIs were evaluated for children aged younger than 5 years during 1990-2001. RESULTS: For 1999-2001, the LRTI-associated hospitalization rate was significantly higher for AI/AN children than for U.S. children (116.1 versus 63.2/1000, respectively), with the disparity being greater for infants than for 1- to 4-year-old children. Also the rate of LRTI-associated outpatient visits among AI/AN infants was higher than that for all U.S. infants (737.7 versus 207.2/1000, respectively). LRTI hospitalization and outpatient visit rates were highest in the Alaska and Southwest Indian Health Service regions. During 1990-2001, the LRTI hospitalization rate among AI/AN infants in the Alaska region and among the general U.S. infant population increased. Bronchiolitis-associated hospitalization rates increased for AI/AN and U.S. infants, whereas the pneumonia-associated hospitalization rate decreased among AI/AN infants and remained stable among U.S. infants. CONCLUSIONS: LRTIs continue to be an important cause of morbidity in children, especially among AI/AN infants in the Alaska and Southwest regions. Strategies to reduce LRTI hospitalizations and outpatient visits are warranted for all infants, but the greatest potential impact would be among AI/AN infants.     

Injury hospitalizations among American Indian youth in Washington

OBJECTIVE: To determine the rate and causes of hospitalizations for injury among American Indian and Alaska Native (AI/AN) youth in the state of Washington, and to compare this with the rate of hospitalizations for injury among youth of all races. METHODS: Subjects were aged 0-19 years and were admitted to civilian hospitals for care of an injury (International Classification of Diseases N codes 800-995) in Washington between 1990 and 1994. Deaths occurring in the prehospital setting and emergency department are not included. Using several fields of identifying information, the Washington state hospital discharge database was linked with the Indian Health Service (IHS) patient registration database to identify AI/AN youth. Denominator data included the total age specific IHS user population for American Indians and US Census derived population estimates. Incidence ratios (IRs) were calculated to compare rates of hospitalization between AI/AN youth and all youth in Washington. RESULTS: A total of 694 and 29,048 hospitalizations for injury were identified for AI/AN youth and all races, respectively. The rate of hospitalization for injuries among AI/AN youth was 507 discharges per 100,000 youth (IR = 1.30; 95% confidence interval (CI) 1.20 to 1.40. The leading mechanism of injury was motor vehicles (IR 1.73, CI 1.49 to 2.01), followed by falls (IR 0.95, CI 0.79 to 1.15), and poisoning (IR 1.20, CI 0.80 to 1.78). The disparity was greater for intentional injuries (IR 1.71, CI 1.44 to 2.04). The highest IR for all unintentional injuries was for injuries from fire (IR 2.35, CI 1.42 to 3.87). AI/AN children aged 15-19 had the greatest disparity for rates of injury hospitalization (IR 1.4, CI 1.25 to 1.56). CONCLUSION: AI/AN youth in Washington had a higher hospitalization rate for injury compared with all youth in the state. Disparities were greatest for injuries related to motor vehicles and assaults. When linked, hospital discharge data can be used for surveillance of AI/AN hospitalizations.     

Kawasaki syndrome hospitalizations among children in Hawaii and Connecticut

OBJECTIVES: To estimate the incidence and describe recent trends of Kawasaki syndrome (KS) in 2 different areas of the United States. METHODS: Retrospective analysis of Hawaii and Connecticut State KS hospital discharge records for children younger than 5 years. RESULTS: In Hawaii, 175 KS hospitalizations for children younger than 5 years were reported during 1994 through 1997; the annual hospitalization rate per 100,000 children was 47.7. The rate for Hawaiian children younger than 1 year (83.2) was greater than that for 1- to 4-year-old children (39.0), and most hospitalizations occurred prior to age 2 years (median age, 17 months). In Connecticut, 171 KS hospitalizations for children younger than 5 years were reported during 1993 through 1996; the annual hospitalization rate per 100,000 children was 18.8, and the median age at hospitalization was 28 months. For both states, most hospitalizations were for boys. Although no clear seasonality was apparent, monthly peaks occurred in some of the years from December through March. CONCLUSIONS: Kawasaki syndrome seems to remain an endemic disease in the United States. A high KS annual hospitalization rate was seen in Hawaii, especially in children younger than 1 year, whereas in Connecticut, the KS rate was more consistent with those previously reported in the continental United States. Arch Pediatr Adolesc Med. 2000;154:804-808     

Kawasaki syndrome in Hawaii

OBJECTIVE: To describe the incidence and epidemiology of Kawasaki syndrome (KS) in Hawaii. METHODS: Retrospective analysis of the State Inpatient Database for Hawaii residents hospitalized with KS during 1996 through 2001. RESULTS: During 1996 through 2001, 267 persons younger than 18 years of age living in Hawaii were hospitalized with KS; 226 (84.6%) were younger than 5 years of age. The average annual incidence for KS was 45.2 per 100,000 children younger than 5 years of age. The incidence was higher for children younger than 1 year of age than for those 1-4 years of age (74.3 and 37.5 per 100,000). The KS incidence for Asian and Pacific Islander children and for White children was 70.9 and 35.3 per 100,000, respectively. Incidence was highest among Japanese American children living in Hawaii (197.7 per 100,000). Honolulu County had the most KS patients (85.0%) and the highest incidence (53.1 per 100,000) among Hawaii counties. For children younger than 5 years of age hospitalized with KS, the median length of stay was 2 days, and the median hospital charge was $9379. CONCLUSION: During 1996 through 2001, the annual incidence rate for KS among children younger than 5 years of age in Hawaii was the highest in the United States. The incidence among Japanese American children in Hawaii was higher than that among other racial groups in the state and when compared with children living in Japan.     

The incidence of Kawasaki syndrome in West Coast health maintenance organizations

BACKGROUND: Kawasaki syndrome (KS) causes an acute vasculitis of unknown etiology. It is a leading cause of acquired heart disease of children in Japan and the United States. METHODS: We examined the incidence of KS in a well-defined population group of children < or =6 years of age, using data collected through the Vaccine Safety Datalink (VSD) project. The VSD database contains information on >1 million children enrolled in four West Coast health maintenance organizations (HMOs). RESULTS: During 1993 through 1996 a total of 234 physician-diagnosed KS patients were reported in the 4 HMOs; 152 (65.0%) were boys and 195 (83.3%) were <5 years of age. The incidence of KS among children <5 years of age in the HMOs ranged from 9.0 to 19.1 per 100,000 person years. KS incidence was higher among boys in 3 of the sites. In the 2 sites with the highest number of KS patients, a seasonal occurrence of KS in winter and early spring was observed. Overall 226 (96.6%) of the KS patients were reported to have been hospitalized; hospitalization rates for children <5 years of age ranged from 9.0 to 16.8 per 100,000 person years. CONCLUSIONS: The incidence of KS in the HMOs was similar to that reported in other population-based studies in the United States and higher than estimates for Australia and several European countries.     

Trends in hospitalization for empyema in Alaska Native children younger than 10 years of age

We analyzed hospitalizations for empyema among Alaska Native (AN) children and the general population of US children <10 years of age during the years 1998 to 2007. We also analyzed invasive pneumococcal disease in AN children. Between 1998 and 2000, the average annual hospitalization rate for empyema was higher for AN children (51.8 per 100,000/yr) than that for US children (24.2 [95% confidence interval: 20.4, 27.9] per 100,000/yr), and had increased in 2004-2007 in both populations (59.6 and 36.0 [95% confidence interval: 30.1, 41.8], respectively). Pneumococcal empyema increased in AN children despite a decrease in invasive pneumococcal disease pneumonia.     

Severe bronchiolitis and respiratory syncytial virus among young children in Hawaii

BACKGROUND: Lower respiratory tract infections are a leading cause of hospitalization and mortality among children worldwide. Our objective was to describe the incidence and epidemiology of severe bronchiolitis, respiratory syncytial virus (RSV), and pneumonia among children in Hawaii. METHODS: Retrospective analysis of the patient-linked hospital discharge data associated with bronchiolitis, RSV, and pneumonia among Hawaii residents younger than 5 years of age during 1997 through 2004 using the Hawaii State Inpatient Database. RESULTS: During 1997 through 2004, the average annual incidence rates for bronchiolitis, RSV, and pneumonia were 3.8, 2.7, and 6.8 per 1000 children younger than 5 years, respectively. The incidence of each condition was higher for infants younger than 1 year (15.1, 9.8, and 15.9 per 1000 infants, respectively) than the incidence for children 1-4 years of age, and higher for boys compared with girls. The incidence of each condition was highest among Native Hawaiian and other Pacific Islander children compared with children of other race groups living in Hawaii. Most hospitalizations occurred during the months of October through February. Estimated median hospital charges were $4806 (bronchiolitis), $5465 (RSV) and $5240 (pneumonia), with overall average annual charges of $11.5 million. CONCLUSION: The incidence and hospitalization rates for bronchiolitis, RSV, and pneumonia among children younger than 5 years of age in Hawaii were low; the corresponding hospitalization rates were lower than those for the general U.S. population. However, the hospitalization rates for each condition among Hawaiian and other Pacific Islander children were much higher than those for other race groups or for the U.S. population.     

Kawasaki syndrome in Denmark

OBJECTIVE: To describe the epidemiologic characteristics of Kawasaki syndrome (KS) and to estimate national KS incidence rates among children in Denmark. METHODS: A retrospective population-based study using hospital discharge records with a KS diagnosis for children younger than 15 years selected from the Danish National Hospital Register for 1981-2004. Incidence rates were calculated using the number of KS patients and corresponding census data. RESULTS: During 1981-2004, 360 children younger than 15 years were hospitalized with KS in Denmark, with 73% younger than 5 years. In this age group, the average annual incidence of KS gradually increased from 1981 to 1999 and thereafter stabilized at 4.5 to 5.0 per 100,000 person-years. The incidence was greater for boys than for girls (RR = 1.6, 95% CI = 1.2-2.0) and was highest among infants younger than 1 year (4.5), declining with increasing age (P = 0.03). However, the age-specific decline in incidence was only observed for boys, whereas the incidence for girls remained unchanged by age. The median length of hospital stay was 12 days, and the incidence peaked in the winter months. CONCLUSIONS: Major epidemiologic characteristics identified among Danish childhood KS are consistent with those described in previous studies, such as highest incidence among young children and winter-seasonality. The KS incidence rate among children younger than 5 years in Denmark increased steadily during the early study period (coinciding with global recognition of KS) and seems to have stabilized from 1998-1999 onwards. Although the incidence among Danish children was lower than that reported for several other European countries, differences in methodology challenge definite comparisons.     

INCIDENCE OF CHILDHOOD LEUKEMIA IN SWEDEN 1975-1980

ABSTRACT. During the six-year period 1975-1980, leukemia was diagnosed in 466 children in Sweden, giving an estimated incidence of 4.4/100000 children per year (0-15 years at diagnosis). The incidence of acute lymphoblastic leukemia (ALL) was 3.7, of acute nonlymphocytic leukemia (ANLL) 0.6 and of chronic myelocytic leukemia (CML) 0.1/100000 children per year. The over all incidence among boys was 4.5/100000 per year and among girls 4.2. The male:female ratio was 1.13. This ratio was 1.22 in ALL and 0.71 in ANLL. Fifty per cent of the children were below 5 years of age at diagnosis, with a pronounced peak between 2-3 years, which was explained by the ALL distribution. In children with acute leukemia 13% had WBC values of >100×10⁹l, 4% had CNS leukemia and 10% had a mediastinal mass at diagnosis. The geographical distribution of leukemia in Sweden was analysed in a search for clusters of cases.     

Epidemiology of invasive and other pneumococcal disease in children in England and Wales 1996–1998

The results of enhanced national surveillance of pneumococcal disease in children <15y of age in England and Wales are reported for the period 1996–1998. Of the 1985 cases of laboratory-confirmed invasive disease (annual incidence 6.6 per 100000 overall and 39.7 per 100000 in infants <1 y of age), 485 (24%) were meningitis (annual incidence of 1.6 per 100000 overall and 15.7 per 100000 in infants <1 y of age). Fifty-nine deaths in children with invasive disease were identified-3% of the total reports. Thirty-one different serogroups/types were identified, with organisms in the 7-valent conjugate vaccine responsible for 69% of the infections in children <5 y of age; this rose to 77% and 82%, respectively, for the 9-and 11-valent vaccines. Resistance to penicillin varied from 2.3% to 6.2% in different years, but erythromycin resistance remained constant at 17%. The vast majority of resistant isolates were in vaccine serotype/groups. Computerized hospital admission records for all children <15 y of age with a discharge diagnosis code indicating probable pneumococcal disease were also analysed for 1997. The annual incidence for cases with a code specifically mentioning S. pneumoniae was 9.9 per 100000 compared with 71.2 per 100000 for lobar pneumonia; the mean duration of stay for both was < 1 wk. The incidence of admission for pneumococcal meningitis (1.9 overall and 19.6 for infants < 1 y of age) was similar to that derived from laboratory reports and resulted in an average duration of stay of 2 wk.
Conclusion : This surveillance has confirmed the substantial burden of morbidity attributable to pneumococcal disease in British children and the potential public health benefits that could be achieved by the use of pneumococcal conjugate vaccines.     

Emergency transport for Japanese children with non‐life‐threatening conditions

Background: Emergency rooms in Japan are overused by children with non‐life‐threatening conditions, and utilization of emergency transport for children in Japan should also be analyzed. Methods: Utilization rates of emergency transport per 1000 live births or 1000 children from 1985 to 2008 in Japan were calculated from national data of emergency transport, child population and annual live births. Results: Emergency transport per 1000 preschool‐age (28 days‐6 years old) and school‐age (7–17 years old) children rose, and that for newborn babies (0–27 days old) per 1000 live births grew from 1985 to 2008. The utilization rates, however, did not grow homogeneously among the different severity groups. The rates of transport for children who needed no hospitalization or those for children who needed inpatient care <3 weeks rose in each of the three age groups. The rates for patients who were dead on arrival or who needed hospitalization ≥3 weeks, however, declined in all the age groups. Conclusions: Emergency transport per 1000 live births or 1000 children grew from 1985 to 2008. The utilization rates, however, did not grow homogeneously among different severity groups. The rates for children with non‐life‐threatening conditions rose, while those for children dead on arrival or with severe conditions declined in the past two decades.     

Surveillance of pediatric injury hospitalizations in Southern California.

OBJECTIVES: This study was designed to determine the incidence and causes of injury hospitalizations/fatalities to children less than 15 years of age. SETTING: Central Orange County, California. DESIGN: Cases were identified through a population based hospital and coroner's office surveillance system. SUBJECTS: The sample consisted of children 0-14 years of age who were residents of the study area and sustained an injury between 1 January 1991 and 31 December 1992 resulting in hospitalization or death. RESULTS: Over the two year study period, 1361 children 0-14 years of age were hospitalized or died as a result of injury. This represents a crude annual injury rate of 318/100,000 children. Rates were highest for children less than 5 years--this age group sustained the highest rate for eight of nine specific causes of injury. Falls were the leading cause of hospitalizations for all ages. Pedestrian injuries were more common among children 1-4 years and 5-9 years, while bicycle injuries were more common among older children. CONCLUSIONS: This study, one of the first population based studies in a Southern California urban/suburban community, found lower rates of injury hospitalization than studies conducted over a decade ago. These lower rates may reflect changes in hospitalization trends and/or injury prevention programs. Comparisons with more recent studies in inner city communities in the north east also show regional differences in rates and causes. Injury prevention efforts should particularly address the higher injury rates among children less than 5 years of age. This study also illustrates the need for regional and local data to guide injury control.     

Spatial and temporal clustering of Kawasaki syndrome cases

BACKGROUND: The etiology of Kawasaki syndrome (KS) remains unknown despite 30 years of intensive search for an agent. Epidemiologic clues to a possible infectious etiology include the seasonal distribution of cases, the previous occurrence of epidemics, the clinical features of the syndrome that mimic other infectious rash/fever illnesses in children, the self-limited nature of the illness, and the peak age incidence in the toddler years. METHODS: We examined the epidemiology and spatial and temporal distribution of KS cases in San Diego County, California during the 6-year period from 1998 to 2003. Clustering in space and time was analyzed using geo-referenced data with the K-function, the local G-statistic, and Knox statistic. RESULTS: A total of 318 patients were identified through active surveillance. The overall annual incidence was 21.7/100,000 in children <5 years, with rates in whites, white Hispanics, and Asian/Pacific Islanders of 15.3, 20.2, and 45.9/100,000, respectively. The Knox test showed significant clustering of cases within the space-time interval of 3 km and 3-5 days. CONCLUSIONS: This is the first study of KS cases to use geo-referenced point pattern analysis to detect spatial and temporal clustering of KS cases. These data suggest that an infectious agent triggers the immunologic cascade of KS.     

Epidemiology of cat-scratch disease hospitalizations among children in the United States

BACKGROUND: Cat-scratch disease (CSD), caused by infection with Bartonella henselae, affects both children and adults but is principally a pediatric disease. Typical CSD is generally benign and self-limited and is characterized by regional lymphadenopathy with fever. Infections can, however, be accompanied by focal or diffuse inflammatory responses (atypical CSD) involving neurologic, organ (liver/spleen), lymphatic or skeletal systems. METHODS: Pediatric hospitalizations with CSD listed as a diagnosis were examined using the Kids' Inpatient Database for the year 2000. National estimates of CSD-associated hospitalizations, hospitalization rates and various hospitalization statistics were examined for patients younger than 18 years of age. RESULTS: During 2000, an estimated 437 (SE 43) pediatric hospitalizations associated with CSD occurred among children younger than 18 years of age in the United States. The national CSD-associated hospitalization rate was 0.60/100,000 children younger than 18 years of age (95% confidence interval, 0.49-0.72) and 0.86/100,000 children younger than 5 years of age (95% CI 0.64-1.07). Accompanying diagnoses included neurologic complications (12%), organ (liver/spleen) involvement (7%) and "other" (5%). Atypical CSD accounted for approximately 24% of the CSD-associated hospitalizations. The median charge for a CSD-associated hospitalization was 6140 dollars with total annual hospital charges of approximately 3.5 million dollars among children in the United States. CONCLUSIONS: The CSD-associated hospitalization rate among children during 2000 appeared similar to those estimated for the 1980s in the United States, despite significant increases in cat ownership in the intervening time. Early serologic and molecular testing for CSD in children is suggested to minimize unnecessary interventions and promote optimally effective care when supportive measures are required.     

Childhood injury deaths: rural and urban differences, Colorado 1980-8.

OBJECTIVES: The purpose of this study is to describe and compare the distribution of injury deaths among rural and urban Colorado children that occurred between 1980-8. METHOD: Death certificates coded E800-E969 were obtained for children who were 0-14 years of age at death between 1980-8 and who were Colorado residents. Average annual rates were computed for rural and urban children, separately by gender. The 1980 census was used to compute rates. Rate ratios were calculated to summarize information related to specific external causes of deaths, contrasting rural and urban children. These differences were evaluated using Z tests. RESULTS: Statistically significant elevated risks were found along rural children for motor vehicle injury deaths. Firearms were involved more often in rural deaths among unintentional injury deaths of children older than 4 years of age, and among homicide related deaths of children 5 years and younger. All rural children who committed suicide used a firearm. CONCLUSIONS: Comparisons between rural and urban injury deaths provide important information that can be used to guide prevention strategies. For example, in Colorado, a child restraint law, passed in 1984, covered children under 4 years of age or under 40 pounds. It was not until 1995, however, that legislation was passed requiring restraint of children 5-16 years of age. Traditionally, rural residents are slower to accept new ideas and to alter current practices than urban residents.