Independent risk factors for injury in pre-school children: three population-based nested case-control studies using routine primary care data

Prevalence of Traumatic Dental Injuries and Associated Risk Factors Among Preschool Children in Goa: A Cross-Sectional Study

BACKGROUND AND AIM

Primary teeth trauma has received very little attention compared to permanent teeth due to their eventual exfoliation. Enamel discolorations, hypoplasias, and enamel-surface abnormalities have been reported in the permanent dentition following primary tooth trauma. Traumatic dental injuries (TDI) also have an impact on the quality of life of an individual. The study aims to determine the prevalence of TDI and its association with various risk factors in preschool children in the state of Goa. The primary objective is to determine the prevalence of TDI in primary anterior teeth in preschool children in the state of Goa. The secondary objective is to determine the association of various risk factors with TDI in preschool children in the state of Goa.

METHODS

A cross-sectional survey was conducted among preschool children aged three to five years across the state of Goa. A total of 971 children were included in the study. Parents or guardians of participants who reported trauma answered an interview addressing the history of the injury. The anterior dental trauma and associated factors such as age, gender, time of injury, month of injury, place of injury, occlusal relationship, lip competence, oral habits, and ordinal position of the child were assessed and analyzed.

RESULTS

Out of the 971 children examined, TDI was reported in 157 (16.1%) children. Of these, 83 of 157 (52.8%) children had experienced TDI at home. Three-year-old children had the highest TDI prevalence of any age group, with 32 of 145 (22.0%) experiencing TDI. The most commonly affected tooth (100 of 233, 10.3%) was the primary maxillary right central incisor. Of the 233 traumatized teeth, 100 (42.9%) had code 2 injuries (enamel fractures only), which were the most frequently reported injuries. Mesio-incisal angle fracture was detected in 84 (34.3%) teeth affected with TDI. With respect to the number of teeth traumatized, 99 of 157 (63.0%) of children had a single tooth traumatized. Among all children who had sustained TDI, 103 (65.6%) were firstborns, 50 (31.8%) were secondborns, and four (2.5%) were thirdborn children. Only eight children received treatment, of which seven received medications and only one child received dental treatment. Parents being unaware of TDI was the main reason for not seeking treatment.

CONCLUSIONS

This study highlights the critical need for educating parents and teachers about TDI prevention and the importance of prompt dental care. The findings offer valuable insights for formulating state- and national-level policies and preventive strategies for managing TDI.

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life.

METHODS

We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2 centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors.

RESULTS

A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.

CONCLUSIONS

In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.

Determinants of unintentional injuries in preschool age children in high-income countries: A systematic review

BACKGROUND

Injuries are the leading cause of death and disability in preschool children who are subject to specific risk factors. We sought to clarify the determinants of unintentional injuries in children aged 5 years and under in high-income countries and report on the methodological quality of the selected studies.

METHODS

A systematic review was conducted of observational studies investigating determinants of unintentional injury in children aged 0-5. Searches were conducted in Web of Science, Medline, Embase, PsycInfo and CINAHL. All methods of data analysis and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2021) guidelines. Determinants are reported at the child, parental, household and area level.

RESULTS

An initial search revealed 6179 records. Nineteen studies met the inclusion criteria: 17 cohort studies and 2 case control studies. While studies included longitudinal surveys and administrative healthcare data analysis, the highest quality studies examined were case-control designs. Child factors associated with unintentional injury include male gender, age of the child at the time of injury, advanced gross motor score, sleeping problems, birth order, attention deficit hyperactivity disorder (ADHD) diagnosis and below average score on the standard strengths and difficulties scale. Parental factors associated with unintentional injuries included younger parenthood, poor maternal mental health, hazardous or harmful drinking by an adult within the home, substance misuse, low maternal education, low paternal involvement in childcare and routine and manual socioeconomic classification. Household factors associated with injury were social rented accommodation, single-parent household, White ethnicity in the United Kingdom, number of children in the home and parental perception of a disorganised home environment. Area-level factors associated with injury were area-level deprivation and geographic remoteness.

CONCLUSION

Child factors were the strongest risk factors for injury, whereas parental factors were the most consistent. Further research is needed to examine the role of supervision in the relationships between these risk factors and injury. Injury intent should be considered in studies using administrative healthcare data. Prospective research may consider utilising linked survey and administrative data to counter the inherent weaknesses of these research approaches.

Epidemiology of unintentional childhood injuries in urban and rural areas of Nepal- A comparative study

Unintentional injuries are one of the leading causes of ill health, disability & death among the children and young adults worldwide. As these injuries are strongly related to social determinants, the burden falls mainly upon the Low- and Middle-Income Countries (LMICs) like Nepal. Thus, the main objective was to explore the epidemiology of unintentional childhood injuries in urban and rural areas of Kavrepalanchok district. A cross sectional analytical study was done in Bethanchok rural municipality and Dhulikhel municipality of Kavrepalanchok district. The respondents were interviewed using a pretested semi-structured questionnaire. The details of injuries sustained within the past 12 months were included. A total of 667 children aged 1-16 years were surveyed, among which 26% from rural and 17.2% from urban areas had unintentional injuries in the past 12 months. Falls were the most common mode of injury in both the areas. Similarly, the proportion of burn was more in rural area (16.1%) whereas, Road Traffic Injuries were more in urban area (12.5%). Majority of the injuries occurred at home (54.5%) while the child was playing (64.1%). Factors like child's gender and place of residence affected the occurrence of unintentional injuries (p<0.05). Out of total injured children, 18 of them had not recovered and 11 were left with some form of permanent disability. As the rate and pattern of unintentional childhood injuries in the rural and urban area differ, the prevention strategies should focus on risk factors that apply to both the areas and awareness should be created among the parents and primary caregivers about the fact that childhood injuries are predictable and preventable.

Maternal psychiatric and somatic illness, and the risk of unintentional injuries in children: variation by type of maternal illness, type of injury and child age

BACKGROUND

Maternal mental illness appears to increase the risk of unintentional childhood injuries, which are a common cause of morbidity and mortality in early childhood. However, little is known about the variations in this association by type of injury and child's age, and studies on the effects of maternal somatic illness on children's injury risk are scarce.

METHODS

We used Finnish total population register data from 2000 to 2017 to link 1 369 325 children to their biological mothers and followed them for maternal illness and childhood injuries until the children's sixth birthday. Cox regression models were used to examine the associations between maternal illness and children's injuries by type of illness (neurological, psychiatric and cancer), type of injury (transport injuries, falls, burns, drowning or suffocations, poisonings, exposure to inanimate and animate mechanical forces) and child's age (<1 year-olds, 1-2 year-olds, 3-5 year-olds).

RESULTS

After adjustment for family structure, maternal age at birth, maternal education, income, child's gender, native language and region of residence, children of unwell mothers showed a higher risk of injuries (HR: 1.21, 95% CI: 1.19 to 1.23). This association was clear for maternal neurological (HR: 1.31, 95% CI: 1.26 to 1.36) and psychiatric illnesses (HR: 1.20, 95% CI: 1.18 to 1.23) but inconsistent for cancer. Maternal illness predicted an increased risk of injury across all age groups.

CONCLUSIONS

Maternal mental and somatic illness may both increase children's injury risk. Adequate social and parenting support for families with maternal illness may reduce childhood injury.

Evaluating the effect of child home safety training upon three family support practitioner groups: a mixed-methods study

AIMS

Unintentional injuries in the home contribute substantially to preschool child morbidity and mortality. Practitioners such as health visitors, family mentors and children's centre staff are well-positioned to facilitate child injury prevention by providing home safety advice to families, and training may enhance their ability to do so. We aimed to assess the impact of child home safety training for these practitioners.

METHODS

An explanatory mixed-methods design was used. Practitioners completed questionnaires before, and up to 7 months after, receiving child home safety training and took part in interviews. Seventy-eight health visitors, 72 family mentors and 11 children's centre staff members completed questionnaires. Items were used to calculate scores on home safety knowledge, confidence to provide home safety advice and belief that child home safety promotion is important. Thematic analysis of interviews with seven health visitors and nine family mentors, open-ended responses to the questionnaires and an additional evaluation form was conducted to explore attendees' perceptions of the training and its impact. In addition, seven health visitors and six children's centre staff who had received no training were interviewed.

RESULTS

Knowledge was greater post-training than pre-training across all participants (p < .001). When practitioner groups were analysed separately, there were significant increases in family mentors' knowledge (p < .001) and belief (p = .016), and health visitors' confidence (p = .0036). Qualitative findings indicated that most training session attendees valued the training, believed their practice relating to child home safety had improved as a result, and felt further similar training sessions would be beneficial. Those who had not attended the sessions described a need for more child home safety training.

CONCLUSIONS

Delivering training to practitioners providing child home safety promotion to families with preschool children can enhance injury prevention knowledge, beliefs and confidence and positively impact on home safety promotion by practitioners.

Implementation fidelity of the 'Stay One Step Ahead' home safety intervention: a mixed-methods analysis

OBJECTIVE

To assess implementation fidelity of the Stay One Step Ahead (SOSA), a complex intervention which was delivered by health visiting teams, children's centres, and family mentors and was aimed at preventing unintentional home injuries in children under 5 in disadvantaged communities.

STUDY DESIGN

A mixed-methods evaluation of the implementation fidelity of the SOSA intervention.

METHODS

A conceptual framework for implementation fidelity was used to triangulate data from questionnaires and semistructured interviews with parents and practitioners, observations of parent and practitioner contacts, and meeting documents. Quantitative data were analysed using logistic regression and descriptive statistics. Thematic analysis was used for qualitative data.

RESULTS

Parents in intervention wards were more likely to receive home safety advice from a practitioner than those living in matched control wards. Monthly safety messages and family mentor home safety activities were delivered with greater fidelity than other intervention components. Content most frequently adapted included the home safety checklist used by health visiting teams, and safety weeks delivered at children's centres.

CONCLUSION

Consistent with similarly complex interventions, SOSA was delivered with variable fidelity in a challenging environment. The findings add to the body of evidence on implementation fidelity of home injury prevention programmes, providing important information for future intervention development and delivery.

Effectiveness of systematically delivered evidence-based home safety promotion to improve child home safety practices: a controlled before-and-after study

OBJECTIVE

Evaluate the effectiveness of systematically delivered evidence-based home safety promotion for improving child home safety practices.

DESIGN

Controlled before-and-after study.

SETTING

Nine electoral wards in Nottingham, UK.

PARTICIPANTS

361 families with children aged 2-7 months at recruitment living in four intervention wards with high health, education and social need; and 401 in five matched control wards.

INTERVENTION

Evidence-based home safety promotion delivered by health visiting teams, family mentors and children's centres including 24 monthly safety messages; home safety activity sessions; quarterly 'safety weeks'; home safety checklists.

OUTCOMES

Primary: composite measure comprising having a working smoke alarm, storing poisons out of reach and having a stairgate. Secondary: other home safety practices; medically attended injuries. Parents completed questionnaires at 12 and 24 months after recruitment plus optional three monthly injury questionnaires.

RESULTS

At 24 months there was no significant difference between groups in the primary outcome (55.8% vs 48.8%; OR 1.58, 95% CI 0.98 to 2.55) or medically attended injury rates (incidence rate ratio 0.89, 95% CI 0.51 to 1.56), but intervention families were more likely to store poisons safely (OR 1.81, 95% CI 1.06 to 3.07), have a fire escape plan (OR 1.81, 95% CI 1.06 to 3.08), use a fireguard or have no fire (OR 3.17, 95% CI 1.63 to 6.16) and perform more safety practices (β 0.46, 95% CI 0.13 to 0.79).

CONCLUSIONS

Systematic evidence-based home safety promotion in areas with substantial need increases adoption of some safety practices. Funders should consider commissioning evidence-based multicomponent child home safety interventions.

TRIAL REGISTRATION NUMBER

ISRCTN31210493.

Exposures and Suspected Intoxications to Pharmacological and Non-Pharmacological Agents in Children Aged 0-14 Years: Real-World Data from an Italian Reference Poison Control Centre

This study describes the exposures and suspected intoxications in children (0-14 years) managed by an Italian reference poison control center (PCC). A seven-year observational retrospective study was performed on the medical records of the Toxicology Unit and PCC, Careggi University Hospital, Florence (Italy). During the study period (2015-2021), a total of 27,212 phone call consultations were managed by the PCC, of which 11,996 (44%) involved subjects aged 0-14 years. Most cases occurred in males (54%) aged 1-5 years (73.8%), mainly at home (97.4%), and with an oral route of intoxication (93%). Cases mainly occurred involuntarily. Consultations were generally requested by caregivers; however, in the age group 12-14 years, 70% were requested by healthcare professionals due to voluntary intoxications. Cleaners (19.44%) and household products (10.90%) were the most represented suspected agents. Pharmacological agents accounted for 28.80% of exposures. Covariates associated with a higher risk of emergency department visit or hospitalization were voluntary intoxication (OR 29.18 [11.76-72.38]), inhalation route (OR 1.87 [1.09-3.23]), and pharmacological agents (OR 1.34 [1.23-1.46]), particularly central nervous system medications. Overall, consultations do not burden national and regional healthcare facilities, revealing the activity of PCCs as having a strategic role in reducing public health spending, even during the COVID-19 pandemic.

The effect of birth order on length of hospitalization for pediatric traumatic brain injury: an analysis of the 1987 Finnish birth cohort

Purpose

This study examines the relationship between birth order and length of hospitalization due to pediatric traumatic brain injury (TBI).

Methods

We prospectively followed 59,469 Finnish newborns from 1987 until age 18 years. Data on first diagnosis of TBI was recorded within the 1987 Finnish Birth Cohort (FBC). Hospitalization period was divided into two categories: 2 days or less and more than 2 days. The latter was considered in this study as longer hospitalization.

Results

Compared with first born siblings, later born siblings had an increased risk of a longer hospitalization for TBI (12.7% of fourth or higher born birth children diagnosed with TBI were hospitalized for 2 or more days, 11.3% of first born, 10.4% of third born and 9.0% of second born). Fourth or higher born children were more likely to experience a repeat TBI; 13.4% of fourth or higher born children diagnosed with TBI had 2–3 TBIs during the study period compared to 9% of third born, 7.8% of second born and 8.8% of the first born. Injuries in the traffic environment and falls were the most common contributors to pediatric TBI and occurred most frequently in the fourth or higher birth category; 29.3% of TBIs among fourth or higher birth order were due to transport accidents and 21% were due to falls.

Conclusions

This study revealed a significant increase in risk for longer hospitalization due to TBI among later born children within the same sibling group. The study provides epidemiological evidence on birth order as it relates to TBI, and its potential to help to explain some of the statistical variability in pediatric TBI hospitalization over time in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00919-x.

Unintentional injuries and potential determinants of falls in young children: Results from the Piccolipiù Italian birth cohort

OBJECTIVES

Unintentional injuries such as falls, are particularly frequent in early childhood. To date, epidemiological studies in this field have been carried out using routine data sources or registries and many studies were observational studies with a cross-sectional design. The aims of the study are to describe unintentional injuries in the first two years of life in the Piccolipiù birth cohort, and to investigate the association between mother and children characteristics and the First Event of Raised surface Fall (FERF).

METHODS

This longitudinal observational study included 3038 children from an Italian birth cohort. Data on socio-demographic factors, socio-economic indicators, maternal health and lifestyle characteristics and child's sleeping behavior, obtained from questionnaires completed at birth, 12 and 24 months of age, were considered in the analyses as potential risk factors of FERF. Time of occurrence of FERF was analyzed using the Kaplan-Meier method. The multivariable analysis for time to event was carried out using a Cox proportional hazards model.

RESULTS

Falls from raised surfaces are the leading cause of unintentional injuries in the cohort with 610 (21.1%) and 577 (20.0%) cases among children during the first and second year of life, respectively. An increased risk of FERF was associated with several risk factors: maternal psychological distress (HR 1.41, 95%CI 1.10-1.81), maternal alcohol intake (HR 1.26, 95%CI 1.10-1.45), and child's sleeping problems (HR 1.28, 95%CI 1.09-1.51). Children with older aged mothers (HR 0.98, 95%CI 0.96-0.99) and living in northern Italy (HR 0.64, 95%CI 0.55-0.75) had a lower risk of FERF.

CONCLUSION

The results of the study suggest that a higher risk of FERF is associated with socio-demographic factors, maternal characteristics and child sleeping behavior that could hinder parent empowerment.

Birth order and pediatric traumatic brain injury

Pediatric traumatic brain injury (TBI) is a significant problem of public health importance worldwide. Large population-based studies on the effect of birth order on health phenomena are exceedingly rare. This study examines the relationship between birth order and risk for pediatric TBI among sibling groups. We performed a retrospective cohort study following 59,469 Finnish newborns from 1987 until age 18 years. Data on first diagnosis of TBI was recorded within the 1987 Finnish Birth Cohort (FBC). Compared with first born siblings, later born siblings had an increased risk of TBI during the follow-up period (hazard ratio [HR] 1.02; 95% confidence interval [CI] 0.91–1.14 for second born, HR 1.09; 95% CI 0.95 1.26 for third born, HR 1.28; 95% CI 1.08–1.53 for fourth or higher). When adjusted for sex and maternal age at child’s birth, HRs (95% CIs) for TBI during the follow-up period were 1.12 (0.99–1.26) for second born, 1.31 (1.12–1.53) for third born and 1.61 (1.33–1.95) for fourth born or higher children, respectively. Within this large register-based population-wide study, order of birth modified risk for pediatric TBI among sibling groups. Taken together, these study findings may serve to stimulate further inquiry into genetic, psychological, or psychosocial factors which underlie differences in risk and depth of effect within and between sibling groups.

Risk of somatic disease and mortality in individuals of parents with alcohol use disorder: a register-based cohort study

AIMS

To estimate the risks of 12 types of somatic disease-alcohol-related, blood, cancer, circulatory, digestive, endocrine and metabolic, genitourinary, infectious, musculoskeletal, nervous, respiratory and skin-in individuals with parental alcohol use disorder (AUD) versus a reference population, and to estimate the risks of all-cause mortality and of death from an alcohol-related cause.

DESIGN

Matched cohort study followed-up through nation-wide health registries. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

SETTING

Denmark.

PARTICIPANTS

A total of 14 008 individuals born 1962-2003 of parents with AUD and 139 087 reference offspring randomly selected from the Danish Civil Registration System were followed from their 15th birthday and onward during 1970-2018. Follow-up time ranged between 2 423 955 and 3 208 366 person-years for somatic diseases and was 3 214 411 person-years for all-cause and alcohol-related mortality.

MEASUREMENTS

Information on somatic disease was obtained from the Danish National Patient Registry. Causes of death were obtained from the Danish Cause of Death Registry.

FINDINGS

Individuals of parents with AUD had a higher risk of alcohol-related diseases (HR = 2.70, 95% CI = 2.24-3.24) compared with the reference individuals. Higher HRs among individuals with parental AUD compared with reference individuals were also observed in all other somatic diseases except for cancer. All-cause mortality (HR = 1.80, 95% CI = 1.63-2.00) and alcohol-related mortality (HR = 3.28, 95% CI = 2.11-5.08) were higher among individuals of parents with AUD compared with the reference individuals. No significant differences were found in relation to the gender of either parents or offspring.

CONCLUSIONS

In Denmark, parental alcohol use disorder appears to predict alcohol-related and non-alcohol-related somatic morbidity and mortality in offspring.

Effects of Cell Phone Use on Caregiver Supervision and Child Injury Risk

OBJECTIVE

Unintentional injuries are the leading killer of children in the United States. Caregiver supervision decreases child injury risk; however, little research has examined the effects of distractions (e.g., cell phone use) on caregiver supervision and subsequent ability to protect children from injury. In particular, despite the prevalence of cell phone use, no research has examined the degree to which caregiver cell phone use may impair caregivers' ability to supervise their children effectively. The present study used a within-subjects design to examine whether caregiver cell phone use impacted caregiver vigilance and child engagement with potential hazards.

METHODS

A total of 51 caregiver-child dyads were observed in a pseudo hazards room across three conditions (cell phone distraction, pen-and-paper distraction, no distraction) to examine the effects of cell phone use on caregiver vigilance and child behavior (i.e., engagement with hazards) related to injury risk.

RESULTS

Caregiver vigilance was higher in the no distraction condition compared to the two distraction conditions (cell phone and pen-and-paper). Moreover, child engagement with hazards was lower in the no distraction condition than in the two distraction conditions. Although both distraction conditions impaired caregiver vigilance, caregivers were more impaired in the pen-and-paper condition compared to the cell phone condition.

DISCUSSION

Regardless the form, distracting tasks (both cell phone use and pen-and-paper task) impacted both caregiver and child behavior associated with injury risk. It is important that professionals working with parents educate them about the risks of supervising children while distracted and encourage mindful supervision to ensure safety.

Day care as a strategy for drowning prevention in children under 6 years of age in low- and middle-income countries

BACKGROUND

Drowning is responsible for an estimated 320,000 deaths a year, and over 90% of drowning mortality occurs in low- to middle-income countries (LMICs), with peak drowning rates among children aged 1 to 4 years. In this age group, mortality due to drowning is particularly common in rural settings and about 75% of drowning accidents happen in natural bodies of water close to the home. Providing adequate child supervision can protect children from drowning, and organized formal day care programs could offer a way to achieve this.

OBJECTIVES

Primary objective • To assess the effects of day care programs for children under 6 years of age on drowning-related mortality or morbidity, or on total drowning accidents (fatal and non-fatal), in LMICs, compared to no day care programs or other drowning prevention interventions Secondary objectives • To assess the effects of day care programs in LMICs for children under 6 years of age on unsafe water exposure • To assess safety within these programs (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) • To assess the incidence of unintentional injury within these programs • To describe the cost-effectiveness of such programs, in relation to averted drowning-related mortality or morbidity SEARCH METHODS: On November 23, 2019, and for an update on August 18, 2020, we searched MEDLINE (PubMed), Embase, CENTRAL, ERIC, and CINAHL, as well as two trial registries. On December 16, 2019, and for an update on February 9, 2021, we searched 12 other resources, including websites of organizations that develop programs targeted to children.

SELECTION CRITERIA

We included randomized, quasi-randomized, and non-randomized controlled studies (with explicitly listed specific study design features) that implemented formal day care programs as a single program or combined with additional out-of-day care components (such as educational activities aimed at preventing injury or drowning or early childhood development activities) for children of preschool age (below 6 years of age) in LMICs for comparison with no such programs or with other drowning prevention interventions. Studies had to report at least one outcome related to drowning or injury prevention for the children enrolled.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection and data extraction, as well as risk of bias and GRADE assessment.

MAIN RESULTS

Two non-randomized observational studies, conducted in rural Bangladesh, involving a total of 252,631 participants, met the inclusion criteria for this review. One of these studies compared a formal day care program combined with parent education, playpens provided to parents, and community-based activities as additional out-of-day care components versus no such program. Overall we assessed this study to be at moderate risk of bias (moderate risk of bias due to confounding, low risk of bias for other domains). This study showed that implementation of a formal day care program combined with parent education, provision of playpens to parents, and community-based activities, in a rural area with a high drowning incidence, likely reduces the risk of death from drowning over the study period of 4 years and 8 months compared to no day care program (hazard ratio 0.18, 95% confidence interval [CI] 0.06 to 0.58; 1 study, 136,577 participants; moderate-certainty evidence). Drowning morbidity (non-fatal drowning resulting in complications), total drowning (fatal and non-fatal), unsafe water exposure, and program safety (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) were not reported, nor was the incidence of other unintentional injuries. Cost-effectiveness was reported as 812 USD (95% CI 589 to 1777) per disability-adjusted life-year averted as a consequence of drowning (moderate-certainty evidence). The second study compared day care programs with or without playpens provided to parents as an additional component versus only playpens provided to parents as an alternative drowning prevention intervention. Overall we assessed the study to be at critical risk of bias because we judged bias due to confounding to be at critical risk. As the certainty of evidence was very low, we are uncertain about the effects on drowning mortality rate of implementing a day care program compared to providing playpens (rate ratio 0.25, 95% CI 0.15 to 0.41; 1 study; 76,575 participants; very low-certainty evidence). Likewise, we are uncertain about the effects of a day care program with playpens provided as an additional component versus playpens provided alone (rate ratio 0.06, 95% CI 0.02 to 0.12; 1 study, 45,460 participants; very low-certainty evidence). The other outcomes of interest - drowning morbidity, total drowning, unsafe water exposure, program safety, incidence of other unintentional injuries, and cost-effectiveness - were not reported.

AUTHORS' CONCLUSIONS

This review provides evidence suggesting that a day care program with additional out-of-day care components such as community-based education, parent education, and playpens provided to parents likely reduces the drowning mortality risk in regions with a high burden of drowning compared to no intervention.

Maternal depression and childhood injury risk: A population-based cohort study in Denmark

AIMS

To assess the association between different stages of maternal depression and injury risk in offspring aged 0-10 years.

METHODS

Population-based cohort study of all live-born children in Denmark from 1 January 1997 until 31 December 2013 (n = 1,064,387). Main outcome measure was emergency department contacts with a main diagnosis of injury coded as DS00-DT98 (chapter XIX) according to the ICD-10. All information was obtained from Danish national registries.

RESULTS

Maternal depression was associated with higher injury hazard in the offspring throughout childhood compared to offspring of mothers with no history of depression. The strongest association was seen for the first year of life. First-time maternal depression was most strongly associated with injury in the child, especially in the first year of life (aHR = 1.70, 95% CI: 1.48-1.96). Children of mothers with relapse depression had 1.57 higher hazard of injury in the first year of life (aHR: 1.57, 95% CI: 1.44-1.70). Children of mothers with previously treated depression (postdepression) had 1.13 higher hazard of injury in the first year of life (aHR: 1.13, 95% CI: 1.09-1.17). Continuous treatment for depression was associated with a nonsignificant higher hazard of injuries in the first year of life (aHR: 1.06, 95% CI: 0.91-1.23).

CONCLUSIONS

Maternal depression was associated with higher injury risk in the offspring, particularly in early childhood. The association persisted in children of mothers with relapse depression. Our results suggest that children of mothers with depression are vulnerable several years after depression onset and treatment cessation.

Association Between Maternal Working Status and Unintentional Injuries Among 3 to 4-Month-Old Infants in Japan

OBJECTIVES

Globally, unintentional injuries are one of the leading causes of infant death. Established risk factors for injuries during infancy include single parent households, socioeconomic disadvantage and maternal postpartum depression. We sought to examine whether maternal working status is associated with unintentional injury among infants in Japan.

METHODS

We used data from an original questionnaire targeting mothers who participated in a 3 or 4-month health check-up program in Aichi prefecture, Japan. Experience of any type of unintentional injury was used as the primary outcome, and we also examined the experience of "falls" and "near-drowning" as secondary outcomes. We conducted multivariable logistic regression analysis, adjusting for covariates. We also performed propensity score matching in order to balance covariates between paid employment and unpaid employment groups.

RESULTS

Among 6,465 valid responses (response rate, 67%), 9.8% of infants experienced unintentional injuries. After matching on propensity for maternal employment (based on 26 covariates), we found that infants of mothers in paid employment were 1.35 times (95% CI: 1.04-1.74) more likely to experience injures, including 1.60 times higher likelihood of falls (95% CI: 1.14-2.24). Near-drowning was not significantly associated with maternal employment. We also found that father's employment status was positively associated with risk of falls.

CONCLUSION

Both multivariable logistic analysis and propensity score matching analysis revealed that maternal paid employment status was associated with unintentional injuries among Japanese infants. To prevent infant injuries, comprehensive support for working families should be considered.

Incident Type 2 Diabetes and Risk of Fracture: A Comparative Cohort Analysis Using U.K. Primary Care Records

OBJECTIVE

To estimate risk of fracture in men and women with recent diagnosis of type 2 diabetes compared with individuals without diabetes.

RESEARCH DESIGN AND METHODS

In this cohort study, we used routinely collected U.K. primary care data from The Health Improvement Network. In adults (>35 years) diagnosed with type 2 diabetes between 2004 and 2013, fractures sustained until 2019 were identified and compared with fractures sustained in individuals without diabetes. Multivariable models estimated time to first fracture following diagnosis of diabetes. Annual prevalence rates included at least one fracture in a given year.

RESULTS

Among 174,244 individuals with incident type 2 diabetes and 747,290 without diabetes, there was no increased risk of fracture among males with diabetes (adjusted hazard ratio [aHR] 0.97 [95% CI 0.94, 1.00]) and a small reduced risk among females (aHR 0.94 [95% CI 0.92, 0.96]). In those aged ≥85 years, those in the diabetes cohort were at significantly lower risk of incident fracture (males: aHR 0.85 [95% CI 0.71, 1.00]; females: aHR 0.85 [95% CI 0.78, 0.94]). For those in the most deprived areas, aHRs were 0.90 (95% CI 0.83, 0.98) for males and 0.91 (95% CI 0.85, 0.97) for females. Annual fracture prevalence rates, by sex, were similar for those with and without type 2 diabetes.

CONCLUSIONS

We found no evidence to suggest a higher risk of fracture following diagnosis of type 2 diabetes. After a diagnosis of type 2 diabetes, individuals should be encouraged to make positive lifestyle changes, including undertaking weight-bearing physical activities that improve bone health.

Parental alcohol intoxication and adverse health outcomes among offspring. A 4-year follow up HUNT study among 2399 Norwegian adolescents

This study aimed to investigate whether experience of parental alcohol intoxication was associated with adverse health outcomes among adolescents four years later. A population-based Norwegian cohort study of 2399 adolescents who participated in the Young-HUNT1 Survey 1995-97 (T1, 13-15 years old) was followed up four years later (T2) in 2000 (Young-HUNT2, 17-19 years old). Measures were based on adolescent self-report of exposure to parental alcohol intoxication, self-rated general health, mental distress (SCL-5) and lifetime hospital admission. Multivariable logistic regression analyses, adjusted for gender, age and parental education were applied. Results show that half of the adolescents (51%) had seen parents intoxicated at age 13-15 years. Four years later, those who had reported parental alcohol intoxication at T1 had increased odds of admission to hospital with odds ratios ranging from OR1.3; CI 1.0-1.7 to OR 2.2; CI 1.3-3.9, poorer self-rated health (odds ratio ranging from 1.8;1.2-2.6 to 2.0;1.1-3.7) and more mental distress (odds ratio ranging from 1.7;1.1-2.5 to 1.9;1.0-3.6). Furthermore, the increased frequency of experience of parental alcohol intoxication are associated with higher prevalence of admission to hospital and mental distress and lower levels of self-rated health. Findings from this large, representative population of Norwegian adolescents indicate that adverse health outcomes among adolescents in a general population are related to relatively common heavy drinking behaviours among parents.

Relationship Between Parental Locus of Control and Childhood Injury

Although pediatricians routinely counsel parents about preventing childhood injuries, we know little about parents' locus of control (LOC) in regards to preventing their children from being injured. We performed an observational analysis of sociodemographic differences in LOC for injury prevention, as measured by four items adapted from the Parental Health Beliefs Scales, in English- and Spanish-speaking parents of infants participating in the treatment arm of an obesity prevention study. First, we examined associations of parental LOC for injury prevention at the time their children were 2 months old with parents' age, race/ethnicity, income, and education. Next, we analyzed time trends for repeated LOC measures when the children were 2, 6, 9, 12, and 24 months old. Last, we examined the association between injury-related LOC items and children's injury (yes/no) at each time point. Of 452 parents, those with lower incomes had both lower internal and higher external LOC. Lower educational achievement was associated with higher external LOC. Both internal and external LOC scores decreased over time. Injuries were more common in children whose parents endorsed low internal and high external LOC. Future studies should examine whether primary care-based interventions can increase parents' sense of control over their children's safety and whether that, in turn, is associated with lower injury rates.Clinical Trial Registration: NCT01040897.

Evaluation of the effectiveness, implementation and cost-effectiveness of the Stay One Step Ahead home safety promotion intervention for pre-school children: a study protocol

BACKGROUND

Unintentional injuries in children under the age of 5 years commonly occur in the home and disproportionately affect those living in disadvantaged circumstances. Targeted home safety promotion should be offered to families most at risk but there is a paucity of standardised evidence-based resources available for use across family-support practitioners.

OBJECTIVE

To assess the effectiveness, implementation and cost-effectiveness of a 2-year home safety programme (Stay One Step Ahead) developed by parents, practitioners and researchers, and delivered by a range of family support providers in inner-city localities, compared with usual care in matched control localities.

METHODS

Parents of children aged 0 to 7 months will be recruited to a controlled before and after observational study. The primary outcome is home safety assessed by the proportion of families with a fitted and working smoke alarm, safety gate on stairs (where applicable) and poisons stored out of reach, assessed using parent-administered questionnaires at baseline, 12 and 24 months.Secondary outcomes include: the impact on other parent-reported safety behaviours, medically-attended injuries, self-efficacy for home safety and knowledge of child development and injury risk using questionnaires and emergency department attendance data; implementation (reach, acceptability, barriers, facilitators) of home safety promotion assessed through interviews and observations; and cost-effectiveness using medically-attended injury costs ascertained from healthcare records.

CONCLUSION

If shown to be effective and cost-effective this study will provide a practical resource to underpin national guidance. The study could inform public health prevention strategies to reduce home injury in children most at risk, while delivering cost savings to health and care services.

TRIAL REGISTRATION NUMBER

ISRCTN31210493; Pre result.

Social Complexity and Risk for Pediatric Burn Injury: A Systematic Review

Social complexity in health outcomes has been attributed to greater risk of injury, adverse health consequences, and early death in a variety of populations. To determine what social complexity factors associated with burn injury in children, a systematic review of the literature was performed. Two different databases (PubMed and SCOPUS) were searched for articles related to environmental and social determinants of burn injury. Selected literature examined social complexity factors to establish the strength of evidence in relation to incidence of burn injury in children. The extent of factors and the most common social complexities were reviewed. The 641 manuscripts found in PubMed and 327 from SCOPUS were initially reviewed for duplication and English language. Subsequently, manuscripts were selected for relevance based on titles followed by abstracts. Forty-seven manuscripts were reviewed in their entirety. The literature supports a relationship between an increased incidence of pediatric burns in lower income families, children with behavioral disorders, fewer years of parental education and children residing in a rural setting. The majority of reports came from Europe followed by Australia, and scattered information from other countries. Social complexity factors in the environment of the child are associated with an increased risk of burn injury in children. The literature supports the influence of lower income, lower parental education, behavioral disorders and living rurally with an increased incidence of injury. By identifying children at increased risk, it is possible to develop targeted burn prevention and education programs to mitigate burn injury.

Association of Parental Mental Illness With Child Injury Occurrence, Hospitalization, and Death During Early Childhood

IMPORTANCE

Injury is a leading cause of childhood morbidity and mortality worldwide. Serious mental illness (SMI) is a major contributor to the global burden of disease.

OBJECTIVE

To compare injury event rates in children from birth to 5 years of age among Taiwanese children with and without parents with SMI, including schizophrenia, bipolar disorder, and major depressive disorder.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective cohort study of an 11-year Taiwanese birth cohort used data from the Taiwan National Health Insurance Research Database (covering 99% of Taiwanese citizens), the Maternal and Child Health Database, and birth and death certificate databases. The study included 1 999 322 singletons with Taiwanese citizenship born from January 1, 2004, to December 31, 2014, and followed up from birth to their fifth birthday, December 31, 2014, or the date of death, yielding a total of 7 741 026 person-years. Data analysis was performed from April 20, 2017, to September 24, 2019.

EXPOSURES

Physician-diagnosed parental SMI defined using outpatient and inpatient records from 6 years before the child's birth to 5 years after delivery.

MAIN OUTCOME AND MEASURES

Rates of medically attended injury events, injury hospitalization, and injury death retrieved from outpatient records, inpatient records, and death certificates. Generalized estimating equation for log-linear models estimated injury incidence rate ratios (IRRs) comparing parental SMI-exposed children and unexposed children.

RESULTS

The study cohort included 1 999 322 singletons (52.1% males without parental SMI and 52.2% males with parental SMI). Incidence rates of child injury-related outcomes were higher among children exposed to parental SMI (294.8 injury events per 1000 person-years) compared with children who were unexposed (256.1 injury events per 1000 person-years). After adjustment for sociodemographic factors, children with parental SMI had higher rates of injury events (IRR, 1.14; 95% CI, 1.13-1.15), injury hospitalization (IRR, 1.49; 95% CI, 1.42-1.57), and injury death (IRR, 1.82; 95% CI, 1.38-2.39) compared with unexposed children. The results were confirmed in sensitivity analyses. Appendicitis, a negative control outcome, was not associated with parental SMI (IRR, 1.10; 95% CI, 0.94-1.28). In addition, children with and without parental SMI had similar patterns of preventive health care. The mean (SD) number of prenatal visits was 8.09 (2.50) for children with parental SMI and 8.17 (2.47) among unaffected children. The mean (SD) number of well-child visits was 5.70 (2.24) for children with parental SMI and 5.80 (2.21) among unaffected children.

CONCLUSIONS AND RELEVANCE

In this study, children with parental SMI had increased risk of injury, particularly serious injury. Excess risk may be reduced by providing effective mental health treatment, parenting support, and home safety education to parents with SMI who are raising young children.

Maternal alcohol consumption during pregnancy associates with bone fractures in early childhood. A birth-cohort study of 6718 participants

Fractures are common injuries in children, but their underlying biological and environmental risk factors are not well known. Maternal alcohol consumption during pregnancy is a known risk factor for bone malformations and impaired growth, in connection with Fetal Alcohol Spectrum Disorders (FASD). There is evidence that even lower doses of alcohol than what is needed for FASD can cause changes in the developing bone. Birth weight and length may also associate to childhood fractures. The aim of this study was to find out whether there exist associations between maternal alcohol use during pregnancy, birth weight or length and fractures of the long bones in childhood. A prospective birth cohort was performed, including all women in Northern Finland with an expected date of delivery between July 1985 and June 1986, and their offspring (N = 9432). The National Hospital Discharge Register (NHDR) provided the information on inpatient treated fractures. The subjects who declined participation or were treated as outpatient were excluded. The final study population consisted of 6718 children (71.2%). 98 (1.5%) of them suffered from inpatient treated fracture of a long bone (N = 105). Maternal alcohol consumption during pregnancy was inquired by questionnaires during late pregnancy or shortly after parturition. The birth length and weight were recorded immediately after birth. Binomial regression analysis was used to determine the association between the potential explanatory variables and bone fractures. Gender, socioeconomic status of the family, maternal age, premature birth, body mass index (BMI) of the children and maternal smoking during pregnancy were taken as possible confounders. In this study, the maternal alcohol consumption during pregnancy was associated to 2.22-fold (CI 1.09-4.12, p < 0.02) increased risk of a long bone fracture before the age of eight. Birth weight or length did not associate to childhood fractures. Bone fractures are an important cause of morbidity in childhood. Their prevention should start from the prenatal period by protecting the fetus from the alcohol exposure.

Social Determinants Associated with Pediatric Burn Injury: A Population-Based, Case-Control Study

Social determinants of health (SDoH) influence risk of injury. We conducted a population-based, case-control study to identify which social determinants influence burn injury in children. Children (≤16 years of age) admitted to a Canadian regional burn center between January 1, 1999 and March 30, 2017 were matched based on age, sex, and geographic location 1:5 with an uninjured control cohort from the general population. Population-level administrative data describing the SDoH at the Manitoba Center for Health Policy (MCHP) were compared between the cohorts. Specific SDoH were chosen based on a published systematic review conducted by the research team. In the final multivariable model, children from a low-income household odds ratio (OR) (95% confidence interval) 1.97 (1.46, 2.65), in care 1.57 (1.11, 2.21), from a family that received income assistance 1.71 (1.33, 2.19) and born to a teen mother 1.43 (1.13, 1.81) were significantly associated with an increased risk of pediatric burn injury. This study identified SDoH that are associated with an increased risk of burn injury. This case-control study supports the finding that children from a low-income household, children in care, from a family that received income assistance, and children born to a teen mother are at an elevated risk of burn injury. Identifying children at increased potential risk allows targeting of burn risk reduction and home safety programs.

Effects of parental mental illness on children's physical health: systematic review and meta-analysis

BACKGROUND

Children of parents with mental disorder face multiple challenges.

AIMS

To summarise evidence about parental mental disorder and child physical health.

METHOD

We searched seven databases for cohort or case-control studies quantifying associations between parental mental disorders (substance use, psychotic, mood, anxiety, obsessive-compulsive, post-traumatic stress and eating) and offspring physical health. Studies were excluded if: they reported perinatal outcomes only (<28 days) or outcomes after age 18; they measured outcome prior to exposure; or the sample was drawn from diseased children. A meta-analysis was conducted. The protocol was registered on the PROSPERO database (CRD42017072620).

RESULTS

Searches revealed 15 945 non-duplicated studies. Forty-one studies met our inclusion criteria: ten investigated accidents/injuries; eight asthma; three other atopic diseases; ten overweight/obesity; ten studied other illnesses (eight from low-and middle-income countries (LMICs)). Half of the studies investigated maternal perinatal mental health, 17% investigated paternal mental disorder and 87% examined maternal depression. Meta-analysis revealed significantly higher rates of injuries (OR = 1.15, 95% CI 1.04-1.26), asthma (OR = 1.26, 95% CI 1.12-1.41) and outcomes recorded in LMICs (malnutrition: OR = 2.55, 95% CI 1.74-3.73; diarrhoea: OR = 2.16, 95% CI 1.65-2.84). Evidence was inconclusive for obesity and other atopic disorders.

CONCLUSIONS

Children of parents with mental disorder have health disadvantages; however, the evidence base is limited to risks for offspring following postnatal depression in mothers and there is little focus on fathers in the literature. Understanding the physical health risks of these vulnerable children is vital to improving lives. Future work should focus on discovering mechanisms linking physical and mental health across generations.

DECLARATION OF INTEREST

None.

Association between Sleep Deprivation in Caregivers and Risk of Injury among Toddlers: A Propensity Score Analysis

Introduction

Unintentional injury remains the leading cause of death in children worldwide. Adequate parental supervision is a crucial strategy for preventing injury. Many factors, such as a large family size, poor socioeconomic status, and the caregiver being a single mother, contribute to unintentional injury in children. In addition, sleep deprivation in caregivers might be associated with injury in children because sleep deprivation causes impaired daytime cognitive function, wake-state instability, and negative moods, thereby impairing caregiver supervision. Therefore, this study determines the association between injury in children and the sleep quality of their primary caregivers.

Method

This is a retrospective case–control study on unintentional injury in children aged 0 to 4 years who visited the emergency department (case group) and an age- and sex-matched control group. Sleep quality in caregivers was assessed using the Chinese version of the Pittsburgh Sleep Quality Index (PSQI). Logistic regression was used to evaluate the association between aspects of the PSQI and injury. A propensity score model was used to generate a quasirandomized design.

Results

This case-control study recruiting 277 injured and 274 noninjured children was conducted in Taiwan. There was no statistically significant difference in child's age and primary caregiver's age between the injured and noninjured groups. The primary outcome, Pittsburgh sleep quality index, was not significantly different between the two groups. The average scores of sleep duration and habitual sleep efficiency in the control group were higher than those in the case group. However, there was no difference between the two groups after adjusting via a propensity score model, including the following potential confounders, child's age, child's sex, number of previous injury, caregiver mental status, caregiver's sex and caregiver's age, and the number of children living together.

Conclusion

Our study was the first to examine the association between injury in children and the sleep quality of their primary caregivers. We observed that no PSQI component significantly affected the risk of injury among children.

Association between maternal and paternal mental illness and risk of injuries in children and adolescents: nationwide register based cohort study in Sweden

OBJECTIVE

To determine the association between parental mental illness and the risk of injuries among offspring.

DESIGN

Retrospective cohort study.

SETTING

Swedish population based registers.

PARTICIPANTS

1 542 000 children born in 1996-2011 linked to 893 334 mothers and 873 935 fathers.

EXPOSURES

Maternal or paternal mental illness (non-affective psychosis, affective psychosis, alcohol or drug misuse, mood disorders, anxiety and stress related disorders, eating disorders, personality disorders) identified through linkage to inpatient or outpatient healthcare registers.

MAIN OUTCOME MEASURES

Risk of injuries (transport injury, fall, burn, drowning and suffocation, poisoning, violence) at ages 0-1, 2-5, 6-9, 10-12, and 13-17 years, comparing children of parents with mental illness and children of parents without mental illness, calculated as the rate difference and rate ratio adjusted for confounders.

RESULTS

Children with parental mental illness contributed to 201 670.5 person years of follow-up, while children without parental mental illness contributed to 2 434 161.5 person years. Children of parents with mental illness had higher rates of injuries than children of parents without mental illness (for any injury at age 0-1, these children had an additional 2088 injuries per 100 000 person years; number of injuries for children with and without parental mental illness was 10 235 and 72 723, respectively). At age 0-1, the rate differences ranged from 18 additional transport injuries to 1716 additional fall injuries per 100 000 person years among children with parental mental illness compared with children without parental mental illness. A higher adjusted rate ratio for injuries was observed from birth through adolescence and the risk was highest during the first year of life (adjusted rate ratio at age 0-1 for the overall association between any parental mental illness that has been recorded in the registers and injuries 1.30, 95% confidence interval 1.26 to 1.33). Adjusted rate ratios at age 0-1 ranged from 1.28 (1.24 to 1.32) for fall injuries to 3.54 (2.28 to 5.48) for violence related injuries. Common and serious maternal and paternal mental illness was associated with increased risk of injuries in children, and estimates were slightly higher for common mental disorders.

CONCLUSIONS

Parental mental illness is associated with increased risk of injuries among offspring, particularly during the first years of the child's life. Efforts to increase access to parental support for parents with mental illness, and to recognise and treat perinatal mental morbidity in parents in secondary care might prevent child injury.

Reducing unintentional injuries in under fives: Development and testing of a mobile phone app

BACKGROUND

Unintentional injuries are a leading cause of preventable death and a major cause of ill health and disability in children under 5 years of age. A health promotion mobile phone application, "Grow up Safely" (GUS), was developed to support parents and carers in reducing unintentional injuries in this population of children.

METHODS

A prototype of the mobile application was developed to deliver health education on unintentional injury prevention linked to stages of child development. In order to explore the usability of the app and refine its content, three focus groups were conducted with 15 mothers. Data were analysed using thematic analysis.

RESULTS

The majority of participants reported previous use of health apps, mainly related to pregnancy and recommended by health professionals. The app was considered user-friendly and easy to navigate. Participants in two focus groups found the app informative and offered new information, and they would consider using it. Participants in the "young mum's" group considered the advice to be "common sense" but found the language too complex. All participants commented that further development of push-out notifications and endorsement by a reputable source would increase their engagement with the app.

CONCLUSION

The GUS mobile phone app, aimed at reducing unintentional injuries in children under five, was supported by mothers as a health promotion app. They would consider downloading it, particularly if recommended by a health professional or endorsed by a reputable organization. Further development is planned with push-out notifications and wider feasibility testing to engage targeted groups, such as young mothers, fathers, and other carers.

Behavioural difficulties in early childhood and risk of adolescent injury

OBJECTIVE

To evaluate long-term associations between early childhood hyperactivity and conduct problems (CP), measured using Strengths and Difficulties Questionnaire (SDQ) and risk of injury in early adolescence.

DESIGN

Data linkage between a longitudinal birth cohort and routinely collected electronic health records.

SETTING

Consenting Millennium Cohort Study (MCS) participants residing in Wales and Scotland.

PATIENTS

3119 children who participated in the age 5 MCS interview.

MAIN OUTCOME MEASURES

Children with parent-reported SDQ scores were linked with hospital admission and Accident & Emergency (A&E) department records for injuries between ages 9 and 14 years. Negative binomial regression models adjusting for number of people in the household, lone parent, residential area, household poverty, maternal age and academic qualification, child sex, physical activity level and country of interview were fitted in the models.

RESULTS

46% of children attended A&E or were admitted to hospital for injury, and 11% had high/abnormal scores for hyperactivity and CP. High/abnormal or borderline hyperactivity were not significantly associated with risk of injury, incidence rate ratio (IRR) with 95% CI of the high/abnormal and borderline were 0.92 (95% CI 0.74 to 1.14) and 1.16 (95% CI 0.88 to 1.52), respectively. Children with borderline CP had higher injury rates compared with those without CP (IRR 1.31, 95% CI 1.09 to 1.57).

CONCLUSIONS

Children with high/abnormal hyperactivity or CP scores were not at increased risk of injury; however, those with borderline CP had higher injury rates. Further research is needed to understand if those with difficulties receive treatment and support, which may reduce the likelihood of injuries.

The British Columbia Healthy Connections Project: findings on socioeconomic disadvantage in early pregnancy

Background

Maternal exposure to socioeconomic disadvantage increases the risk of child injuries and subsequent child developmental and mental health problems — particularly for young mothers. To inform early intervention planning, this research therefore aimed to describe the health and social adversities experienced by a cohort of girls and young women in early pregnancy in British Columbia (BC), Canada.

Methods

Participants were recruited for the BC Healthy Connections Project (BCHCP), a randomized controlled trial examining the effectiveness of Nurse-Family Partnership, a home visitation program, in improving child and maternal outcomes. Baseline data were collected from 739 participants on trial entry. Participants were selected on the basis of preparing to parent for the first time and experiencing socioeconomic disadvantage. Analyses involved descriptive statistics and age-group comparisons.

Results

Most participants reported having low income (84%), having limited education (52%) and being single (91%) at trial entry. Beyond these eligibility criteria, other health and social adversities included: housing instability (52%); severe anxiety or depression (47%); other diagnosed mental disorders (22%); prenatal nicotine and cannabis use (27 and 21%); physical health problems (20%); child maltreatment when younger (56%); and intimate partner violence recently (50%). As well, few (29%) had received income assistance entitlements. More than two thirds (70%) were experiencing four or more forms of adversity. Age-group differences were observed for cognitive functioning, being single, low income, limited education, psychological distress and service use (p-value ≤0.05).

Conclusions

This cohort was selected on the basis of socioeconomic disadvantage. Yet all participants were experiencing substantial added adversities — at higher rates than other Canadians. Furthermore, despite Canada’s public programs, these pregnant girls and young women were not being adequately reached by social services. Our study adds new data to inform early intervention planning, suggesting that unacceptably high levels of socioeconomic disadvantage exist for some young British Columbians. Therefore greater health and social supports and services are warranted for these young mothers and their children.

Trial registration

Registered August 24, 2012 with ClinicalTrials.gov Identifier: NCT01672060. Active not recruiting.

The Moderating Role of Maternal Supervision in the Relation of Social-Ecological Risk Factors to Children's Minor Injuries

Although maternal supervision has been found to reduce injury risk in young children, it is not clear whether supervision moderates the impact of social-ecological risk variables on children's injury frequency. This study examined whether maternal supervision moderated the relation of child, maternal, and family risk factors to children's minor injuries. Mothers (N = 170) of toddlers were interviewed biweekly about their children's injuries and their supervision over a 6-month period, and mothers completed measures about child and family variables. Supervision moderated the effect of mothers' marital/partner relationship satisfaction on children's injury frequency; closer supervision was protective for mothers with lower relationship satisfaction. Findings suggest that helping mothers with low levels of relationship satisfaction provide closer supervision for their children may mitigate the effects of low marital satisfaction on children's injury frequency.

Parental offending and children's emergency department presentations in New South Wales, Australia

OBJECTIVES

Children whose parents have a history of criminal offending may be at risk of higher rates of emergency department (ED) presentation, along with other adverse health outcomes. We used data from a large, population-based record linkage project to examine the association between maternal and paternal criminal offending and the incidence of ED presentations among child offspring.

METHODS

Data for 72 772 children with linked parental records were drawn from the New South Wales Child Development Study. Information on parental criminal offending (spanning 1994-2016) and child ED presentations (spanning 2005-2016; approximately ages 2-12 years) was obtained from linked administrative records. Cox proportional hazards regression analyses were conducted to examine the association between parental offending and the incidence of children's ED presentations for any reason and for physical injury, while accounting for important covariates.

RESULTS

Child rates of ED presentation, particularly for physical injury, were higher among those with parental history of criminal offending, after adjusting for covariates. The magnitude of the association was higher for paternal criminal offending (ED presentation for any reason: HR=1.44 (95% CI 1.41 to 1.48); physical injury: HR=1.70 (95% CI 1.65 to 1.75)) than maternal criminal offending (any reason: HR=0.99 (95% CI 0.95 to 1.03); physical injury: HR=1.05 (95% CI 1.00 to 1.10)).

CONCLUSION

Children of parents, particularly of fathers, with a history of criminal offending have an increased incidence of ED presentation, including for potentially avoidable physical injury. These findings require replication and further research to understand the mechanisms underlying these associations.

Prematurity Does Not Increase Early Childhood Fracture Risk

OBJECTIVE

To evaluate the impact of prematurity on fracture by age 5, controlling for medications and comorbidities of prematurity.

STUDY DESIGN

We performed a retrospective cohort study of infants born in Military Treatment Facilities in 2009-2010 with ≥5 years of follow-up care. Gestational age, low birth weight, comorbidities of prematurity (osteopenia, necrotizing enterocolitis, chronic lung disease, and cholestasis) and fractures were identified by International Classification of Disease, 9th Edition, codes. Pharmaceutical records identified treatment with caffeine, diuretics, postnatal corticosteroids, and antacids. Poisson regression analysis determined fracture rate by 5 years of life.

RESULTS

There were 65 938 infants born in 2009-2010 who received care in the military health system for ≥5 years, including 3589 born preterm; 165 born at ≤28^6/7 weeks of gestation, 380 born at 29-31^6/7 weeks of gestation, and 3044 born at 32-36^6/7 weeks of gestation. Preterm birth at any gestational age was not associated with fracture rate in adjusted models. The fracture rate was increased with cholestasis, proton pump inhibitor exposure, and male sex.

CONCLUSIONS

Prematurity was not associated with fracture rate. Neonatal cholestasis and proton pump inhibitor treatment were associated with increased fractures by age 5.

Demographic and clinical characteristics of hospitalised unintentional poisoning in Aboriginal and non-Aboriginal preschool children in New South Wales, Australia: a population data linkage study

OBJECTIVES

To investigate differences in demographic and clinical characteristics of Aboriginal and non-Aboriginal children aged 0-4 years hospitalised for unintentional poisoning in New South Wales (NSW), Australia.

DESIGN AND SETTING

Retrospective whole-of-population cohort analysis of linked hospital and mortality data for 2000-2014.

PARTICIPANTS

All children (Aboriginal and non-Aboriginal) under the age of 5 years who were born in a hospital in NSW from 2000 to 2009.

OUTCOMES

The primary outcome was hospitalisation for unintentional poisoning. Logistic regression was used to estimate odds of poisoning hospitalisation for Aboriginal and non-Aboriginal children. Poisoning agents and clinical outcomes were compared by Aboriginality.

RESULTS

The cohort included 767 119 children, including 28 528 (3.7%) Aboriginal children. Aboriginal children had approximately three times higher rates of hospitalised poisoning (1.34%) compared with non-Aboriginal children (0.41%). Poisoning incidence peaked at 2-3 years of age. Male sex, socioeconomic disadvantage and geographical remoteness were associated with higher odds of poisoning hospitalisation for Aboriginal and non-Aboriginal children, but associations with disadvantage and remoteness were statistically significant only for non-Aboriginal children. Most (83%) poisonings were caused by pharmaceutical agents. Few Aboriginal and non-Aboriginal children had repeat admissions for poisoning; most had a length of stay of 1 day or less. Only 8% of poisoning admissions involved contact with a social worker.

CONCLUSION

Commonly used medications in the general population contribute to poisonings among both Aboriginal and non-Aboriginal preschool-aged children. This study highlights a need to develop culturally safe poisoning prevention strategies and policies.

Risk Factors at Birth Predictive of Subsequent Injury Among Japanese Preschool Children: A Nationwide 5-Year Cohort Study

OBJECTIVE

To identify risk factors at birth that are predictive of subsequent injury among preschool children.

METHODS

Retrospective analysis of population-based birth cohort data from the "Longitudinal Survey of Babies Born in the 21st Century" was performed from 2001 through 2007 in Japan (n = 47,015). The cumulative incidence and the total number of hospitalizations or examinations conducted at medical facilities for injury among children from birth up to the age of 5 years were calculated. To identify risk factors at birth that are predictive of injury, multivariate analysis of data for hospitalization or admission because of injury during a 5-year period (age, 0-5 years) was performed using the total number of hospital examinations as the dependent variable.

RESULTS

The cumulative incidence (95% confidence interval) of hospital examinations for injury over the 5-year period was 34.8% (34.2%-35.4%) for boys and 27.6% (27.0%-28.2%) for girls. The predictive risk factors at birth we identified for injury among preschool children were sex (boys), heavy birth weight, late birth order, no cohabitation with the grandfather or grandmother, father's long working hours, mother's high education level, and strong intensity of parenting anxiety.

CONCLUSION

Based on the results of this study, we identified a number of predictive factors for injury in children. To reduce the risk of injury in the juvenile population as a whole, it is important to pursue a high-risk or population approach by focusing on the predictive factors we have identified.

Maternal depression is associated with injuries in children aged 2-4 years: the Pelotas 2004 Birth Cohort

Introduction

Injuries during childhood, which mostly consist of falls, burns, drowning, poisonings and car crashes, are among the main causes of death among children and young adults in several countries.

Objectives

To investigate the association between maternal depression and the incidence of injuries during childhood.

Methods

In 2004, children who were born in the municipality of Pelotas, Brazil, were enrolled in a population-based birth cohort, with evaluations at birth and at 3, 12, 24 and 48 months of age. Maternal depression during pregnancy was evaluated at the time of delivery. At 12 and 24 months post partum, the Edinburgh Postnatal Depression Scale (EPDS) was used. The injuries incidence rates at ages of 24–48 months and the crude and adjusted IRRs were calculated with 95% CI through Poisson’s regression.

Results

A total of 3533 children were analysed. The incidence of injuries was higher among children whose mothers presented depressive symptoms during pregnancy and at 12 and 24 months compared with those whose mothers did not present any symptoms. In the adjusted analysis, the IRR among girls whose mothers presented depressive symptoms during pregnancy and EPDS ≥13 at 12 and 24 months was 1.31 (1.15–1.50); and, among boys, 1.18 (1.03–1.36).

Interpretation

Maternal depression is associated with higher incidence of injuries between 24 and 48 months of age, in both sexes.

Socioeconomic inequalities in injuries treated in primary care in Madrid, Spain

Background

Socioeconomic inequalities in injury morbidity are an important yet understudied issue in Southern Europe. This study analysed the injuries treated in primary care in the Community of Madrid, Spain, by socioeconomic status (SES), sex and age.

Methods

This was a cross-sectional study of injuries registered in the primary care electronic medical records of the Madrid Health Service in 2012. Incidence stratified by sex, SES and type of injury were calculated. Poisson regression was performed.

Results

A statistically significant upward trend in global injury incidence was observed with decreasing SES in all age groups. By type of injury, the largest differences were observed in injuries by foreign body in men aged 15-44 and in poisonings in girls under 15 years of age. Burns risk also stood out in the group of girls under 15 years of age with the lowest SES. In the group above 74 years of age, wounds, bruises and sprains had the lowest SES differences in both sexes, and the risk of fractures was lower in the most socioeconomically advantaged group.

Conclusion

People with lower SES were at a greater risk of injury. The relationship between SES and injury varies by type of injury and age.

Risk Factors for Acute Unintentional Poisoning among Children Aged 1-5 Years in the Rural Community of Sri Lanka

Background

Acute poisoning in children is a major preventable cause of morbidity and mortality in both developed and developing countries. However, there is a wide variation in patterns of poisoning and related risk factors across different geographic regions globally. This hospital based case-control study identifies the risk factors of acute unintentional poisoning among children aged 1−5 years of the rural community in a developing Asian country.

Methods

This hospital based case-control study included 600 children. Each group comprised three hundred children and all children were recruited at Anuradhapura Teaching Hospital, Sri Lanka, over two years (from February 2012 to January 2014). The two groups were compared to identify the effect of 23 proposed risk factors for unintentional poisoning using multivariate analysis in a binary logistic regression model.

Results

Multivariate analysis identified eight risk factors which were significantly associated with unintentional poisoning. The strongest risk factors were inadequate supervision (95% CI: 15.4–52.6), employed mother (95% CI: 2.9–17.5), parental concern of lack of family support (95% CI: 3.65–83.3), and unsafe storage of household poisons (95% CI: 1.5–4.9).

Conclusions

Since inadequate supervision, unsafe storage, and unsafe environment are the strongest risk factors for childhood unintentional poisoning, the effect of community education to enhance vigilance, safe storage, and assurance of safe environment should be evaluated.

Childhood Injury Prevention: Predictors of Home Hazards in Latino Families Enrolled in SafeCare®

Objective

This archival project (a) examined potential risk and protective factors for hazards in the homes of Spanish-speaking immigrant Latino families and (b) provided an independent examination of the SafeCare®+ Home Safety module adapted for Latino families at high risk for child neglect.

Methods

The sample comprised 92 Latina caregivers of young children enrolled in SafeCare®+.

Results

Results of the negative binomial regression model of predictors of home hazards before the Home Safety module found none of the factors were significant. The longitudinal analysis with a negative binomial model found significant effects both during (b = -0.905, p < .001) and after (b = -2.118, p < .001) the intervention. Depression was negatively associated with the number of hazards (b = -0.026, p < .05, β = -.1858).

Conclusions

Support for application of SafeCare®+ Home Safety module to prevent access to hazards for Latino children was found.

Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives

Background

Unintentional injuries among 0- to 4-year-olds are a major public health problem incurring substantial NHS, individual and societal costs. However, evidence on the effectiveness and cost-effectiveness of preventative interventions is lacking.

Aim

To increase the evidence base for thermal injury, falls and poisoning prevention for the under-fives.

Methods

Six work streams comprising five multicentre case–control studies assessing risk and protective factors, a study measuring quality of life and injury costs, national surveys of children’s centres, interviews with children’s centre staff and parents, a systematic review of barriers to, and facilitators of, prevention and systematic overviews, meta-analyses and decision analyses of home safety interventions. Evidence from these studies informed the design of an injury prevention briefing (IPB) for children’s centres for preventing fire-related injuries and implementation support (training and facilitation). This was evaluated by a three-arm cluster randomised controlled trial comparing IPB and support (IPB+), IPB only (no support) and usual care. The primary outcome was parent-reported possession of a fire escape plan. Evidence from all work streams subsequently informed the design of an IPB for preventing thermal injuries, falls and poisoning.

Results

Modifiable risk factors for falls, poisoning and scalds were found. Most injured children and their families incurred small to moderate health-care and non-health-care costs, with a few incurring more substantial costs. Meta-analyses and decision analyses found that home safety interventions increased the use of smoke alarms and stair gates, promoted safe hot tap water temperatures, fire escape planning and storage of medicines and household products, and reduced baby walker use. Generally, more intensive interventions were the most effective, but these were not always the most cost-effective interventions. Children’s centre and parental barriers to, and facilitators of, injury prevention were identified. Children’s centres were interested in preventing injuries, and believed that they could prevent them, but few had an evidence-based strategic approach and they needed support to develop this. The IPB was implemented by children’s centres in both intervention arms, with greater implementation in the IPB+ arm. Compared with usual care, more IPB+ arm families received advice on key safety messages, and more families in each intervention arm attended fire safety sessions. The intervention did not increase the prevalence of fire escape plans [adjusted odds ratio (AOR) IPB only vs. usual care 0.93, 95% confidence interval (CI) 0.58 to 1.49; AOR IPB+ vs. usual care 1.41, 95% CI 0.91 to 2.20] but did increase the proportion of families reporting more fire escape behaviours (AOR IPB only vs. usual care 2.56, 95% CI 1.38 to 4.76; AOR IPB+ vs. usual care 1.78, 95% CI 1.01 to 3.15). IPB-only families were less likely to report match play by children (AOR 0.27, 95% CI 0.08 to 0.94) and reported more bedtime fire safety routines (AOR for a 1-unit increase in the number of routines 1.59, 95% CI 1.09 to 2.31) than usual-care families. The IPB-only intervention was less costly and marginally more effective than usual care. The IPB+ intervention was more costly and marginally more effective than usual care.

Limitations

Our case–control studies demonstrate associations between modifiable risk factors and injuries but not causality. Some injury cost estimates are imprecise because of small numbers. Systematic reviews and meta-analyses were limited by the quality of the included studies, the small numbers of studies reporting outcomes and significant heterogeneity, partly explained by differences in interventions. Network meta-analysis (NMA) categorised interventions more finely, but some variation remained. Decision analyses are likely to underestimate cost-effectiveness for a number of reasons. IPB implementation varied between children’s centres. Greater implementation may have resulted in changes in more fire safety behaviours.

Conclusions

Our studies provide new evidence about the effectiveness of, as well as economic evaluation of, home safety interventions. Evidence-based resources for preventing thermal injuries, falls and scalds were developed. Providing such resources to children’s centres increases their injury prevention activity and some parental safety behaviours.

Future work

Further randomised controlled trials, meta-analyses and NMAs are needed to evaluate the effectiveness and cost-effectiveness of home safety interventions. Further work is required to measure NHS, family and societal costs and utility decrements for childhood home injuries and to evaluate complex multicomponent interventions such as home safety schemes using a single analytical model.

Trial registration

Current Controlled Trials ISRCTN65067450 and ClinicalTrials.gov NCT01452191.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 14. See the NIHR Journals Library website for further project information.

Assessment of Sex Differences in Fracture Risk Among Patients With Anorexia Nervosa: A Population-Based Cohort Study Using The Health Improvement Network

Though previous studies have demonstrated an increased fracture risk in females with anorexia nervosa (AN), fracture risk in males is not well characterized. The objective of this study was to examine sex differences in fracture risk and site-specific fracture incidence in AN. We performed a population-based retrospective cohort study using The Health Improvement Network (THIN; a large database of anonymized electronic medical records collected at primary care clinics throughout the United Kingdom). The median calendar year for the start of the observation period was 2004-2005. We identified 9239 females and 556 males <60 years of age with AN, and 97,889 randomly selected sex-, age-, and practice-matched participants without eating disorders (92,329 females and 5560 males). Multivariable Cox regression was used to estimate the hazard ratio (HR) for incident fracture. Median age at start of observation was 29.8 years in females and 30.2 years in males. The HR for fracture associated with AN differed by sex and age (interaction p = 0.002). Females with AN had an increased fracture risk at all ages (HR, 1.59; 95% confidence interval [CI], 1.45 to 1.75). AN was associated with a higher risk of fracture among males >40 years of age (HR, 2.54; 95% CI, 1.32 to 4.90; p = 0.005) but not among males ≤40 years. Females with AN had a higher risk of fracture at nearly all anatomic sites. The greatest excess fracture risk was noted at the hip/femur (HR, 5.59; 95% CI, 3.44 to 9.09) and pelvis (HR, 4.54; 95% CI, 2.42 to 8.50) in females and at the vertebrae (HR, 7.25; 95% CI, 1.21 to 43.45) for males with AN. AN was associated with higher incident fracture risk in females across all age groups and in males >40 years old. Sites of highest fracture risk include the hip/femur and pelvis in females and vertebrae in males with AN. © 2016 American Society for Bone and Mineral Research.

Unintentional Childhood Injuries in Urban Delhi: A Community-Based Study

Background:

Childhood injuries claim around a million lives around the world each year. A community-based study on childhood injuries would provide valuable information on the epidemiology of injuries.

Objective:

To assess the prevalence of unintentional childhood injuries in an urban locality and determine various sociodemo graphic factors associated with childhood injuries.

Methods:

The study was done in urban Delhi among 1,639 children aged less than 18 years. Information on injuries in the last one year was collected. Only those injury episodes where treatment was sought or the child was left disabled after the injury were included. Treatment seeking behavior and the impact of injury on the child and the household were also assessed.

Results:

Among 1,639 children, 102 children suffered 116 episodes of various types of injuries in the last one year. Prevalence of injuries was 7.1% (95% CI: 5.9-8.4). Mean age was 8.5 ± 5.1 years. Prevalence was more in boys (8.4%) than girls (5.1%). Accidental falls (37.1%), dog bites (25%), and road traffic injuries (18.9%) were the three most common modes of injury. Two-thirds of children with injuries were taken to the emergency facility for treatment while 40% resorted to home remedies. Treatment expenses in some families led to the need for borrowing money, additional employment by another family member, and selling of household assets.

Conclusions:

The prevalence of childhood injuries in the past one year was 7.1%. Maximum injuries occurred at home and were mostly accidental falls and dog bites. Childhood injuries caused loss of school attendance and financial burden to the family.

Association Between Maternal Postpartum Depression and Unintentional Injury Among 4-Month-Old Infants in Japan

OBJECTIVES

Unintentional injury among infants is a major public health issue; however, the relationship between unintentional infant injury and postpartum depression remains unclear. In this study, we aim to investigate the association between the two.

METHODS

We administered an original questionnaire to mothers participating in a 3- or 4-month health check-up program (target n = 9707). This questionnaire assessed infant health, including types of unintentional injury experiences used in previous study, and maternal mental health such as postpartum depression, by the validated screening tool, the Edinburgh Postnatal Depression Scale (EPDS). Associations between infant injury and postpartum depression were assessed using logistic regression adjusted for covariates, including parental, infant, and household characteristics.

RESULTS

In total, 6534 women responded to the questionnaire with valid answers on the EPDS (valid response rate, 67 %). Of the sample, 9.8 % of infants experienced unintentional injury (fall: 5.6 %; near-drowning: 1.2 %), and 9.5 % of mothers had postpartum depression (EPDS score of 9+). After adjusting for covariates, postpartum depression was significantly positively associated with any unintentional injury (odds ratio [OR] 1.59, 95 % confidence interval [CI] 1.24-2.04), and falls (OR 1.41, 95 % CI 1.02-1.95), although near-drowning was not significantly associated.

CONCLUSION

Postpartum depression might be a risk factor for unintentional injury of infants aged up to 4 months. Further prospective studies are needed to confirm the association between postpartum depression and unintentional injury of infants.

Community-Based Study on Family-Related Contributory Factors for Childhood Unintentional Injuries in an Urban Setting of Sri Lanka

A community-based descriptive cross-sectional study was carried out among children aged 1 to 4 years residing in an urban setting of Sri Lanka to assess the incidence and associated family-related factors of unintentional injuries. A total of 458 children were recruited using simple random sampling technique, giving a response rate of 91.6%. The incidence of unintentional injuries that needed medical attention during the study period of 3 months was 28.1 per 100 children (95% CI = 19.46-36.74). The factors that were significantly associated with the occurrence of unintentional injuries among children are low monthly income of the family (P = .045), low social support to the mother of index child (P = .022), nonauthoritative type of parenting of the mother of index child (P = .039), cared by person other than mother during day time (P = .002), frequent arguments between parents (P = .004), and frequent alcohol consumption of father (P = .001).

Risk factors for long-bone fractures in children up to 5 years of age: a nested case-control study

AIM

To investigate risk factors for first long-bone fractures in children up to 5 years old in order to provide evidence about which families could benefit from injury prevention interventions.

METHODS

Population-based matched nested case-control study using The Health Improvement Network, a UK primary care research database, 1988-2004. Maternal, household and child risk factors for injury were assessed among 2456 children with long-bone fractures (cases). 23,661 controls were matched to cases on general practice. Adjusted ORs and 95% CIs were estimated using conditional logistic regression.

RESULTS

Fractures of long-bones were independently associated with younger maternal age and higher birth order, with children who were the fourth-born in the family, or later, having a threefold greater odds of fracture compared to first-born children (adjusted OR 3.12, 95% CI 2.08 to 4.68). Children over the age of 1 year had a fourfold (13-24 months, adjusted OR 4.09 95% CI 3.51 to 4.76) to fivefold (37+ months, adjusted OR 4.88 95% CI 4.21 to 5.66) increase in the odds of a long-bone fracture compared to children aged 0-12 months. Children in families with a history of maternal alcohol misuse had a raised odds of long-bone fracture (adjusted OR 2.33, 95% CI 1.13 to 4.82) compared to those with no documented history.

CONCLUSIONS

Risk factors for long-bone fractures in children less than 5 years old included age above 1 year, increasing birth order, younger maternal age and maternal alcohol misuse. These risk factors should be used to prioritise families and communities for injury prevention interventions.

Persistence of health inequalities in childhood injury in the UK: a population-based cohort study of children under 5

Background

Injury is a significant cause of childhood death and can result in substantial long-term disability. Injuries are more common in children from socio-economically deprived families, contributing to health inequalities between the most and least affluent. However, little is known about how the relationship between injuries and deprivation has changed over time in the UK.

Methods

We conducted a cohort study of all children under 5 registered in one of 495 UK general practices that contributed medical data to The Health Improvement Network database between 1990–2009. We estimated the incidence of fractures, burns and poisonings by age, sex, socio-economic group and calendar period and adjusted incidence rate ratios (IRR) comparing the least and most socio-economically deprived areas over time. Estimates of the UK annual burden of injuries and the excess burden attributable to deprivation were derived from incidence rates.

Results

The cohort of 979,383 children experienced 20,804 fractures, 15,880 burns and 10,155 poisonings, equating to an incidence of 75.8/10,000 person-years (95% confidence interval 74.8–76.9) for fractures, 57.9 (57.0–58.9) for burns and 37.3 (35.6–38.0) for poisonings. Incidence rates decreased over time for burns and poisonings and increased for fractures (p<0.001 test for trend for each injury). They were significantly higher in more deprived households (IRR test for trend p<0.001 for each injury type) and these gradients persisted over time. We estimate that 865 fractures, 3,763 burns and 3,043 poisonings could be prevented each year in the UK if incidence rates could be reduced to those of the most affluent areas.

Conclusions

The incidence of burns and poisonings declined between 1990 and 2009 but increased for fractures. Despite these changes, strong socio-economic inequalities persisted resulting in an estimated 9,000 additional medically-attended injuries per year in under-5s.

Risk of fracture in urolithiasis: a population-based cohort study using the health improvement network

BACKGROUND AND OBJECTIVES

Studies have shown decreased bone mineral density in individuals with urolithiasis, but their burden of fracture remains unclear. This study sought to determine whether urolithiasis is associated with increased fracture risk across the lifespan and to delineate sex effects.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A population-based retrospective cohort study using The Health Improvement Network was performed. The median calendar year for the start of the observation period was 2004 (1994-2012). This study identified 51,785 participants with ≥1 of 87 diagnostic codes for urolithiasis and 517,267 randomly selected age-, sex-, and practice-matched participants. Cox regression was used to estimate the hazard ratio (HR) for first fracture. Fractures identified using diagnostic codes were classified by anatomic site.

RESULTS

Median age was 53 years, and 67% of participants were men, confirming their greater urolithiasis burden. Median time from urolithiasis diagnosis to fracture was 10 years. The HR for fracture associated with urolithiasis differed by sex and age (P for interactions, P≤0.003). In men, the adjusted HR was greatest in adolescence (1.55; 95% confidence interval [95% CI], 1.07 to 2.25) with an overall HR of 1.10 (95% CI, 1.05 to 1.16). Urolithiasis was associated with higher fracture risk in women aged 30-79 years (HR, 1.17-1.52), and was highest in women aged 30-39 years (HR, 1.52; 95% CI, 1.23 to 1.87). Peak background fracture rates were highest in boys aged 10-19 years and in women aged 70-79 years. The incidence per 10,000 person-years in participants with versus without urolithiasis was 392 versus 258 in male participants aged 10-19 years, and 263 versus 218 in women aged 70-79 years. Distribution of fracture site within sex did not differ between participants with versus without urolithiasis.

CONCLUSIONS

Urolithiasis was associated with higher incident fracture risk. The significantly higher risk at times of peak background fracture incidence in adolescent boys and elderly women has profound public health implications.