Epidemiology of non-intentional injuries in an Australian urban region: results from injury surveillance

Epidemiological risk analysis of home injuries in Italy (1999-2006)

Home injuries are an important public health issue in both developed and developing countries. This study focused on the Italian epidemiological framework between 1999 and 2006, using a nation-representative sample provided by the National Institute of Statistics. Every year, about 3,000,000 Italian residents reported at least one home injury, with an overall annual rate of 5.2/100 (95% CI 5.1–5.4); 3.2/100 (3.0–3.4) for males and 7.2/100 (6.9–7.4) for females. Poisson regression models were used for different age-specific populations (children, young/adults and older people), to evaluate the effects of socio-demographic, health/income satisfaction and housing variables. For children, non-applicable variables (including smoking and health satisfaction) were taken as those of the head of family, while housework time was taken the family mean time. Evidence of decreasing time trend in risk of home injury was found only among young/adults (p < 0.01). The following were risk factors: female gender (adjusted relative risk—RR 2.0 for older people and RR 1.9 for young/adults, p < 0.01); one additional hour of work at home (RR 1.009, p < 0.01 for young/adults and RR 1.016, p = 0.01 for children); smoking (RR 1.3, p < 0.01 for young/adults and p = 0.02 for children); health dissatisfaction (RR 1.3, p = 0.05 for children, RR 1.6 for young/adults and RR 1.7 for older people, p < 0.01); income dissatisfaction (RR 1.2, p < 0.01 for young/adults ); living alone (RR 1.5, p < 0.01 for young/adults and RR 1.2, p < 0.02 for the older people); having a garden (RR 1.1, p < 0.01 for young/adults ). Awareness of the need for safety at home could be boosted by information campaigns on the risk, and its social cost could be reduced by specific prevention schemes. Developing tools for assessing the risk at home and for removing the main hazards would be useful for both informative and prevention interventions.

Home injuries in Italy: patterns of injury and the most exposed people

Home injuries are a significant public health problem in developed and developing countries. To support future policies for reducing their occurrence and controlling their consequences, this study investigated the home injuries situation in Italy in 1999, using a nation-representative sample. The weighted correspondence analysis showed four different patterns of injury and seven profiles of the people most exposed to them. As results of this study falls were followed by bumps and cuts requiring specialist assistance then burns. Women were the most exposed to burn and fall risks and men to the risk of cuts and bumps. Among the elderly and children, falls and bumps leading to fractures, wounds or other consequences were frequent. The risks were highest for people with a lower level of education. Bumps and cuts were prevalent among unmarried and with the highest education level subjects. These injury risks were higher for young males. Cuts in adults doing do-it-yourself jobs had the worst consequences, while domestic work cuts generally did not need medical treatment. Burns occurred almost exclusively in the kitchen (90%) and did not need specialist assistance. Because home injuries are largely preventable, an efficient public health policy could promote and disseminate home safety culture.

Using 0.45% saline solution and a modified dosing regimen for infusing N-acetylcysteine in children with paracetamol poisoning

INTRODUCTION

N-acetylcysteine (NAC) administration is recommended to all patients judged to be at risk of developing hepatotoxicity following paracetamol overdose. However, it has been shown that standard i.v. dosing can cause symptomatic hyponatraemia in children. We describe a case series using 0.45% NaCl plus 5% dextrose for infusing i.v. NAC in children with paracetamol poisoning.

CASE SERIES

A retrospective review of medical records of patients treated with NAC using 0.45% saline plus 5% dextrose, and a novel two-stage dosing regimen between January 2003 and July 2006 were undertaken.

RESULTS

A total of 40 patients (20 male and 20 female) who received NAC in 0.45% sodium chloride (NaCl) with 5% dextrose were identified. Mean age was 9 years 6 months (95% CI 4 years 4 months to 15 years 1 month) and the range 3 months to 17 years. All patients had NAC infused in a two-stage infusion regimen (150 mg/kg bolus over 1 h followed by a continuous infusion of 10 mg/kg/h for 20 h). The serum sodium was measured in all 40 patients with a mean of 140 (range of 133 to 152 mmol/L). Repeat sodium was measured in 35 cases, with a mean of 140 mmol/L (range from 134 to 149 mmol/L).

CONCLUSION

These findings support the use of saline-containing solutions to administer NAC as an alternative to 5% dextrose, and suggest that a two-stage infusion regimen should be further investigated with prospective studies.

A review of injury epidemiology in the UK and Europe: some methodological considerations in constructing rates

BACKGROUND

Serious injuries have been stated as a public health priority in the UK. However, there appears to be a lack of information on population-based rates of serious injury (as defined by a recognised taxonomy of injury severity) at national level from either official statistics or research papers. We aim to address this through a search and review of literature primarily focused within the UK and Europe.

METHODS

The review summarizes research papers on the subject of population based injury epidemiology published from 1970 to 2008. We examined critically methodological approaches in measuring injury incident rates including data sources, description of the injury pyramid, matching numerator and denominator populations as well as the relationship between injury and socioeconomic status.

RESULTS

National representative rates come from research papers using official statistics sources, often focusing on mortality data alone. Few studies present data from the perspective of an injury pyramid or using a standardized measure of injury severity, i.e. Injury Severity Score (ISS). The population movement that may result in a possible numerator - denominator mismatch has been acknowledged in five research studies and in official statistics. The epidemiological profile shows over the past decades in UK and Europe a decrease in injury death rates. No major trauma population based rates are available within well defined populations across UK over recent time periods. Both fatal and non-fatal injury rates occurred more frequently in males than females with higher rates in males up to 65 years, then in females over 65 years. Road traffic crashes and falls are predominant injury mechanisms. Whereas a straightforward inverse association between injury death rates and socio-economic status has been observed, the evidence of socioeconomic inequalities in non-fatal injuries rates has not been wholly consistent.

CONCLUSION

New methodological approaches should be developed to deal with the study design inconsistencies and the knowledge gaps identified across this review. Trauma registries contain injury data from hospitals within larger regions and code injury by Abbreviated Injury Scale enabling information on severity; these may be reliable data sources to improve understanding of injury epidemiology.

The epidemiology of paediatric head injuries: data from a referral centre in Victoria, Australia

AIM

Currently, there are no population-based or hospital-based studies on the full spectrum of paediatric head injuries (HIs) in Australia. We set out to provide detailed information on the incidence rates, causes and clinical management of all severities of HI in children and adolescents at an Australian tertiary referral centre using emergency department (ED) and admission data as a basis for further investigations and prevention efforts.

METHODS

A retrospective chart review of all children aged 0-16 years who attended the Royal Childrens Hospital (RCH), Melbourne, following a HI in 2004 was used. The cases were identified using the International classification of diseases 10th revision codes, and all medical records were reviewed based on a piloted data form. Information was collected on demographics, injury factors and clinical management of HIs in the hospital setting.

RESULTS

Over the 12-month period, there were 1115 children with an HI who attended the RCH ED, or were admitted. Ninety per cent were classified as mild, 8% as moderate and 3% as severe. Males and children under 3 years had the higher attendance rates. Falls, sports and motor vehicle accidents were the main HI causes. The main sport played (30%) when sustaining an HI was Australian rules football. Thirty-two per cent of children were admitted, 67% of these with mild HI. Twenty-one per cent had a radiology imaging study, most (67%) with a normal result.

CONCLUSIONS

Many HI causes appear preventable, in particular, falls from heights in infants and sports safety. High rates of admission and radiology imaging of mild HI warrant further investigation.

Injury risk from popular childhood physical activities: results from an Australian primary school cohort

BACKGROUND

Children engage in various physical activities that pose different injury risks. However, the lack of adequate data on exposure has meant that these risks have not been quantified or compared in young children aged 5-12 years.

OBJECTIVES

To measure exposure to popular activities among Australian primary school children and to quantify the associated injury risks.

METHOD

The Childhood Injury Prevention Study prospectively followed up a cohort of randomly selected Australian primary and preschool children aged 5-12 years. Time (min) engaged in various physical activities was measured using a parent-completed 7-day diary. All injuries over 12 months were reported to the study. All data on exposure and injuries were coded using the International classification of external causes of injury. Injury rates per 1000 h of exposure were calculated for the most popular activities.

RESULTS

Complete diaries and data on injuries were available for 744 children. Over 12 months, 314 injuries relating to physical activity outside of school were reported. The highest injury risks per exposure time occurred for tackle-style football (2.18/1000 h), wheeled activities (1.72/1000 h) and tennis (1.19/1000 h). Overall, boys were injured more often than girls; however, the differences were non-significant or reversed for some activities including soccer, trampolining and team ball sports.

CONCLUSION

Although the overall injury rate was low in this prospective cohort, the safety of some popular childhood activities can be improved so that the benefits may be enjoyed with fewer negative consequences.

Socio-economic distribution of environmental risk factors for childhood injury

OBJECTIVE

Childhood injury remains the single most important cause of mortality in children aged between 1-14 years in many countries. It has been proposed that lower socio-economic status (SES) and poorer housing contribute to potential hazards in the home environment. This study sought to establish whether the prevalence of observed hazards in and around the home was differentially distributed by SES, in order to identify opportunities for injury prevention.

METHODS

This study was a cross-sectional, random sample survey of primary school children from 32 schools in Brisbane. Interviews and house audits were conducted between July 2000 and April 2003 to collect information on SES (income, employment and education) and previously identified household hazards.

RESULTS

There was evidence of a relationship between prevalence of household environmental hazards and household SES; however, the magnitude and direction of this relationship appeared to be hazard-specific. Household income was related to play equipment characteristics, with higher SES groups being more likely to be exposed to risk. All three SES indicators were associated with differences in the home safety characteristics, with the lower SES groups more likely to be exposed to risk.

CONCLUSION

The differential distribution of environmental risk factors by SES of household may help explain the SES differential in the burden of injury and provides opportunities for focusing efforts to address the problem.

Quantifying the risk of sports injury: a systematic review of activity-specific rates for children under 16 years of age

Injuries caused by sports and other forms of physical activity in young children constitute a significant public health burden. It is important to quantify this risk to ensure that the benefits of sport participation are not outweighed by the potential harms. This review summarises the literature reporting exposure-based injury rates for various forms of physical activity in children aged 15 years and younger. Forty eight studies were found, of which 27 reported injury rates per hourly based exposure measured and 21 reported injury rates according to some other measure. Fourteen different sports and activities were covered, mostly team ball sports, with soccer being the most widely studied. Injury definition and the method of ascertaining and measuring injuries differed between studies, which created a large variation in reported injury rates that did not necessarily represent actual differences in injury risk between activities. The highest hourly based injury rates were reported for ice hockey, and the lowest were for soccer, although the range of injury rates for both of these activities was wide. Very few studies have investigated sports-related injuries in children younger than 8 years or in unorganised sports situations.

Quantifying the association between physical activity and injury in primary school-aged children

BACKGROUND

Regular physical activity is strongly advocated in children, with recommendations suggesting up to several hours of daily participation. However, an unintended consequence of physical activity is exposure to the risk of injury. To date, these risks have not been quantified in primary school-aged children despite injury being a leading cause for hospitalization and death in this population.

OBJECT

Our goal was to quantify the risk of injury associated with childhood physical activity both in and out of the school setting and calculate injury rates per exposure time for organized and non-organized activity outside of school.

METHODS

The Childhood Injury Prevention Study prospectively followed a cohort of randomly selected Australian primary school-and preschool-aged children (4 to 12 years). Over 12 months, each injury that required first aid attention was registered with the study. Exposure to physical activity outside school hours was measured by using a parent-completed 7-day diary. The age and gender distribution of injury rates per 10 000 hours of exposure were calculated for all activity and for organized and non-organized activity occurring outside school hours. In addition, child-based injury rates were calculated for physical activity-related injuries both in and out of the school setting.

RESULTS

Complete diary and injury data were available for 744 children. There were 504 injuries recorded over the study period, 396 (88.6%) of which were directly related to physical activity. Thirty-four percent of physical activity-related injuries required professional medical treatment. Analysis of injuries occurring outside of school revealed an overall injury rate of 5.7 injuries per 10000 hours of exposure to physical activity and a medically treated injury rate of 1.7 per 10000 hours.

CONCLUSION

Injury rates per hours of exposure to physical activity were low in this cohort of primary school-aged children, with <2 injuries requiring medical treatment occurring for every 10000 hours of activity participation outside of school.

Childhood sporting deaths

Exercise-induced collapse and sudden death are unusual in childhood. For this reason, a study was undertaken of a series of 12 cases of sudden death in childhood occurring during physical exertion associated with sporting activities. The age range was 7 to 16 years (mean 12.3 years, M:F ratio 5:1). Deaths resulted from trauma associated with the sporting activity, from an idiosyncratic response to exertion, or from exacerbation of a known underlying disease. Trauma was directly fatal (n = 4: vascular trauma in 1, head injury in 2, drowning in 1), exacerbated an underlying medical condition (n = 1: hypertrophic obstructive cardiomyopathy), or followed collapse from underlying organic disease (n = 1: drowning in epilepsy). Deaths after exertion occurred when there was an unexpected response to underlying occult disease (n = 4: aortic stenosis in 1, cerebral arteriovenous malformation in 1, hypertrophic obstructive cardiomyopathy in 1, coronary atherosclerosis in 1) or to preexisting known disease (n = 2: surgically corrected transposition of the great vessels in 1, asthma in 1). The fatal episodes often resulted from a complex interplay of a variety of factors, including physical exertion, possible trauma, and underlying organic disease. Testing of other family members may be indicated in cases where a rare, possibly familial, disease is found. Evaluation of cases required descriptions of activities before death, information from the medical history of the deceased, and detailed findings from the autopsy.

Gradients in risk for youth injury associated with multiple-risk behaviours: a study of 11,329 Canadian adolescents

This study used the Canadian version of the World Health Organization-Health Behaviour in School-Aged Children (WHO-HBSC) Survey to examine the role of multiple risk behaviours and other social factors in the etiology of medically attended youth injury. 11,329 Canadians aged 11-15 years completed the 1997-1998 WHO-HBSC, of which 4152 (36.7%) reported at least one medically attended injury. Multiple logistic regression analyses failed to identify an expected association between lower socio-economic status and risk for injury. Strong gradients in risk for injury were observed according to the numbers of multiple risk behaviours reported. Youth reporting the largest number (7) of risk behaviours experienced injury rates that were 4.11 times (95% CI: 3.04-5.55) higher than those reporting no high risk behaviours (adjusted odds ratios for 0-7 reported behaviours: 1.00, 1.13, 1.49, 1.79, 2.28, 2.54, 2.62, 4.11; p(trend) < 0.001). Similar gradients in risk were observed within subgroups of young people defined by grade, sex, and socio-economic level, and within restricted analyses of various injury types (recreational, sports, home, school injuries). The gradients were especially pronounced for severe injury types and among those reporting multiple injuries. The analyses suggest that multiple risk behaviours may play an important role in the social etiology of youth injury, but these same analyses provide little evidence for a socio-economic risk gradient. The findings in turn have implications for preventive interventions.

Injury surveillance in the ED: design, implementation, and analysis

Comprehensive, population-based surveillance for nonfatal injuries requires uniform methods for data collection from multiple hospitals. To show issues related to design and implementation of multihospital, emergency department (ED), injury surveillance, a city-wide system in the United States is discussed. From October 1, 1995 to September 30, 1996 all injury-related ED visits among District of Columbia residents <3 years of age were ascertained at the 10 hospitals where city children routinely sought care. Information was abstracted from 2,938 injury-related, ED visits (132.7 visits/1,000 person-years). Based on this experience, suggestions to facilitate design of multihospital, injury surveillance in other locations are offered. Importantly, injury-related visits were reliably ascertained from ED logs, and for most variables, a systematic sample of injury-related visits was representative of the total injured population. However, there is a need for more complete documentation of circumstances surrounding injuries and for standardization of data elements on ED logs and treatment records.

Evaluation of the Latrobe Valley Better Health Injury Prevention Program

OBJECTIVE

To evaluate the Latrobe Valley Better Health Injury Prevention Program, a regional community based intervention in south east Victoria, Australia.

METHOD

The evaluation design was quasiexperimental including pre-intervention and post-intervention observations in a predominately town dwelling population of approximately 76,000. There was no comparison community. Process measures included key informant interviews. Impact evaluation utilised self reported changes in injury risk and protective factors, gathered by a random household telephone survey. Outcome evaluation was based on five years of emergency department injury surveillance data for the Latrobe Valley.

RESULTS

The program built strategic partnerships, increasing the emphasis on local safety. Activities were implemented in the targeted areas of home, sport, and playground injuries. Some 47,000 educational contacts were made with the community and at least 6,000 resource items distributed. There were significant increases in home safety knowledge. Some changes in the areas of playground and sport safety were achieved after partnership development with relevant agencies. Poisson regression models showed significant decreases in the presentation rate for all home injury and for the more severe home injuries.

CONCLUSION

This study clearly demonstrates the difficulty of conducting robust evaluation in the absence of readily available and reliable data and adequate budgets. The Latrobe Valley Better Health Program activities contributed to structural, environmental, and organisational changes that have the potential to reduce injury. The extent of this contribution beyond that made by the statewide injury prevention strategy is not able to be determined.

Surface characteristics, equipment height, and the occurrence and severity of playground injuries

OBJECTIVES

To evaluate whether surface characteristics (absorption level (g-max), material) and the height of play equipment are related to the occurrence and severity of injuries from falls.

SETTING AND METHODS

During the summers of 1991 and 1995, conformity of play equipment to Canadian standards was assessed in a random sample (n = 102) of Montreal public playgrounds. Surface absorption (g-max) was tested using a Max Hic instrument and the height of equipment was measured. Concurrently, all injuries presenting at the emergency department of Montreal's two children's hospitals were recorded and parents were interviewed. Inspected equipment was implicated in 185 injuries. The g-max measurements (1995 only) were available for 110 of these playground accidents.

RESULTS

One third of falls (35 %) occurred on a surface exceeding 200 g and the risk of injury was three times greater than for g level lower than 150 (95% confidence interval (CI) 1.45 to 6.35). On surfaces having absorption levels between 150 g and 200 g, injuries were 1.8 times more likely (95% CI 0.91 to 3.57). Injuries were 2.56 times more likely to occur on equipment higher than 2 m compared with equipment lower than 1.5 m. Analysis of risk factors by severity of injury failed to show any positive relationships between the g-max or height and severity, whereas surface material was a good predictor of severity.

CONCLUSIONS

This study confirms the relationships between risk of injury, surface resilience, and height of equipment, as well as between type of material and severity of injury. Our data suggest that acceptable limits for surface resilience be set at less than 200 g, and perhaps even less than 150 g, and not exceed 2 m for equipment height. These findings reinforce the importance of installing recommended materials, such as sand, beneath play equipment.

Injury surveillance in Victoria, Australia: developing comprehensive injury incidence estimates

This study aimed to develop an estimate of the incidence of all medically-treated injury by level of severity and to broadly describe the epidemiology of injury in the Australian State of Victoria in a given year. Victoria has developed a relatively comprehensive injury surveillance system. Data is currently collected by various agencies on injury deaths, hospitalisations and emergency department attendances. The method used to establish the incidence of both unintentional and intentional injury is described. Incidence figures were directly derived, or estimated from, the available Victorian health sector and Coronial data bases for three level of severity (deaths, hospitalisations and medical treatment only) and for causes of injury, age and gender groups, location of the injury event and activity at the time of injury. In 1993/1994, injuries resulted in at least 1487 deaths, 67,402 persons hospitalised and an estimated 397,160 medically-treated, non-hospitalised injured persons in Victoria. In total, over 466,000 people were injured or 10.5 persons per year for every 100 residents. Males sustain 62% of all injuries yet represent 49.5% of the population. Almost three-quarters of injury fatalities and over 60% of non-fatal injuries occur among males. Young people aged 15-24 years account for 22% of all injuries yet represent only about 16% of the Victorian population. Children (0-14 years) also suffer relatively high injury rates, although mainly less severe, while the elderly are at risk of more severe injuries. The leading cause of injury death in Victoria is suicide, followed by motor vehicle accidents, whereas falls are the leading cause of all non-fatal injury. Most injuries occur in the home (36%), areas of sport and recreation (12.5%) and transport (11.7%). They are mainly associated with leisure activities (33.1%), work (11%) and transportation (10.8%). This study demonstrates a method for the development of comprehensive injury incidence estimates. The results indicate that injuries have a significant impact on the Victorian community, health care system and economy in general. Reliable incidence data are necessary for descriptive epidemiology and provide the basis for quality of life and economic cost studies. Together this information has potential application for evidence-based strategic planning and evaluation in injury research and prevention.

Children at play: the death and injury pattern in New South Wales, Australia, July 1990-June 1994

OBJECTIVES

To describe and to understand the pattern of play-related deaths and injury (excluding organized sports) among children in New South Wales (NSW), Australia.

METHODOLOGY

This study utilized a state-wide prospective surveillance data collection of paediatric traumatic deaths and injuries at the Royal Alexandra Hospital for Children. Deaths and injury cases were selected from the NSW Trauma Death Registry and Childsafe NSW database. Information including basic demographics, the surrounding circumstances of death and injury incidents, and the required treatment was collected.

RESULTS

There were 30 play-related deaths and 92 drownings over the 4-year period. The male to female ratio was about 2:1. Excluding drowning, which has been reported elsewhere, and sports, the leading causes of play-related deaths were burns (eight) and asphyxiation (eight). An average of 6444 presentations to the emergency departments per year were recorded with sex ratio and age distribution pattern similar to the deaths. The home was the most common place (55.5%) of play-related injury, specifically the living and sleeping area. Falls, both under and above 1 metre, were the most common causes of injury (50.9%). The leading mechanism was cuts and lacerations (21.2%). Nearly one-third (32.7%) of all injuries were to the head, with face, cheek, forehead and scalp as the most common injured body part. Significant associations between place of injury, injured body parts and age were observed.

CONCLUSIONS

Play-related injury is common among children, and in some cases causes severe injury and death. To tackle the problem of play-related deaths and injuries, a holistic approach is suggested. This includes the provision of a safe environment, supervision by parents, education of children and detailed data collection.

Permanent sequelae in sports injuries: a population based study

AIM

To identify permanent sequelae after sports injuries in children and adolescents.

METHODS

In 1985, a prospective register was drawn up of all sports related injuries reported that year by the residents of Trieste, Italy aged 6-15 years. Moderate to severe injuries (scoring >/= 2 on the abbreviated injury scale (AIS)) were the object of a longitudinal clinical study. In 1988, 30.9% of the 220 subjects enrolled had sequelae. A further follow up was undertaken in 1997.

RESULTS

The follow up in 1997 involved 54 subjects (26 girls; average age 24.5 years). Subjective and objective sequelae, by now considered to be permanent, were found in 61.1%, corresponding to 15% of the AIS >/= 2 injuries recorded in 1985. The prevalence of sequelae was similar in the two sexes, in relation to the child's age at time of injury, and in the different sports practised. It was higher in relation to the severity of the lesion (89% of AIS 3 injuries examined, 56% of AIS 2 injuries) and to the type of lesion and its location. With regard to AIS >/= 2 injuries, permanent sequelae were found in 50% of ankle fractures, 43% of elbow fractures, 33% of leg/foot fractures, 25% of knee sprains, and 23% of ankle sprains.

CONCLUSIONS

The frequency of sequelae in sports injuries in children and adolescents is high. The risk appears to be connected to certain anatomical and functional age characteristics. Prevention strategies should include specific assessment of physical fitness and adequate follow up after the accident, particularly rehabilitation.

Unintentional poisoning hospitalisations among young children in Victoria

OBJECTIVES

To describe the epidemiology of unintentional childhood poisoning hospitalisation in Victoria, Australia, in order to monitor trends and identify areas for research and prevention.

METHODS

For children under 5 years, all Victorian public hospital admissions, July 1987 to June 1995, due to unintentional poisoning by drugs, medicines, and other substances were analysed. Similar cases were also extracted from the database of the Royal Children's Hospital intensive care unit, Melbourne for the years 1979-91. Log linear regression modelling was used for trend analyses.

RESULTS

The annual average childhood unintentional poisoning rate was 210.7 per 100,000. Annual rates for males consistently exceeded those for females. The most common agents were those acting on the respiratory system and on smooth and skeletal muscles (muscle relaxants, cough and cold medicines, antiasthmatics), aromatic analgesics (paracetamol), and systemic agents (including antihistamines). Further investigation is justified for cardiac agents, some respiratory agents, and asthma medications.

CONCLUSIONS

Childhood poisoning hospitalisation rates have not decreased in Victoria over recent years. A focused, agent specific approach, as well as a series of generic measures for the prevention of poisoning to children under 5 is advocated. The ongoing surveillance, collection and analysis of data, in addition to research on specific poisoning agents are essential components of any prevention strategy.

Sport and active recreation injuries in Australia: evidence from emergency department presentations

OBJECTIVE

Despite the rise in specialist clinical services for the management of sports and active recreation injury, many patients attend hospital emergency departments for treatment. The purpose of this study was to describe sports injury cases presented to selected hospital emergency departments around Australia for the period 1989-1993.

METHODS

Routinely collected emergency department injury presentation data from the Australian National Injury Surveillance Unit were examined. Data on 98,040 sports and active recreation emergency department presentations were analysed. Sports and active recreation activities were ranked according to frequency of presentation. Relative proportions of injury type and body region injured were determined. Data are presented separately for children (<15 years of age) and adults (>15 years of age).

RESULTS

Among the 10 activities that most commonly led to a sports or active recreation injury presentation for all ages were cycling, Australian football, basketball, soccer, cricket, netball, and rugby. For children, injuries were also commonly associated with roller skating/blading, skateboarding, and trampolining. Hockey, martial arts, and dancing injuries were frequent in adults. Most sporting injuries occurred during organised competition or practice whereas the active recreation injuries occurred in a variety of settings. Fractures, strains, and sprains, particularly to the lower and upper extremities, were common types of injury.

CONCLUSION

The rich, but nevertheless limited, information available about sports and active recreation injuries from data collected in emergency departments indicates that these activities are a common context for injury at the community level in Australia.

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.

Reduction in paediatric burn admissions over 25 years, 1970-94

Objective–To describe trends in burn admissions to a large paediatric burn centre, between 1970 and 1994.

Methods–Hospital records of the Royal Children's Hospital burns unit were audited for the years 1970-94 (n=4992), statewide hospital admissions identified from the Victorian Inpatient Minimum Database for the period, 1987-94 (n=3353), and Victorian burn deaths ascertained from the Australian Bureau of Statistics (n=163), 1970-94.

Results–Between 1970 and 1994 there was a 66% reduction in the annual number of burn admissions to the Royal Children's Hospital, a similar reduction across the state, from 52.4 (95% confidence interval (CI): 48 to 57)/100 000 in 1987 to 34.5 (95% CI:31 to 38)/100 000 in 1994 (p<0.05), and over a 40% fall in the mortality rate. Reductions occurred for all types of burns: scalds 60%; flame burns 55%; and contact burns 70%, but at differing time periods corresponding to the introduction of product legislation, education programs, or changes in heating practices. There was no decline in beverage related scalds. The proportion of children admitted with severe burns increased over the 25 year period, probably reflecting changes in referral practice, while the average length of hospital stay steadily declined, independent of burn type or burn severity.

Conclusions–We believe these reductions reflect the effects of mandatory changes in sleepwear standards and regulations, modifications in heating practices, legislated improvements in the safety of household products, and to a lesser extent the effect of burn education prevention campaigns in the media, especially those directed towards hot water burn injuries among younger children.

Automatic dishwasher detergent poisoning: opportunities for prevention

We investigated the antecedents of ingestion of dishwashing machine detergent to enable the development of effective countermeasures. Parents who had sought advice from the Victorian Poisons Information Centre about dishwasher detergent poisoning exposures of their children were interviewed by telephone. Almost all the children (94 per cent) were aged between 6 and 29 months. Of the 61 children included in the survey, 53 (87 per cent) gained access to the detergent from the dishwasher. Of these, 50 (94 per cent) took the detergent from the dispenser on the internal surface of the door of the machine, and 38 (76 per cent) of these ingested detergent remaining in the dispenser after operation of the machine. Parents were present in the room on 78 per cent of occasions at the time of ingestion. Most parents (72 per cent) were aware of the toxicity of the detergents. Relocation of the dispenser or redesigning it to prevent access both before and after operation would have prevented most of the exposures to detergent. Altering the detergent to prevent caking or sludging might prevent many of the exposures to detergent remaining in the dispenser after operation of the machine. The level of prior knowledge about toxicity suggests that education or additional warnings are unlikely to contribute substantially to prevention of poisoning. Telephone call-back to identified cases is a useful method of investigating complex poisoning problems and developing effective countermeasures.

Annual incidence of unintentional injury among 54,000 children

OBJECTIVE

To enhance the case definition of unintentional injuries in childhood by applying an objective severity measure to fatal and non-fatal cases.

DESIGN

A descriptive prospective epidemiological study of a defined resident childhood population (< 16 years of age) for a one year period, 1990.

SETTING

Newcastle upon Tyne, England. Child population estimate for 1990 was 54,400.

SUBJECTS

Resident children who died, were admitted to local hospitals, or attended local accident and emergency departments.

OUTCOME MEASURES

Using recognised severity scoring systems (for example the injury severity score, trauma score) injuries were classified as severe, moderate, or mild.

RESULTS

There were six deaths, 904 admissions, and 11,682 accident and emergency department attendances. All deaths, 25% of admissions, and 1% of accident and emergency attenders were classified as severe. The underlying determinants of severe injuries are different than those for all other injuries (for example age, social class). A comparison with a local survey in 1986 showed a 26% rise in hospital admissions, but no significant rise in the frequency of severe or moderately injured children. Comparisons with other international data showed higher rates of injury admissions and attendances for England, but no significant differences in the frequency of severe injuries.

CONCLUSIONS

Objective severity scoring enhances the case definition of unintentional injuries in childhood by allowing for the identification, and, therefore, the more reliable ascertainment of severely injured children. This more completely ascertained set of population cases increases the accuracy of comparisons of injury frequency over time and by place, and, in addition, enhances our basic understanding about the epidemiological characteristics of childhood unintentional injury.

Rollerblading injuries in young people

OBJECTIVE

To study injuries in young people associated with the use of rollerblades, draw comparisons with skateboarding and rollerskating injuries, and suggest strategies for injury prevention.

METHODOLOGY

Injuries associated with the use of rollerblades, skateboards and rollerskates in young people aged < or = 14 years recorded on the Victorian Injury Surveillance System database since its inception in 1989 were examined to identify secular trends. All injuries associated with these pastimes recorded on the database by three sentinel hospitals during a 1 year period were examined in detail. Medical notes were perused to verify features of the event and obtain further information. A semi-structured telephone interview of a sample of 10-14 year old rollerbladers, the most commonly injured age-group, was carried out to obtain more specific information.

RESULTS

There has been a marked increase in the absolute numbers of injuries associated with the use of rollerblades since 1989. In 1992, they were most common in the 10-14 year age group, which sustained 59% of all injuries; 47% of injuries were fractures of the forearm and wrist. Of a sample of 33 of those injured in the 10-14 year age group, 10 (30%) had been using rollerblades for the first time. There is some evidence to suggest a concomitant fall in skateboarding injuries.

CONCLUSIONS

Injury surveillance data collected in Melbourne suggest an increasingly important contribution by rollerblading to the pattern of injury seen in young people. Preventive strategies require further evaluation but could include learning basic techniques in a controlled setting, separation from road traffic and the wearing of helmets and wrist, elbow and knee guards.

A case-control study of child bicycle injuries: relationship of risk to exposure

In order to assess the relationship of the risk of injury requiring hospital attendance in children riding bicycles to sociodemographic factors and to measures of exposure, a population-based case-control study is being undertaken in a large area of suburban Melbourne, Australia. Particular attention is given to the measurement of individual exposure in several dimensions. Analysis of interim data from 109 cases and 118 controls shows that 51% of injuries occurred while the child was playing rather than making a trip on the bicycle and only 22% involved another vehicle. Boys used bicycles more commonly than girls but there was minimal evidence of an increased risk of injury in boys, adjusting for exposure. There was no evidence for an age trend in injury risk, but children from families in the lowest income category were at significantly increased risk. Exposure measures showed complex patterns of association with injury risk. Estimated time spent riding was more closely associated with risk than distance travelled, with an odds ratio of 2.2 (95% confidence interval 1.1-4.2) for children riding for more than 3 hours per week compared to children riding less than 1 hour. Riding more than 5 km on the sidewalk was also associated with increased risk (odds ratio 3.1, 95% CI 1.1-8.5). The elevated risk associated with sidewalk riding may be due to difficulties in negotiating uneven surfaces. The case-control study provides an ideal design for this type of investigation but valid and reliable measurement of exposure is difficult.

Injury morbidity in Victoria among adults 25 to 64 years of age: implications for prevention

The aim of this retrospective study was to complete the baseline descriptive epidemiology of hospital-treated injury for all ages in Victoria, by focusing on the age group, 25 to 64 years, to identify major categories of injury and the potential for prevention. We analysed injury databases for hospital admissions and emergency department presentations for major variables influencing injury frequency and rates. We found that nearly 40 per cent (158 537) of all hospitalisations for injury occurred in the study age range. The major causes of injury were health-care related causes (32 per cent), falls (15 per cent), transport (14 per cent), and intentional causes (10 per cent). The leading reason for emergency department presentation (excluding admission) was unintentional cutting or piercing injury. The home was the major location of injury. Vehicles, man-made and natural surfaces, knives, and floors and flooring materials were among the leading five factors potentially associated with both admissions and presentations. Injury prevention in this age range will be largely addressed by the injury-prevention strategy being implemented in Victoria. However, specific additional issues were identified, including falls from ladders and scaffolds, pedestrian and female passenger injury, and injury associated with power tools, chain saws, and knives.

Deaths from injury in childhood in Western Australia 1983-1992

OBJECTIVE

To examine the factors associated with deaths from injury in childhood.

SETTING

Western Australia.

DESIGN

Mortality rates and population data provided by the Australian Bureau of Statistics for children aged 0-14 years between 1983 and 1992 were examined retrospectively. Deaths from injury were extracted and cause of death, district of residence, age, sex and race (Aboriginal or non-Aboriginal) identified. A similar study from 1953 to 1962 and extracts from the World health statistics annual (1991) were used for comparison.

RESULTS

In the 10-year period, 462 children died from injury. Almost two-thirds were boys. The annual mortality rate (per 100,000) was 12.2: 9.9 in metropolitan areas and 16.6 in the country. This had fallen from a rate of 29.6 in 1953-1962. Causes of death and mortality rates were: motor vehicle accidents, 5.1; drowning, 2.9; suffocation and inhalation, 0.6; burns, 0.4; poisonings, 0.3; and others, 2.0. The mortality rate for Aboriginal children was 40.6, nearly four times that of non-Aboriginal children. There was a reduction in deaths due to burns and poisoning and a considerable reduction in deaths of child motor vehicle passengers, except in the age group 0-1 year. Drowning remains a serious problem, particularly for the 1-4 year olds. Australian childhood mortality rates are higher than for some European countries, but lower than for New Zealand and the United States.

CONCLUSIONS

To further reduce deaths from injury in childhood, I recommend that car seat restraint legislation be extended to include all children. Deaths from drowning and all deaths from injury in Aboriginal children need further investigation to develop strategies for prevention.

Head injuries in helmeted child bicyclists

OBJECTIVE

To determine the characteristics and the severity of head and facial injuries to helmeted child bicyclists, and whether the helmet contributed to the injury, and to study factors related to bicycle accidents.

DESIGN

Retrospective review of two case series. Children sustaining head injury while not wearing helmets were studied as a form of reference group.

SETTING

Large paediatric teaching hospital.

SUBJECTS

34 helmeted child bicyclists and 155 non-helmeted bicyclists, aged 5-14 years.

MAIN OUTCOME MEASURES

Number of injuries, type of injuries, injury severity score, deaths, and accident circumstances.

RESULTS

79% of the head injuries of the helmeted child group were mild and two thirds of these had facial injuries. Children in the helmet group were in a greater proportion of bike-car collisions than the no helmet group and at least 15% of the helmets were lost on impact. There were no injuries secondary to the helmet.

CONCLUSIONS

Most of the head injuries sustained by the helmeted children were of mild severity and there was no evidence to suggest that the helmet contributed to injury. Nevertheless, consideration should be given to designing a facial protector for the bicycle helmet and to improvement of the fastening device.

Work-related deaths of children and adolescents in Australia, 1982 to 1984

Work-related deaths of children and adolescents up to the age of 19 years were studied as part of a larger investigation into all work-related fatalities in Australia in the three-year period, 1982 to 1984. This study aimed to characterise the circumstances which led to the deaths of these children. Of 1738 work-related fatalities identified over the three years in the larger investigation, 67 (4 per cent) were aged under 15 years, and 117 (7 per cent) were aged 15 to 19 years. The fatalities were characterised by a number of variables, the most important being age, sex, bystander status, location (farm or other) and vehicle involvement (especially tractors). The causes of death differed between subgroups. Although existing controls may be reasonably effective in minimising child deaths in most work places, farms are an exception. On farms, home and work activities overlap, and informal participation in work by the young is quite common. Preventive efforts should give special attention to farms and tractors, to toddlers and male children, and to measures (such as safety devices and other external control measures) which do not rely on behavioural change in the young people at risk. Adults responsible for young children should be educated to anticipate dangerous situations and thus ensure children are protected from injury hazards.

Child injury in Brisbane South 1985-91: implications for future injury surveillance

Specific childhood injury types are ranked by occurrence rate for mortality, hospital admission and emergency department attendance. Cases are drawn from the resident population of Brisbane South, 0-13 years of age, for the period 1 July 1985 to 30 June 1991. A total of 47,244 injuries, 7056 admissions and 99 deaths were analysed. The overall mortality rate was 12.6/100,000 per year (95% confidence interval (CI), 10.2-15.3), the overall admission rate was 911/100,000 per year (95% CI, 890-932) and the overall hospital attendance rate was 6013/100,000 per year (95% CI, 5958-6067). A fall was the most frequent injury mechanism for admissions and 65% of attendances involved injury in the child's own home. The surveillance data establish regional variation for childhood injury risk within Australia and identify an unexplained downward trend in head injury that requires further investigation. The future development of injury surveillance in Australia requires simplified coding which can be integrated into new computerized patient management information systems.

Neuropathological chewing: a dental management protocol and treatment appliances for pediatric patients

Neuropathological chewing in hospitalized, comatose patients can occur from severe brain damage following a closed head injury, hypoxia, and septic shock. The dental management protocol developed by the Department of Dentistry at the Royal Children's Hospital, Melbourne, Australia, is presented. Treatment appliances utilizing a mandibular cast-silver cap splint with acrylic bite blocks and a maxillary mouthguard with acrylic bite blocks are discussed.

The socio-economic context of child injury in Australia

After the first year of life, injury is the leading cause of mortality in children and adolescents in Australia and a major cause of morbidity and hospitalization. Studies from Europe and North American and more recently New Zealand have demonstrated that injury rates differ between different socio-economic groups, with a relatively consistent pattern of higher rates being found in lower socio-economic groups. To date, the pattern of child injury morbidity by socio-economic group has not been studied in Australia. Eighteen months of data from Brisbane and Melbourne collections of the National Injury Surveillance Unit data base were analysed and linked to census data from each postcode in the collecting area to calculate injury rates. Injury rates for each postcode were correlated with measures of disadvantage derived from the same census data. There was a consistent pattern of moderately strong statistically significant associations (Pearson correlation coefficients generally 0.30-0.60) found between measures of disadvantage and injury rate at the postcode level of aggregation. This association was present across cities, age groups, type of injury and for those hospitalized as well as those treated as outpatients. It is apparent that residence in a low income area is a significant predictor of child injury in Australia.

Australian Rules football injuries in children and adolescents

OBJECTIVE

To ascertain the incidence, severity, risk factors, and outcomes of injuries in children and adolescents playing Australian Rules football.

DESIGN

SETTING AND SUBJECTS

A prospective cohort study of football injuries in children and adolescents playing community football. We studied a stratified random sample of 54 teams and clinics (18 under-15 teams, 18 under-10 teams and 18 Vickick clinics for children under 10 years) from the Melbourne metropolitan area. Football exposure, injuries and associated risk factors were recorded for 1253 players during the 1992 football season.

RESULTS

Vickick, a modified form of the game, had the lowest rates of injury for all levels of injury severity, with an overall rate of 3.49 injuries per 1000 player-hours. The rate in the under-10 age group was 2.4 times higher (95% confidence interval [CI], 1.5-3.8) than that in Vickick, and the under-15 rate was 1.2 times (95% CI, 0.9-1.6) that of the under-10s. The under-15 age group had significantly more injuries that led to use of health services than the under-10 and Vickick groups, with rates of 3.93 (95% CI, 2.9-4.9), 0.64 (95% CI, 0.2-1.4), and 0.33 (95% CI, 0.1-0.8) injuries per 1000 players-hours respectively. Injuries were largely to soft tissues (sprains 26%, haematomas 25%) and to the lower limb (43%). Very few serious injuries occurred (19 fractures and three injuries with loss of consciousness); nearly all of these were in the under-15s. Rule modifications in under-10 teams and clinics were associated with an injury rate of 5.8 injuries per 1000 player-hours (95% CI, 4.4-7.3) compared with 7.5 injuries per 1000 player-hours (95% CI, 5.2-9.8) when no modification was used. Alterations to the ruck contest, decreased contact, field size and player numbers were significantly associated with lower injury rates, while body size was not. Of the 30% of injuries resulting in a health service consultation, the most common health provider was a medical practitioner. Very few required expensive investigation or treatment.

CONCLUSION

Injury rates were low in children under age 10, but higher in adolescents. Most injuries were minor, and did not result in a health professional consultation. Rule modifications were associated with substantially lower injury rates at the under-10 level, and should be promoted as a safe way to learn football skills.

Role of a children's hospital safety centre in injury control

Over the past 13 years, child safety centres have been established at several Australian Children's hospitals. In a short time, they have developed an important role in community injury control programmes. These centres provide an efficient conduit for transferring up-to-date injury surveillance and prevention information to families, industry, health and education professionals, and government. The activities of the Child Safety Centre at the Royal Children's Hospital in Melbourne are described, together with ways in which a degree of self-funding can be achieved.