The epidemiology of road accidents in childhood

Traffic Accidents in Children and Adolescents: A Complex Orthopedic and Medico-Legal Approach

Traffic accidents involving children and adolescents present complex challenges from both the medico-legal and orthopedic standpoints. Despite the implementation of road traffic safety laws, pediatric road traffic injuries continue to be a significant contributor to mortality rates, physical harm, and hospitalization on a global scale. For children and young people, automobile accidents are considered to be the primary culprit of mortality in developed nations. Even in highly developed nations, trauma is a significant factor in infant mortality. Each age category, from childhood to young adulthood, has its fracture patterns, as their skeletons are considerably different from those of adults. The consequences of traffic accidents extend beyond the immediate physical trauma. The medico-legal aspects surrounding these incidents add another layer of complexity, as legal repercussions may affect the responsible adult or parent, particularly in cases involving child fatalities. To effectively address traffic accidents in children and adolescents, a comprehensive approach is necessary. This approach should involve not only medical professionals but also legal experts and policymakers. Collaboration between orthopedic specialists, medico-legal professionals, law enforcement agencies, and relevant government bodies can facilitate the development and implementation of strategies aimed at prevention, education, the enforcement of traffic laws, and improved infrastructure. By addressing both the medical and legal aspects, it is possible to enhance road safety for children and adolescents, reducing the incidence of injuries and their associated long-term consequences. In this review, we aimed to summarize traffic accidents in children and adolescents from a complex orthopedic and medico-legal approach.

Clinical evaluation and outcomes in children ≤10 years old involved in road traffic accidents, presenting to Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

Background. Road traffic accidents (RTAs) are a leading cause of injury and death globally, particularly among children. Pedestrians are most often injured, especially in middle- and low-income countries. The epidemiology, patterns and severity of injuries in children involved in RTAs in our community are hard to obtain.Objectives. To evaluate the aetiological spectrum, injury characteristics and treatment outcomes of paediatric patients involved in RTAs, who presented to Chris Hani Baragwanath Academic Hospital (CHBAH), a tertiary hospital in Soweto, South Africa. Methods. Patients ≤10 years old, who were involved in RTAs and seen at CHBAH, were included in the study.Results. The study was conducted from 20 August 2017 to 31 March 2018, and included the data of 156 patients. Their ages ranged from 13 days to 10 years (65% were boys). Pedestrian vehicle accidents accounted for 78.8% of the injuries, with 60.8% of the children being unaccompanied by an adult. Motor vehicle accidents accounted for 19.2% of the injuries, with 92% of the children being unrestrained in the vehicle. Of the patients, 73.2% (n=112/153) underwent radiography and 44.4% required computed tomography (CT) scans, the majority being CT scans of the brain for suspected head injuries. Soft-tissue injuries accounted for 78.9% of cases, followed mainly by head (39.7%) and limb (16%) injuries. Only 12% of patients required surgical intervention, with 42% of the operations being for orthopaedic injuries.Conclusion. The abovementioned data demonstrate that there is a lack of use of child restraints for children travelling as passengers in vehicles, and inadequate supervision of children on and around roads. This study supports other evidence, as it suggests that the paediatric population involved in RTAs is largely injured as pedestrians, and that males tend to be involved in more RTAs than females. The majority of injuries sustained involved the soft tissues, followed by head injuries.

Road traffic accidents in children: the 'what', 'how' and 'why'

INTRODUCTION

Road traffic accidents (RTAs) in Singapore involving children were evaluated, with particular focus on the epidemiology, surrounding circumstances and outcomes of these accidents. Key factors associated with worse prognosis were identified. We proposed some measures that may be implemented to reduce the frequency and severity of such accidents.

METHODS

This was a retrospective study of RTAs involving children aged 0-16 years who presented to the Children's Emergency at KK Women's and Children's Hospital, Singapore, from January 2011 to June 2014. Data was obtained from the National Trauma Registry and analysed in tiers based on the Injury Severity Score (ISS).

RESULTS

A total of 1,243 accidents were reviewed. RTA victims included motor vehicle passengers (60.4%), pedestrians (28.5%), cyclists (9.9%) and motorcycle pillion riders (1.2%). The disposition of emergency department (ED) patients was consistent with RTA severity. For serious RTAs, pedestrians accounted for 63.6% and 57.7% of Tier 1 (ISS > 15) and Tier 2 (ISS 9-15) presentations, respectively. Overall use of restraints was worryingly low (36.7%). Not restraining increased the risk of serious RTAs by 8.4 times. Young age, high ISS and low Glasgow Coma Scale score predicted a longer duration of intensive care unit stay.

CONCLUSION

The importance of restraints for motor vehicle passengers or helmets for motorcycle pillion riders and cyclists in reducing morbidity requires emphasis. Suggestions for future prevention and intervention include road safety education, regulation of protective restraints, use of speed enforcement devices and creation of transport policies that minimise kerbside parking.

Temporal variation in childhood injury from common recreational activities

BACKGROUND/PURPOSE

To investigate the month and day of the week of injury in common childhood activities using the National Electronic Injury Surveillance System database.

METHODS

All emergency department visits 2002–2006 from bicycles/tricycles, scooters, playground equipment, swimming/water activities, skiing/snowboarding, trampolines, and skating were analysed. The NEISS weighted and stratified data set was analysed using SUDAAN software. Weekday and month of injury, gender, race, anatomical location of the injury, geographical location of injury, and disposition were tabulated. Simple variation by month or weekday was analysed using cosinor analysis; combined variation for both month and weekday was analysed by topographical analysis.

RESULTS

There were an estimated 4.61 million emergency department visits for injuries from these activities in children in the United States. The average age was 9.5 years; there were 1.65 million girls (35.9%) and 2.97 boys (64.1%). Cosinor analysis demonstrated significant single peaks for month of injury for snow activities (January 27), trampolines (June 10), scooters (June 24), cycling (July 6), and water (July 12) activities. Double cosinor peaks were noted for skating (April 13 and September 12) and playground (April 22 and September 21) activities. Cosinor analyses demonstrated that the peak week days of injury were Monday for trampoline and snow activities, Saturday/Sunday for skating activities, Sunday for cycling, and Wednesday for playground equipment. There was no peak injury day for scooter or water activities. Topographical representation of paediatric injuries demonstrated that injuries from slides most frequently occurred April–May on Wednesdays and Saturdays, and those on swings April–May all days except Tuesday. Monkeybar injuries were bimodal, with the spring peak on Wednesday–Thursday in April/May and the fall peak Tuesday–Friday in September. Rollerblade injuries occurred Saturday–Sunday from March/April; rollerskates on Saturday–Sunday in January–April, and skateboards Saturday–Monday in August–October and Sundays in April.

CONCLUSIONS

These findings can be used to further guide childhood injury prevention programmes/campaigns and especially track improvements after targeted prevention programmes. Public parks and schools should check/correct the status of playground landing surfaces just before the bimodal peaks. Education campaigns reinforcing the need for bicycle helmets could be concentrated immediately before the increase in cycling activity – March on weekends and April/May for weekdays.

Status and risk factors of unintentional injuries among Chinese undergraduates: a cross-sectional study

Background

Injuries affect all age groups but have a particular impact on young people. To evaluate the incidence of non-fatal, unintentional, injuries among undergraduates in Wenzhou, China, assess the burden caused by these injuries, and explore the associated risk factors for unintentional injuries among these undergraduates, we conducted a college-based cross-sectional study.

Methods

Participants were selected by a multi-stage random sampling method, and 2,287 students were asked whether they had had an injury in the last 12 months; the location, cause, and consequences of the event. The questionnaire included demographic and socioeconomic characteristics, lifestyle habits, and the scale of type A behaviour pattern (TABP). Multivariate logistic regression models were used; crude odds ratios (ORs), adjusted ORs and their 95% confidence intervals (CIs) were estimated, with students having no injuries as the reference group.

Results

The incidence of injuries among undergraduates in Wenzhou was 18.71 injuries per 100 person-years (95%CI: 17.12~20.31 injuries per 100 person-years). Falls were the leading cause of injury, followed by traffic injuries, and animal/insect bites. Male students were more likely to be injured than female students. Risk factors associated with unintentional injuries among undergraduates were: students majoring in non-medicine (adjusted OR: 1.53; 95% CI: 1.19-1.96); type A behaviour pattern (adjusted OR: 2.99; 95% CI: 1.45-6.14); liking sports (adjusted OR: 1.86; 95% CI: 1.41-2.45).

Conclusions

Injuries have become a public health problem among undergraduates. Falls were the major cause of non-fatal injury. Therefore, individuals, families, schools and governments should promptly adopt preventive measures aimed at preventing and controlling morbidity due to non-fatal injury, especially among students identified to be at high-risk; such as male students with type A behaviour pattern who like sports.

The association of light trucks and vans with paediatric pedestrian deaths

The hypothesis that relative to cars, light trucks and vans (including sports utility vehicles) are more likely to result in fatal paediatric pedestrian injury was investigated. It was further hypothesized that this increased risk is a result of head injuries. The study sample consisted of 18 117 police records of motor vehicles involved in crashes in which one or more pedestrians aged 5 to 19 years old was injured or killed. Frequencies and case fatality ratios for each vehicle body type were calculated. A logistic regression analysis was conducted, with light truck or van vs. car as the exposure variable and fatal/non-fatal pedestrian injury as the outcome variable. After controlling for driver age, driver gender, vehicle weight, road surface condition and presence of head injury, 5 to 19 year-olds struck by light trucks or vans were more than twice as likely to die than those struck by cars (odds ratio (OR) 2.3; 95% CI 1.4, 3.9). For the 5 to 9 year-old age group, light trucks and vans were four times as likely to be associated with fatal injury (OR 4.2; 95% CI 1.9, 9.5). There was an association between head injury and light trucks and vans (OR 1.2; 95% CI 1.1, 1.3). It was concluded that vehicle body type characteristics play an important role in paediatric pedestrian injury severity and may offer engineering-based opportunities for injury control.

Risk of vehicle-pedestrian and vehicle-bicyclist collisions among children with disabilities

OBJECTIVES

To examine the potential association between disability and risk of vehicle-pedestrian and vehicle-bicyclist collisions among children.

METHODS

Data from the 2002 National Transportation Availability and Use Survey for Persons with Disabilities (NTAUSPD) were analyzed.

RESULTS

Among 5019 persons who completed the survey, there were a total of 687 children between 5-17 years of age, including 299 respondents with and 388 without disabilities. After controlling for potential confounding variables, children with disabilities were more than five times more likely to have been hit by a motor vehicle as a pedestrian or bicyclist than children without disabilities (adjusted OR = 5.53, 95% confidence interval (CI): 1.43-21.41). For all children, regardless of their disability status, children who reported having some difficulty with traffic had a significantly higher risk of collisions (adjusted OR = 50.71, 95% CI: 7.35-349.86). The most commonly reported traffic difficulties for all children with and without disabilities were "Too few or missing sidewalks/paths," "Do not know when it's safe to cross," and "Insensitive/unaware drivers."

CONCLUSIONS

Existing effective transportation safety interventions should be effective in reducing the risk of vehicle-pedestrian and vehicle-bicyclist collisions in children with disabilities. Future research and safety interventions should focus on how to promote the use of existing effective transportation safety interventions among children with disabilities and their families.

Childhood trauma fatality and resource allocation in injury control programs in a developing country

Background

Only a few studies have addressed the trimodal distribution of childhood trauma fatalities in lesser developed countries. We conducted this study to evaluate pre-hospital, Emergency Department (ED) and in-hospital distribution of childhood injury-related death for each mechanism of injury in Tehran, Iran. This information will be used for the efficient allocation of the limited injury control resources in the city.

Methods

We used Tehran's Legal Medicine Organization (LMO) database. This is the largest and the most complete database that receives information about trauma fatalities from more than 100 small and large hospitals in Tehran. We reviewed all the medical records and legal documents of the deceased registered in LMO from September 1999 to September 2000. Demographic and injury related characteristics of the children 15 years old or younger were extracted from the records.

Results

Ten percent of the 4,233 trauma deaths registered in LMO occurred among children 15 years old or younger. Motor vehicle crashes (MVCs) (50%), burns (18%), falls (6%) and poisonings (6%) were the most common mechanisms of unintentional fatal injuries. Prehospital, emergency department and hospital deaths comprised 42%, 20% and 37% of the trauma fatalities, respectively. While, more than 80% of fatal injuries due to poisoning and drowning occurred in prehospital setting, 92% of burn-related fatalities happened after hospital admission.

Conclusion

Injury prevention is the single most important solution for controlling trauma fatalities due to poisoning and drowning. Improvements in the quality of care in hospitals and intensive care units might substantially alleviate the magnitude of the problem due to burns. Improvements in prehospital and ED care might significantly decrease MVC and falls-related fatalities.

An ecological study of the locations of schools and child pedestrian injury collisions

Geographic studies of the incidence and prevalence of child pedestrian injury collisions in different community environments have been primarily descriptive and idiosyncratic, reflecting one or another likely determinant of the places where these injuries occur. The current study maintains that multiple determinants of child pedestrian injury collisions must be considered in evaluating the unique contributions of any one community feature to injury rates. These features include local characteristics of populations, such as rates of unemployment, and places, such as locations of schools. Schools are one stable geographic feature associated with regular, often concentrated periods of complex and congested traffic patterns. The objective of the present study was to examine annual rates of child pedestrian injury in four California communities with a focus on the unique contribution of schools to injury risk. We predicted that annual numbers of child pedestrian injury collisions (both in-school and summer combined) would be greater in communities with higher youth population densities, more unemployment, fewer high-income households, and higher traffic flow. It was hypothesized that youth population density and its interaction with the number of schools in a given area would be related to greater rates of child pedestrian collisions during in-school months. An ecological approach was taken that divided the four communities into 102 geographic units with an average of 6321 people residing in each unit. Archival data on traffic flow, number of child pedestrian injury collisions and locations of schools were obtained from state agencies. Individual-level data were obtained from a general population survey conducted in the communities. The results showed that annual numbers of injuries were greater in areas with higher youth population densities, more unemployment, fewer high-income households, and greater traffic flow. Annual numbers of injuries during in-school months were greater in areas containing middle schools and greater population densities of youth.

A matched case-control study evaluating the effectiveness of speed humps in reducing child pedestrian injuries

OBJECTIVES

We evaluated the protective effectiveness of speed humps in reducing child pedestrian injuries in residential neighborhoods.

METHODS

We conducted a matched case-control study over a 5-year period among children seen in a pediatric emergency department after being struck by an automobile.

RESULTS

A multivariate conditional logistic regression analysis showed that speed humps were associated with lower odds of children being injured within their neighborhood (adjusted odds ratio [OR] = 0.47) and being struck in front of their home (adjusted OR = 0.40). Ethnicity (but not socioeconomic status) was independently associated with child pedestrian injuries and was adjusted for in the regression model.

CONCLUSIONS

Our findings suggest that speed humps make children's living environments safer.

Socioeconomic differences in children's health: how and why do these relationships change with age?

The effects of socioeconomic status (SES) on health are well documented in adulthood, but far less is known about its effects in childhood. The authors reviewed the literature and found support for a childhood SES effect, whereby each decrease in SES was associated with an increased health risk. The authors explored how this relationship changed as children underwent normal developmental changes and proposed 3 models to describe the temporal patterns. The authors found that a model's capacity to explain SES-health relationships varied across health outcomes. Childhood injury showed stronger relationships with SES at younger ages, whereas smoking showed stronger relationships with SES in adolescence. Finally, the authors proposed a developmental approach to exploring mechanisms that link SES and child health.

Characteristics of injured children attending the emergency department: patients potentially in need of rehabilitation

OBJECTIVE

To provide an epidemiological overview of the characteristics of injured children and to compare hospitalized and nonhospitalized injured children to identify predictors of hospitalization and, with that, possible predictors of disablement.

DESIGN

Retrospective analysis of data obtained from a computerized trauma registration system and medical records.

SETTING

Department of Traumatology, University Hospital Groningen, the Netherlands.

SUBJECTS

Children (0-19 years) injured in 1996 and 1997 (n = 5,057).

RESULTS

The majority of children were injured in home and leisure accidents (53%) and sustained minor injuries. Only 55 (1%) children were severely injured (Injury Severity Score (ISS) > or = 16). Overall, 512 (10%) patients required hospitalization, 19 children were referred to a rehabilitation centre, and 24 children died due to their injuries. The majority of these patients were injured in traffic. Compared with the group of nonhospitalized patients, the group of hospitalized patients consisted of more males and traffic victims, were more severely injured and sustained more head/neck, spine, and thorax and abdomen injuries. Nonhospitalized patients incurred proportionally more upper and lower extremity injuries. The ISS, the body region of most severe injury, and injury cause (traffic accidents) were significant predictors of hospitalization.

CONCLUSIONS

Young traffic victims, severely injured children in terms of high ISS scores, and children with injuries affecting the head/neck/face or thorax/abdomen carry the highest risk of hospitalization.

Hotep's story: exploring the wounds of health vulnerability in the US

A wide variety of forms of domination has resulted in a highly heterogeneous health risk category, "the vulnerable." The study of health inequities sheds light on forces that generate, sustain, and alter vulnerabilities to illness, injury, suffering and death. This paper analyzes the case of a high-risk teen from a Boston ghetto that illuminates intersections between "race" and class in the construction of vulnerability in the US. Exploration of his "wounds" helps specify how large-scale social and cultural forces become embodied as individual experience of disparate health risk. The case demonstrates that health inequities would not occur if resources--employment, income, wealth, education, housing, profiling in the legal system, and health care--were more justly managed in keeping with standards outlined in the Universal Declaration of Human Rights. Professional responses to the "wounds of vulnerability" may reveal important aspects of who we are and what our work as scholars, practitioners, and advocates must become.

Assessment of hospital and police ascertainment of automobile versus childhood pedestrian and bicyclist collisions

Information about automobile versus pedestrian or bicyclist collisions differ according to the source of collision ascertainment. Hospital records and police reports focus on different characteristics of a collision, which reflects differences in case finding as well as information regarding risk factors. Pedestrians and bicyclists 0-14 years of age who were involved in a motor vehicle collision in the city of Long Beach, CA, between January 1, 1992 and June 30, 1995, were included in the study. Police reports and medical records were used to identify cases. Police reports were found for 1,015 cases, and medical records identified 474 cases; 379 cases were common to both sources. A capture-recapture model was used to evaluate the degree of overlap between the two sources and to derive "ascertainment corrected" injury rates. The injury rate from combined sources was 333.5/100,000 children per year, the pedestrian injury rate was 210.6/100,000 children per year and the bicyclist injury rate was 122.9/100,000 children per year. The "ascertainment corrected" injury rate overall was 381.3/100,000 children per year, 233.0/100,000 for pedestrians and 153.9/100,000 children per year for bicyclists. Eighty percent of hospital-reported cases were captured in the police database, whereas only 37% of police-reported cases were captured by the hospital database. We found that hospital sources identified younger children, fewer bicyclists, more Asian and Hispanic children, and fewer African-American children when compared to police sources. For more comprehensive surveillance resulting in more accurate incidence rates and more complete information, it is better to use multiple sources of data.

Maternal reports of child injuries in Canada: trends and patterns by age and gender

OBJECTIVES

This study examines gender and age differences in maternal reports of injuries in a cross sectional group of children aged 0-11 years. The cause, nature, body part injured, and location of injury are explored, as are the associations with family socioeconomic indicators and associations with limitations in activities.

METHODS

Data for 22831 children and their families come from cycle 1 of the Canadian National Longitudinal Survey of Children and Youth collected in 1995. Descriptive analyses and chi2 tests for trends are used to examine injury variations by child gender and age. Logistic regressions are used to examine the relationship between socioeconomic indicators and injury and the associations between injury and limitations in activities.

RESULTS

Consistent with findings from hospital data, boys experience more injuries than girls, and injuries increase with child age. Falls are the most common sources of maternally reported injuries, followed by scalds/poisonings for young children and sports injuries for school aged children. The majority of injuries occur in or around the home for young children, but at school for older children. For maternal reports of childhood injuries, single marital status is a risk factor for boys.

CONCLUSIONS

Maternally reported injuries occur in 10% of Canadian children and many of these are associated with limitations in activities. Preventative strategies should take both child age and gender into consideration.

Pathologic features of childhood pedestrian fatalities

A retrospective analysis of 68 cases of fatal childhood pedestrian accidents in South Australia that occurred over a 20-year period from January 1977 to December 1996 was undertaken. The age range was 12 months to 16 years (average, 7.6 years), with a male to female ratio of 41:27. The most common site of significant injury was the head (91.2%), followed by the abdomen (50%), chest (47.1%), and neck (38.2%). The most frequently encountered significant injury combinations involved the head, chest, and abdomen (14.7%); the head and chest (11.8%); and the head, neck, and abdomen (11.8%). Injuries were severe, consisting of extensive compound and comminuted skull fractures, neck fractures, and massive intraparenchymal brain and internal organ damage with avulsions and fragmentation. Non-life-threatening limb injuries occurred in 88% of cases. A distinct subgroup involved infants and younger children playing in driveways at home who were hit by reversing vehicles. The injuries were often of such a severe nature that death was instantaneous and with no possibility of successful medical intervention. More deaths occurred during the winter than summer months.

Patterns of unintentional injury in childhood and their relation to socio-economic factors

OBJECTIVE

To estimate the rate of childhood injury resulting in attendance at Accident and Emergency Departments, to describe the types of accidents and injuries seen and to relate these to socio-economic indices for ward of residence.

METHODS

Data were collected from Accident and Emergency records, on every fifth day for a year, for children 0-14 y, who attended following unintentional injury and were resident within the study area.

RESULTS

1147 children fulfilled the inclusion criteria. The annual rate of attendance was 138.2 per 1000. There was a higher rate of attendance in boys than in girls in all age groups and the gender difference was particularly marked for severe injuries. Social deprivation, measured by Townsend score, of ward of residence was a powerful predictor of risk of attendance; accounting for 33% of the variance between wards.

CONCLUSION

Unintentional injury results in high rates of attendance at Accident and Emergency Departments although the rates in this community were substantially lower than those reported from elsewhere in the United Kingdom. Risk of injury was strongly related to social disadvantage. District based data collection can be used to facilitate the development of priorities and a locally applicable safety agenda for children.

Impact of user charges and socio-economic environment on visits to paediatric trauma unit in Finland

In this report we (i) measure the strength of the association between paediatric trauma visit rates and regional socioeconomic and demographic variables, and (ii) quantify any selective impact of user charges on service demand in socioeconomically and demographically different areas. During the period 1989-94, a total of 30,362 home and leisure injury visits were made to the Aurora City Hospital. The visit rates are analysed using a random effects model. In addition, the areas are ranked into three groups in accordance with a socioeconomic index measure, and the annual visit rates of the three groups are calculated. We found fairly minor differences in children's visit rates between unequal socioeconomic areas, and it is apparent that socioeconomic status cannot explain the change in visit rates as a result of the introduction of user charges. We speculate that these changes in emergency visit rates will not lead to long-term health problems among any segment of the city population.

Children's exposure to traffic and pedestrian injuries

OBJECTIVES

The purpose of this study was to estimate children's exposure to traffic (number of streets crossed) and to determine the role of exposure in pedestrian injury.

METHODS

Questionnaires were distributed to a random sample of 4080 first- and fourth-grade children in 43 Montreal schools.

RESULTS

When analyzed by police district, injury and exposure rates were positively correlated (r2 = 0.53). Crossings were similar by sex but increased with age and were inversely related to socioeconomic status.

CONCLUSIONS

These results suggest that although children's exposure to traffic could be reduced by transporting them to school, a more reasonable prevention strategy involves environmental changes.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Program for reducing pedestrian-motor vehicle crashes

Injury prevention has been identified as a component of emergency medicine. However, involvement of emergency physicians in injury prevention has been hindered by clinical responsibilities, lack of financial support, and limited expertise in skills necessary for effective injury prevention programs. This article describes the development and content of a statewide pedestrian safety plan prepared by the Department of Emergency Medicine at the University of New Mexico. The plan included a written document, community input through focus groups, and a public information campaign. The written document included a synthesis of published literature, state-specific data, information on community interventions, and recommendations for state agencies and other groups interested in reducing pedestrian injuries. This project can be modeled at other academic EDs with an interest in injury prevention and pedestrian safety.

A review of risk factors for child pedestrian injuries: are they modifiable?

PURPOSE

To identify modifiable risk factors for child pedestrian injuries.

DATA SOURCES

(1) MEDLINE search from 1985 to 1995; search term used was traffic accidents; (2) review of reference lists from retrieved articles and books; (3) review of reference lists from three systematic reviews on childhood injuries and (4) consultation with 'key informants'.

STUDY SELECTION

All studies that examined the risk factors for child pedestrian injuries were targeted for retrieval. Seventy potentially relevant articles were identified using article titles, and, when available, abstracts. Of the 70 retrieved articles, 44 were later assessed as being relevant.

QUALITY ASSESSMENT

Articles were classified on the basis of study design as being either descriptive (hypothesis generating) (26) or analytical (hypothesis testing) (18) studies. Consensus was used for difficult to classify articles.

DATA EXTRACTION

Variables judged to be risk factors for child pedestrian injuries were extracted by one author.

DATA SYNTHESIS

A qualitative summary of the information extracted from relevant articles is presented in tabular form.

RESULTS

Risk factors for child pedestrian injuries were classified as: (1) child, (2) social and cultural, (3) physical environment, and (4) driver. Risk factors within each classification are summarized and discussed.

Children's exposure to traffic and risk of pedestrian injury in an urban setting

Pedestrian injuries to children represent a major urban health problem in the United States. Thousands of children each year are struck by moving motor vehicles; such collisions result in numerous hospitalizations and deaths. At particular risk are young school-age children between the ages of 5 and 9 years. Using a survey methodology, we collected data regarding the method by which children in an urban setting travel to and from school, in addition to the number of streets they cross in a typical school day. This information was compared with data from police records on street intersection locations of pedestrian collisions. There is a wide variation in the number of streets children cross in 1 day, calculated as the number of streets crossed in the entire day, not only those crossed to and from school. Children whose parents own a car and home cross an average of 3.7 streets per day, whereas children whose parents do not own both a car and home cross an average of 5.4 streets per day; this difference is highly significant (P < 0.0001). The largest differences in traffic exposure are between families reporting car- and-home ownership (x = 3.70 streets) versus those who do not own both a car and home (x = 5.39 streets) (Mann-Whitney = -5.5, P < 0.0001). There is a significant correlation between the proportion of children driven home from school and the rate of pedestrian injury in different regions of Baltimore. In areas where children are driven home, rates of pedestrian injury are significantly lower, whereas in areas where children walk home, rates of pedestrian injury are high (r = -0.79, P < 0.01). This study underscores the importance of adapting the child's environment to prevent injury. Interventions that alter the nature of the hazard are indicated. Changing the environment may ultimately prove more useful than attempting to change children's behavior.

Child pedestrian and bicyclist injuries: results of community surveillance and a case-control study

OBJECTIVES

To describe the dimensions of childhood pedestrian and bicyclist injuries in Long Beach, California, and to identify risk factors for these injuries.

POPULATION

Long Beach residents aged 0-14 years who were involved in an auto versus pedestrian or bicyclist incident that resulted in a hospital visit and/or police response, between 1 September 1988 and 31 August 1990.

METHODS

Cases were identified retrospectively using hospital charts, police records, and coroner's reports; demographic, clinical, and situational information were abstracted from the same. A nested case-control study was conducted to examine the street environments where children were injured, and to identify environmental risk factors at these case sites.

RESULTS

288 children comprised the sample population. Midblock dart-outs emerged as the single most common type of incident. Most incidents happened on residential streets, but the risk of injury was greatest on larger boulevards, and tended to cluster by region within the city. Adjusted odds ratios show that case sites had a larger proportion of traffic exceeding posted speed limits, and were also four times more likely to be near a convenience store, gas station, or fast food store than control sites.

CONCLUSIONS

The findings of this study suggest three possible routes for the prevention of childhood pedestrian and bicyclist injuries: education, law enforcement, and environmental modification.

The effects of a 4-year program promoting bicycle helmet use among children in Quebec

OBJECTIVES

This study assessed the effectiveness of a 4-year program of bicycle helmet promotion that targeted elementary school children in one region of Quebec. The program revolved primarily around persuasive communication and community organization, combining standard educational activities and activities to facilitate helmet acquisition and use.

METHODS

Helmet use was compared between more than 8000 young cyclists in municipalities exposed or not exposed to the program. Factors influencing helmet use were controlled through the use of multivariate analyses.

RESULTS

Helmet use increased from 1.3% before program implementation to 33% in 1993. The program was clearly effective in most cycling circumstances and for various groups of children. However, the benefits of the program were unequally distributed; the program was one third as effective in poorer municipalities as in "average-rich" ones.

CONCLUSIONS

This community-based program that combined various types of activities appeared to be effective. New intervention models are needed to ensure an equitable distribution of benefits.

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

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

Who's prepared for advocacy? Another inverse law

OBJECTIVES

To examine the characteristics of parents responding to a petition calling for greater efforts to ensure the safety of children as pedestrians and to contrast factors predictive of advocacy with risk factors for child pedestrian injury.

SETTING

The Auckland region of New Zealand.

METHODS

Parents participating in the Auckland Child Pedestrian Injury Study, a community based case-control study, were invited to support a series of recommendations based on the study results, by signing and returning a petition that was to be delivered to the New Zealand Minister for Transport. Characteristics of petitioners were determined by linking their petition responses to the study questionnaires using an unique identifier. The characteristics of petitioners and nonpetitioners were summarised using odds ratios.

RESULTS

31% of parents signed and returned the petition; 19% were parents of cases and 36% were parents of controls. The sociodemographic groups whose children were at the lowest risk of pedestrian injury were the most likely to return the petition. Children in the most disadvantaged socioeconomic group and children of Pacific Island parents were at greatest risk of injury but the parents of these children were the least likely to respond to the petition.

CONCLUSIONS

The frequency with which parents advocate for child safety varies inversely with the need for it. Models of health promotion based on community ownership and empowerment alone are unlikely to address the steep socioeconomic gradients in childhood injury mortality.

Effect of environmental factors on risk of injury of child pedestrians by motor vehicles: a case-control study

OBJECTIVE

To identify and assess contribution of environmental risk factors for injury of child pedestrians by motor vehicles.

DESIGN

Community based case-control study. Environmental characteristics of sites of child pedestrian injury were compared with the environmental characteristics of selected comparison sites. Each comparison site was the same distance and direction from home of control child as was the injury site from home or relevant case child. Two control sites were selected for each injury site.

SETTING

Auckland region of New Zealand.

SUBJECTS

Cases were 190 child pedestrians aged < 15 who were killed or hospitalised after collision with a motor vehicle on a public road during two years and two months. Controls were 380 children randomly sampled from population and frequency matched for age and sex.

MAIN OUTCOME MEASURE

Traffic volume and speed and level of parking on curbs at injury sites and comparison sites.

RESULTS

Risk of injury of child pedestrians was strongly associated with traffic volume: risk of injury at sites with highest traffic volumes was 14 times greater than that at least busy sites (odds ratio 14.30; 95% confidence interval 6.98 to 29.20), and risk increased with increasing traffic volume. High density of curb parking was also associated with increased risk (odds ratio 8.12; 3.32 to 19.90). Risk was increased at sites with mean speeds over 40 km/h (odds ratio 2.68; 1.26 to 5.69), although risk did not increase further with increasing speed.

CONCLUSION

Reducing traffic volume in urban areas could significantly reduce rates of child pedestrian injury. Restricting curb parking may also be effective.

Using a geographic information system to understand child pedestrian injury

Data from police accident reports involving pedestrians less than 20 years of age in Hartford, Conn, during 1988 through 1990 were abstracted and entered into a geographic information system. Two high-frequency collision areas were identified and compared. There were 374 child pedestrians involved in collisions (a rate of 28 per 10,000). Two high-occurrence areas accounted for 30% of collisions. Collisions in one of these areas were more likely to involve younger children (8.1 vs 10.2 years of age) and to occur in the late afternoon, and occurred closer to the child's residence, than collisions in the other area. The geographic information system is a useful tool in the study of child pedestrian collisions.

Pedestrian exposure and the risk of child pedestrian injury

The authors used data from the New Zealand Household Travel Survey to examine the extent to which children's pedestrian exposure varies with age, sex and household income. Pedestrian injury morbidity data were combined with pedestrian exposure data to examine age-specific pedestrian injury risk. The annual number of road crossings for girls was greater than that for boys. Pedestrian exposure increased with increasing age. Children aged 5-9 years in the lowest household income bracket crossed approximately 50% more roads than those in the middle and upper income brackets. However, for children aged 10-14 years there was little variation with household income. Sex differences in pedestrian injury rates cannot be explained by differences in exposure although increased exposure may partly explain the increased injury rates for children in lower socio-economic groups. Prevention strategies might aim to reduce pedestrian exposure for alternatively to reduce pedestrian injury risk per unit of exposure by making safer urban living environments.

Blaming children for child pedestrian injuries

Pedestrian injuries are a leading cause of childhood mortality. In this paper a case study of a child pedestrian death is presented in order to examine the apportionment of responsibility for child pedestrian injuries. The case presented illustrates how responsibility is located with the child, whilst structural contributors, in particular aspects of the transport system, are ignored. The strength and pervasiveness of the ideology of victim blaming in child pedestrian injuries is explained by the special position that the road transport system holds in relation to dominant economic interests. Victim blaming ideology is a strategy that serves to maintain these interests at the expense and suffering of children. Increased recognition of the political roots of the ideology of victim blaming in child pedestrian injuries, by the sectors of the community who suffer its consequences, will be an important step towards effective preventive action.

Why have child pedestrian death rates fallen?

Pedestrian injuries are a leading cause of childhood mortality and disability. Over the past two decades in Britain child pedestrian death rates have fallen despite large increases in traffic volume. In this paper Roberts examines the likely reasons for this decline. He argues that neither prevention programmes nor improvements in medical care are a plausible explanation and that the decline is most likely the result of a substantial reduction in children's traffic exposure. He believes, however, that restricting children's traffic exposure exacerbates socioeconomic differentials in childhood mortality and denies children their right to mobility. Roberts is convinced that one answer is for British transport policy to be aimed at providing mobility equitably rather than struggling to meet the ever increasing demands of car travel.

Childhood injury mortality in New South Wales: geographical and socio-economic variations

This paper reports a retrospective study of deaths due to unintentional injury in children aged between 0 and 14 years of age in New South Wales between 1985 and 1987. The aims were to determine whether the pattern of child injury mortality differed between rural and metropolitan New South Wales and to establish the relationship between socio-economic status, based on a geographical indicator of socio-economic status and child injury mortality. The child injury mortality rate for New South Wales in 1985-87 was 12.3 deaths per 100,000 population per year. The rate in the country area of 15.3 deaths per 100,000 was significantly higher than that for the metropolitan area of 11.3 per 100,000 (P < 0.05). Deaths of passengers in motor vehicle traffic accidents (P < 0.01) and deaths due to fires (P < 0.01) were greater in the country area. A negative linear association between socio-economic status and child injury mortality was found in the Sydney metropolitan area (P < 0.01). This trend was most apparent for deaths of child pedestrians (P < 0.01).

Pediatric injury prevention

Pediatric injuries are the leading cause of childhood death and disability and are responsible for more childhood deaths than all other diseases combined. The panel summarized the principles of pediatric injury prevention and reviewed the incidence, epidemiology, and prevention of six common pediatric injuries.

An area analysis of child injury morbidity in Auckland

The geographical distribution of child injury morbidity in Auckland between 1982 and 1987 was examined. Analysis of total injury, pedestrian injury and vehicle occupant injury, with the census area unit as the basic spatial entity revealed distinct variations in child injury morbidity by census area unit. Morbidity rates were above average in parts of the central urban area and South Auckland and below average on the North Shore. Total injury morbidity and pedestrian injury morbidity rates were strongly correlated with census area unit unemployment rates, which were used as a measure of socio-economic deprivation. Geographical areas with high rates of child injury morbidity, to which injury prevention resources can be directed, were identified. In particular, the results suggest that injury prevention programmes should be targeted at socio-economically disadvantaged communities.

Injury control in childhood

The behavior and environment of individuals are key determinants of both unintentional and intentional injuries in childhood and adolescence. These two determinants often interact so that certain behaviors lead to different injury outcomes depending on the environmental context of the injury. For example, depression is more likely to lead to suicide in the presence of alcohol intoxication. Alcohol intoxication is much more likely to lead to the choice of a firearm in a suicide attempt. Children with poor pedestrian crossing skills are far more likely to be hit in a busy urban intersection than in a safer location. The science of injury control has attempted to learn more about both the behavioral, environmental, and agent characteristics that lead to injury. Each of these dimensions offers opportunities for injury prevention or amelioration of the outcome. Despite increasing knowledge about how certain behaviors are associated with specific types of injuries, there has been only limited success achieved by attempts to modify behavior, particularly by persuasion or education. More success has been derived by legislative mandates. The most success, particularly in the prevention of unintentional injury, has been achieved by modification of the environments and the agents that are most often associated with injury. Because intentional injuries involve extremely complex and aberrant behavior, there is a persistent concern that attempts to modify the environment (e.g., handgun control) will be overridden by those with a high level of intent, i.e., they will seek another method. Although this may be true for carefully premeditated acts, suicide attempts and assaults by youth are usually precipitated by an acute stressor that depends on the availability of a weapon at that immediate time. While we develop more sophisticated psychosocial epidemiologic models that accurately predict violent behavior, we must continue to analyze aspects of intentional injuries that offer an opportunity to reduce the injury severity after the injury has occurred. Pediatricians and other health providers of children have played three important historical roles in the field of injury control. As clinicians, we have a unique opportunity to discuss these concerns with our patients and use our influence to attempt to modify individual behavior and inform about risks. As investigators, pediatricians have been important advocates of research initiatives to use the same epidemiologic methods used to study infectious diseases and cancer and apply them to the study of injury. Finally, pediatricians have played a critical public policy role in the evolution of injury control. Pediatricians have been at the helm behind most legislative initiatives to reduce injury among all people.(ABSTRACT TRUNCATED AT 400 WORDS)

Geographical and socio-ecological variations of traffic accidents among children

This paper deals with geographical and socio-ecological variations of pedestrian and cyclist accidents (n = 1233) among children (less than 15 years) on the Island of Montreal. The model includes variables on each child and his behavior when the accident happened and other temporal and spatial characteristics; environmental and socio-ecological data on the areas in which accidents occurred were also recorded. Descriptive, spatial and comparative analyses show specific patterns of location and occurrence of accidents. Factor analysis identifies the structure of characteristics linked to high accident areas for children's traffic accidents. A strong similarity between zone characteristics emerged from the factor analysis for both types of accident. Only a few census tracts (between 9% to 13%) are high accident areas, but they are very concentrated spatially, and for some of them (2% for pedestrians and 4% for cyclists) the rate is five to eight times higher than for the rest of the urban area. Population structure and density factors contribute 40% of the variation in accident rates. In terms of numbers, fewer children were injured as cyclists than as pedestrians, and more boys than girls are involved in these accidents. Accidents occur under good conditions of visibility and on straight streets. Parked cars in school areas are also a sign of danger. Difficulties in interpreting information on directions and speed of moving vehicles are associated with high accident frequencies, particularly for young pedestrians (6-7 years).

Geographical variations of motor-vehicle injuries in Quebec, 1983-1988

Data furnished by the Régie de l'Assurance Automobile du Québec (RAAQ) were used to describe the geography of motor vehicle accidents in the province of Quebec for the period 1983-1988. These were also used to evaluate the risk factors associated with zones of high risk with regards to accidents for the 97 Municipalités Régionales de Comté (MRC). The results demonstrate that non-severe accidents are more frequent in the urban context. On the other hand, severe accidents are more frequent in the rural context. The Standard Morbidity Ratio (SMR) highlights those MRC's with the risk of severe or non-severe accidents, where risks are twice that of Quebec as a whole. The demographic characteristics (age, sex) of the driver and passengers and the place of the accident (region, density) were used in the model LOGIT to evaluate risk factors associated with high risk zones. Results of the model for those severely injured are different from those for non-severely injured people. This holds true for the location of accidents as well as for demographic characteristics. In both models, women and people over 65 years of age are low-risk groups for accidents. The authors indicate certain action to be undertaken in Quebec by the Government to improve this situation.

Predicting traffic injuries in childhood: a cohort analysis

Data from a sample of more than 16,000 children born in the United Kingdom in 1958 were studied to identify factors that may affect the risk of having a traffic injury. Five sets of risk factors were examined: physical, developmental, educational, behavioral, and family. Information about these factors were obtained systematically from parents, teachers, and physicians when the children were 7 and 11 years of age. The results were related to traffic injuries occurring for the first time during each subsequent 4-year period. Between 8 and 11 years of age, 431 children had a traffic injury requiring medical attention, and between 12 and 16 years the number was 590. Logistic regression analyses identified a small number of factors associated with injuries, which varied according to the age and gender of the child. When all these factors were entered into a final model, only five remained: fidgety, abnormal behavior, and three measures of family disruption or disadvantage--crowding, family problems, and being removed from the family and placed in the care of the local authority. These findings suggest that it may be unwise to place much reliance on "high risk" preventive strategies by measures of this kind. Instead, more emphasis should be placed on community-based passive and environmental strategies.

A case-control study of pedestrian and bicyclist injuries in childhood

We identified children ages 0 to 14 years injured in traffic as pedestrians or bicyclists in Montreal, Canada. Two hundred children with injuries who received a score of 2 or more on the Maximum Abbreviated Injury Severity scale were considered as cases and compared with 400 uninjured children seen in the same hospitals for non-traumatic reasons. Systematic, blinded interviews and tests were conducted with parents to determine the role of a series of social, familial, personal, and behavioral characteristics. After adjustment for age, gender and socioeconomic area of residence, logistic regression analyses showed higher risks of injury to be related to fewer years of parents' education, a history of accident to a family member, an environment judged as unsafe, and poor parental supervision. Absence of physical health problems, fewer family preventive behaviors and reported lack of cautiousness were also related to a higher risk, whereas neither aggressivity nor behavioral disturbance, whether internalizing or externalizing, showed any such relation. These data suggest that the child's personality and behavior are weaker risk factors for pedestrian and bicyclist injuries than are family and neighborhood characteristics.

Incidence, causes and severity of injuries in Aquitaine, France: a community-based study of hospital admissions and deaths

This paper reports the results of a study of injuries conducted during a one-year period within a defined geographic population of 2.7 million persons (Aquitaine, France). Cases were defined as unintentional or intentional injuries, either resulting in immediate death before reaching hospital or requiring hospital admission. During the one-year period, 1,181 deaths were registered and 8,190 hospital admissions occurred during the sample periods. The three leading causes of injury were falls (40 per cent), traffic accidents (27 per cent), and poisonings (15 per cent). The overall incidence of injuries was 136 per 10,000 person years. Incidence by sex and age was assessed for the main external causes. The ratios of nonfatal to fatal cases were calculated by sex and age and by external cause. The origin of the injury was suicide in 14 per cent of cases and assault or homicide in 3 per cent. The severity of injuries, assessed using an automatic computation of the Injury Severity Score (ISS), ranged from 1 to 66 with a mean of 6.9. Substantial variations of ISS were observed according to external cause. At the 8th day following admission, 31 per cent of hospital-treated patients were still hospitalized and 0.8 per cent had died in hospital. The outcome correlated well with the ISS.

Childhood injury deaths: national analysis and geographic variations

Twenty-three causes of injury mortality in children ages 0-14 in the United States were analyzed by age, race, sex, and state of residence for the years 1980-85. Motor vehicles caused 37 per cent of all injury-related deaths and were the leading cause of injury mortality in every group except children younger than one year, for whom homicide was the leading cause. Male death rates were at least four times female rates for suicide, unintentional firearm injury, and injuries related to farm machinery or motorcycles. The drowning rate among Whites was almost twice that of Blacks for ages 1-4, but in the 10-14 year age group the drowning rate for Blacks was over three times that of Whites. In general, the highest injury death rates were in the mountain states and the south. Between 1980 and 1985, the suicide rate in the 10-14 year age group more than doubled.