The effects of postural support padding modifications to child restraints for children with disability on crash protection

OBJECTIVE

Many children with physical disabilities need additional postural support when sitting and supplementary padding is used on standards approved child restraints to achieve this when traveling in a motor vehicle. However, the effect of this padding on crash protection for a child is unknown. This study aimed to investigate the effect of additional padding for postural support on crash protection for child occupants in forward facing child restraints.

METHODS

Forty frontal sled tests at 49 km/h were conducted to compare Q1 anthropometric test device (ATD) responses in a forward-facing restraint, with and without additional padding in locations to increase recline of the restraint, and/or support the head, trunk and pelvis. Three padding materials were tested: cloth toweling, soft foam, and expanded polystyrene (EPS). The influence of padding on head excursion, peak 3 ms head acceleration, HIC15, peak 3 ms chest acceleration and chest deflection were analyzed.

RESULTS

The influence of padding varied depending on the location of use. Padding used under the restraint to increase the recline angle increased head injury metrics. Toweling in multiple locations which included behind the head increased head excursion and chest injury metrics. There was minimal effect on injury risk measures with additional padding to support the sides of the head or the pelvis position. Rigid EPS foam, as recommended in Australian standards and guidelines, had minimal effect on injury metrics when used inside the restraint, as did tightly rolled or folded toweling secured to the restraint at single locations around the body of the child.

CONCLUSIONS

This study does not support the use of postural support padding to increase recline of a forward-facing restraint or padding behind the head. Recommendations in published standards and guidelines to not use foam that is spongy, soft or easily compressed, with preference for secured firm foam or short-term use of tightly rolled or folded toweling under the child restraint cover is supported. This study also highlights the importance of considering the whole context of child occupant protection when using additional padding, particularly the change in the child's seated position when adding padding in relation to the standard safety features of the restraint.

History of airbag safety benefits and risks

OBJECTIVE

The history of airbags was reviewed for benefits and risks as they became a supplement to lap-shoulder belts. Sled and crash tests were evaluated and field data was analyzed for airbag effectiveness. Field data on airbag deaths and studies on mechanisms of deployment injury were analyzed. The history was reviewed as airbags evolved from the early 1970s to today.

METHODS

Airbag benefits were determined from NHTSA crash tests with unbelted and belted dummies in 40, 48, and 56 km/h (25, 30, and 35 mph) frontal impacts with and without airbags. The literature was reviewed for testing of passive restraints with and without airbags. Recent NCAP tests were compared with earlier tests to determine the change in occupant responses with seatbelts and supplemental airbags in modern vehicles. 1994-2015 NASS-CDS field data was analyzed for MAIS 4 + F injury. Risks were compared for belted and unbelted occupants in frontal impacts by delta V. Airbag risks were identified from field deployments and research. The 1973-76 GM fleet had two deaths due to the occupant being out-of-position (OOP). The mechanisms of injury were determined. From 1989-2003, NHTSA investigated 93 driver, 184 child passenger, and 13 adult passenger airbag deaths. The data was reviewed for injury mechanisms. Second generation airbags essentially eliminated OOP airbag deaths. More recently, three suppliers were linked to airbag rupture deaths. The circumstances for ruptures were reviewed.

RESULTS

The risk for serious head injury was 5.495% in drivers and 4.435% passengers in 40-48 km/h (25-30 mph) frontal crash tests without belts or airbags. It was 80.5% lower at 1.073% in drivers and 82.0% at 0.797% in passengers with belts and airbags in 35 mph NCAP crash tests of 2012-20 MY vehicles. NASS-CDS field data showed a 15.45% risk for severe injury (MAIS 4 + F) to unbelted occupants and 4.68% with belted occupants in 30-35 mph frontal crash delta V with airbags, as deployed. The reduction in risk was 69.7% with belt use and airbags deploying in 96.1% of crashes. There were benefits over the range of delta V. Two airbag deaths were studied from the 1970s GM fleet of airbags. The unbelted driver death was caused by punchout force with the airbag cover blocked by the occupant and membrane forces as the airbag wrapped around the head, neck or chest with the occupant close to the inflating airbag. The unbelted child death was from airbag inflation forces from pre-impact braking causing the child to slide forward into the deploying airbag. Research showed that unrestrained children may have 13 different positions near the passenger airbag at deployment. NHTSA investigation of first generation airbag deaths found most driver deaths were females (75.3%) sitting forward on the seat track, close to the driver airbag. Seatbelt use was only 30%. Most child deaths (138, 75.4%) involved no or improper use of the lap-shoulder belts. Of these, 115 deaths involved pre-impact braking. Only 37 (20.2%) children were in child seats with 29 in rear-facing and 8 in forward-facing child seats. Eight child deaths (4.4%) occurred with lap-shoulder belt use. Airbag designs changed. More recently, Takata airbags were related to at least 24 deaths by airbag rupture prompting a recall; the successor company Joyson had an airbag recall. ARC airbags have experienced a chunk of the inflator propelled into the driver during deployment with several deaths leading to a recall.

CONCLUSIONS

Airbags are effective in preventing death and injury in crashes. They provide the greatest protection in combination with seatbelt use. NHTSA estimated airbags saved 28,244 lives through 1-1-09 while causing at least 320 deployment deaths, which has prompted improved designs, testing, and recalls.

Exploring the Potential of a Behavior Theory-Informed Digital Intervention for Infant Fall Prevention: Mixed Methods Longitudinal Study

BACKGROUND

Falls are the most common hospitalized injury mechanism in children aged ≤1 years, and currently, there are no targeted prevention interventions. The prevention of falls in children of this age requires changes in the behavior of their caregivers, and theoretically informed digital behavior change interventions (DBCIs) may provide a unique mechanism for achieving effective intervention. However, user acceptance and the ability of DBCIs to effect the required changes in behavior are critical to their likelihood of success.

OBJECTIVE

This study aims to evaluate a behavior theory-informed digital intervention developed following a user-centered approach for user experience, the potential for this intervention to prevent infant falls, and its impact on behavioral drivers underpinning fall risk in young children.

METHODS

Parents of infants aged <1 year were recruited and asked to use the intervention for 3 months. A pre-post longitudinal design was used to examine the change in the potential to reduce the risk of falls after a 3-month exposure to the intervention. Postintervention data on behavioral drivers for fall prevention, user acceptability, and engagement with the app were also collected. Interviews were conducted to explore user experiences and identify areas for further improvement of the intervention.

RESULTS

A total of 62 parents participated in the study. A statistically significant effect on the potential to reduce falls was observed after the intervention. This effect was higher for new parents. Parents agreed that the intervention targeted most of the target behavior drivers. The impact of behavior drivers and intervention on the potential for fall prevention had a positive correlation. The intervention demonstrated good levels of acceptability. Feedback from participants was mostly positive, and the primary area identified for further improvement was widening the scope of the intervention.

CONCLUSIONS

This study demonstrated the promise of a newly developed digital intervention to reduce the risk of infant falls, particularly among new parents. It also showed a positive influence of the DBCI on the drivers of parental behaviors that are important for fall reduction among infants. The acceptability of the app was high, and important insights were gained from users about how to further improve the app.

Slicing Through the Layers of Pediatric Unintentional Injury With the Swiss Cheese Model: A Topical Review

Pediatric unintentional injury significantly burdens children, families, and society. Behavioral researchers have examined the problem for decades, identifying many risk factors and greatly enhancing knowledge of the injury antecedent process. Approaches using theories and models to guide inquiry into etiology and prevention are still needed. We offer an approach borrowed from the field of human factors to enhance understanding and prevention. We focus our exploration on an error modeling and accident investigation tool called the Swiss Cheese Model. We first introduce the basic elements of the model. Next, we apply error modeling concepts to example scenarios drawn from real unintentional incidents and discuss the implications for understanding etiology and prevention. Finally, potential future directions are discussed to illustrate paths for the advancement of injury etiology and prevention.

"Before I Could Get Him, He Fell": Experiences, Concerns, and Fall Prevention Strategies of Parents With Young Children

Little is known about parents' perceptions and prevention strategies regarding childhood falls. In this qualitative study using semi-structured interviews, we sought to describe parental reports of child fall experiences, concerns, and prevention strategies in the home. Sixteen parents with at least one child younger than 18 months were asked about their awareness of fall risks, falls experienced by the child, fall concerns, prevention strategies, and where in the home the child spends time throughout the day. Seven themes emerged: (1) "falls are unexpected," (2) "role of the physical environment," (3) "children's temperament and developmental stage," (4) "physical barriers and baby products," (5) "addressing walking surfaces," (6) "modifying the height of a fall," and (7) "supervision." Parents are aware of in-home fall hazards and actively use strategies to lessen fall risk. Anticipatory guidance should promote evidence-based and evidence-informed prevention strategies and augment effective strategies some parents use to lower fall risk.

Post-Natal Short-Term Home Visiting Programs: An Overview and a Volunteers-Based Program Pilot

Post-natal home visits have been shown to be one of the most effective ways to prevent child maltreatment and reduce risks among children. Unfortunately, these programs tend to be expensive and thus not accessible or practical in many contexts. To address this problem, this paper reviews the literature on home visits conducted shortly after giving birth, considering different types of programs and their outcomes, while focusing on short-term and volunteer-based programs, two approaches that can answer the gap in accessibility. It then introduces a new, innovative, short-term, home visiting program that was developed in Israel. This post-natal program is uniquely structured as volunteer-based to allow it to be culturally informed and inexpensive and therefore accessible to municipalities. The paper describes how experts in the field developed the program and how the volunteers were trained. It elaborates on the protocol for the three defined home visits, each with a specific focus: (1) preventing risks at home, (2) providing parents with emotional support and tools to deal with stress, and (3) connecting them to community resources. We detail the pilot implementation process and some of the challenges that arise. Finally, we describe the design of the evaluation study that is currently collecting data in an Arab town in the north of Israel, with a final discussion on insights gained thus far from the overall process in light of the literature.

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.

Development of a core dataset for child injury surveillance: a modified Delphi study in China

Background

Understanding the occurrence and severity of child injuries is the cornerstone of preventing child injuries. Currently, there is no standardized child injury surveillance dataset in China.

Methods

Multistage consultation by a panel of Chinese experts in child injury to determine items to include in the core dataset (CDS) was performed. The experts participated in two rounds of the modified Delphi method comprising a consultation questionnaire investigation (Round 1) and a face-to-face panel discussion (Round 2). Final consensus was established based on the opinions of the experts regarding the modified CDS information collection items. Enthusiasm and authority exhibited by the experts were evaluated by the response rate and using the expert authority coefficient, respectively.

Results

The expert panel included 16 experts in Round 1 and 15 experts in Round 2. The experts during both rounds had a high degree of authority, with an average authority coefficient of 0.86. The enthusiasm of the experts was 94.12%, and the proportion of suggestions reached 81.25% in Round 1 of the modified Delphi method. The draft CDS evaluated in Round 1 included 24 items, and expert panelists could submit recommendations to add items. Based on findings in Round 1, four additional items, including nationality, residence, type of family residence, and primary caregiver were added to the draft of the CDS for Round 2. After Round 2, consensus was reached on 32 items arranged into four domains-general demographic information, injury characteristics, clinical diagnosis and treatment, and injury outcome-to include in the final CDS.

Conclusion

The development of a child injury surveillance CDS could contribute to standardized data collection, collation, and analysis. The CDS developed here could be used to identify actionable characteristics of child injury to assist health policymakers in designing evidence-based injury prevention interventions.

Injury in Children with Developmental Disorders: A 1:1 Nested Case-Control Study Using Multiple Datasets in Taiwan

Although past studies have identified predictors related to child injuries with developmental disorders, national-level research in Asia is limited. The objective of this study was to explore the risk factors for child injuries with developmental disorders in Taiwan using a national-level integrated database for the period between 2004-2015 (The Maternal and Child Health Database, National Health Insurance Research Database, Census Registry, and Indigenous Household Registration). Children younger than 12 years old who had records of visiting the ER or being hospitalized due to injury or without injury were included in this study. A 1:1 nested case-control study (injury vs. noninjury) to examine the risk factors for child injury with developmental disorder was performed. A total of 2,167,930 children were enrolled. The risk factors were associated with repeated ER visits or hospitalization: being indigenous (adjusted odds ratio [AOR]: 1.51; CI: 1.45-1.57); having a developmental disorder (AOR: 1.74; CI: 1.70-1.78); and having parents with illicit drug use (AOR: 1.48; CI: 1.32-1.66), alcohol abuse (AOR: 1.21; CI: 1.07-1.37), or a history of mental illness (AOR: 1.43; CI: 1.41-1.46). Being indigenous, having developmental disorders, and having parents with history of illicit drug use, alcohol abuse, or mental illness were predictors related to injuries in children.

The shape of the New Zealand child injury prevention workforce

OBJECTIVE

To describe the characteristics of the New Zealand child injury prevention workforce and the organisations they represent.

METHODS

Representatives of organisations on the Safekids Aotearoa database were invited to complete an online survey. The standardised questionnaire asked for information about injury prevention focus and expertise, communication preferences and information access.

RESULTS

Of 196 respondents, the majority were female and identified as New Zealand European. For only a small proportion of respondents, child injury prevention is the main focus of their role. The key sources of child injury data and injury prevention information identified was Safekids Aotearoa, followed by the Ministry of Health. Respondents indicated that they would like to receive information on new research, training opportunities and upcoming events, and information from other organisations.

CONCLUSIONS

Males and people of Pacific and Asian ethnicity are under-represented in the New Zealand child injury prevention workforce in New Zealand. The low engagement of the sector with Māori authorities is of concern, given the inequities in rates of child injury that exist.

IMPLICATIONS FOR PUBLIC HEALTH

There is a need to conduct a wider and more regular audit of the child injury prevention sector to determine its composition and identify areas of concern.

Exploring Infant Fall Events Using Online Parenting Discussion Forums: Infodemiology Study

BACKGROUND

Falls represent the most common mechanism of injury requiring hospitalization among children under 12 months, and they commonly result in traumatic brain injury. Epidemiological studies exploring infant falls demonstrate the experienced burden, but they lack contextual information vital to the development of preventive interventions.

OBJECTIVE

The objective of this study was to examine contextual information for falls involving children under 12 months, using online parenting discussion forums.

METHODS

Online parenting forums provide an unobtrusive rich data source for collecting detailed information about fall events. Relevant discussions related to fall incidents were identified and downloaded using site-specific Google Search queries and a programming script. A qualitative descriptive approach was used to analyze the incidents and categorize contextual information into "precursor events" and "influencing factors" for infant falls.

RESULTS

We identified 461 infant fall incidents. Common fall mechanisms included falls from furniture, falls when being carried or supported by someone, falls from baby products, and falls on the same level. Across the spectrum of fall mechanisms, common precursor events were infant rolling off, infant being alone on furniture, product misuse, caretaker falling asleep while holding the infant, and caretaker tripping/slipping while carrying the infant. Common influencing factors were infant's rapid motor development, lapses in caretaker attention, and trip hazards.

CONCLUSIONS

The findings define targets for interventions to prevent infant falls and suggest that the most viable intervention approach may be to target parental behavior change. Online forums can provide rich information critical for preventive interventions aimed at changing behavior.

Families following pediatric traumatic medical events: identifying psychosocial risk profiles using latent profile analysis

BACKGROUND

Post-traumatic stress symptoms (PTSS) are often experienced by children and family members after pediatric traumatic medical events (PTMEs). Assessing families' psychosocial risk factors is a crucial part of trauma-informed practice as it helps identify risk for PTSS in the aftermath of PTME.

OBJECTIVES

Using the Psychosocial Assessment Tool 2.0 (PAT2.0), this study describes the psychosocial risk of families following PTMEs in two ways: 1. Describing the psychosocial risk defined by the PAT2.0 based on three-tiered risk levels; 2. Using latent profile analysis (LPA); identifying psychosocial risk profiles and examining how child- and injury-related factors can affect profile membership.

METHODS

Caregivers of 374 children following PTMEs admitted to a pediatric rehabilitation department in Israel completed the PAT2.0. Total PAT2.0 score and the seven PAT2.0 subscales (family structure/resources, social support, child problems, sibling problems, family problems, caregiver stress reactions, and family beliefs) were included in the first analysis. Mean PAT2.0 scores of three risk categories (universal, targeted, clinical) were calculated; LPA, which allows for cross-sectional latent variable mixture models to identify heterogeneity within a population, and multinomial logistic regressions using six out of the seven PAT2.0 subscales, were used to determine distinct profile differences and predictors of profile membership.

RESULTS

The three-tiered risk levels revealed were relatively high, as compared to levels in families of children with other clinical diagnoses. LPA yielded a three-profile solution: low family risk (63.53%); high caregiver stress, above-average levels of family risk (22.5%); and sibling problems, above-average levels of family risk (13.94%). Ethnicity and type of injury predicted group membership.

CONCLUSION

Families of children following PTMEs are at increased psychosocial risk. A clinically useful approach to identifying and preventing PTSS may be to evaluate specific domain patterns rather than just the total PAT2.0 risk level alone, based on the PAT2.0 subscales.

Toward a Behavior Theory-Informed and User-Centered Mobile App for Parents to Prevent Infant Falls: Development and Usability Study

BACKGROUND

Falls account for approximately 50% of infant injury hospitalizations, and caretaker behavior is central to preventing infant falls. Behavior theory-informed interventions for injury prevention have been suggested, but to date, few have been reported. The potential of using smartphones for injury prevention intervention delivery is also underexploited.

OBJECTIVE

This study aims to develop a behavior theory- and evidence-based as well as user-centered digital intervention as a mobile app for parents to prevent infant falls following agile development practices.

METHODS

Infant falls while feeding was selected as the fall mechanism to demonstrate the approach being taken to develop this intervention. In phase 1, the Behaviour Change Wheel was used as a theoretical framework supported by a literature review to define intervention components that were then implemented as a mobile app. In phase 2, after the person-based approach, user testing through think-aloud interviews and comprehension assessments were used to refine the content and implementation of the intervention.

RESULTS

The target behaviors identified in phase 1 were adequate rest for the newborn's mother and safe feeding practices defined as prepare, position, and place. From behavioral determinants and the Behaviour Change Wheel, the behavior change functions selected to achieve these target behaviors were psychological capability, social opportunity, and reflective motivation. The selected behavior change techniques aligned with these functions were providing information on health consequences, using a credible source, instruction on performing each behavior, and social support. The defined intervention was implemented in a draft Android app. In phase 2, 4 rounds of user testing were required to achieve the predefined target comprehension level. The results from the think-aloud interviews were used to refine the intervention content and app features. Overall, the results from phase 2 revealed that users found the information provided to be helpful. Features such as self-tracking and inclusion of the social and environmental aspects of falls prevention were liked by the participants. Important feedback for the successful implementation of the digital intervention was also obtained from the user testing.

CONCLUSIONS

To our knowledge, this is the first study to apply the Behaviour Change Wheel to develop a digital intervention for child injury prevention. This study provides a detailed example of evidence-based development of a behavior theory-informed mobile intervention for injury prevention refined using the person-based approach.

Hospitalised infants due to falls aged less 12 months in New South Wales from 2002 to 2013

AIM

Falls are the most common injury mechanism of children <12 months in Australia. We aimed to determine the prevalence of hospital admission following a fall among New South Wales (NSW) infants and changes in admission rate over time. Secondary aims were to examine demographics, nature of injury and trends by age groups associated with developmental milestones and fall mechanism.

METHODS

This was a retrospective, population-based study across NSW from 2002 to 2013 using the NSW Admitted Patient Data collection. Infants with recorded falls, external causes of morbidity and mortality and activity codes were assessed. Main outcome measures were absolute numbers, rates and proportions by year, age group, socio-demographics, fall mechanism, injury type, body region affected and admission outcome.

RESULTS

A total of 4380 cases were identified. Numbers increased over years (342 in 2002 to 469 in 2013). Rate of admissions per 10 000 population were 40.37 in 2002 and 47.18 in 2013 (average increase 0.9% per year, P = 0.25). 76% resided in a major city, 23% resided in the least disadvantaged areas and 18% in the most disadvantaged. Falls from furniture and falls while being carried were most common. 85% suffered a head injury, 70% of which had a traumatic brain injury (TBI). There were seven deaths and one quarter of surviving infants were admitted for 2 or more days.

CONCLUSIONS

Hospital admission following a fall is a long-standing problem with no improvement among infants in NSW, commonly leading to head injury and traumatic brain injury. Effective prevention interventions are needed.

Environmental change interventions to prevent unintentional home injuries among children in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION

Unintentional home injury is an important cause of death and disability among children, especially those living in low- and middle-income countries (LMICs). This systematic review aimed to synthesize evidence about the effectiveness of environmental interventions to prevent unintentional child injury and/or reduce injury hazards in the home in LMICs.

METHODS

Seven electronic databases were searched for randomized controlled trials (RCTs) and controlled before and after (CBA) studies published up to 1 April 2018. Potentially eligible citations were screened by title and abstract and full texts of studies obtained. Synthesis was reported narratively, and where possible, meta-analysis was conducted.

RESULTS

Four studies met the inclusion criteria: One CBA study reported changes in injury incidence, and three RCTs reported changes in frequency of home hazards. In one study, child resistant containers were found effective in reducing the incidence of paraffin ingestion by 47% during and by 50% postintervention. A meta-analysis of two trials found that home inspection, safety education and safety devices reduced postintervention mean scores for poisoning hazards [mean difference (MD) -0.77; 95% CI [-1.36, -0.19]] and burn-related unsafe practices (MD -0.37; 95% CI [-0.66, -0.09]) but not for falls or electrical and paraffin burn hazards. A single trial found that home inspection and safety education reduced the postintervention mean scores for fall hazards (MD -0.5; 95% CI [-0.66, -0.33]) but not for ingestion hazards.

CONCLUSION

There is limited evidence that environmental change interventions reduce child injuries but evidence that they reduce some home hazards. More evidence is needed to determine if altering the physical home environment by removing potential hazards reduces injuries in LMICs.

Overloaded and Unrestrained: A Qualitative Study with Local Experts Exploring Factors Affecting Child Car Restraint Use in Cape Town, South Africa

(1) Background: Children in South Africa experience significant impacts from road injury due to the high frequency of road crashes and the low uptake of road safety measures (including the use of appropriate child restraints). The current study aimed to assess the feasibility of a child restraint program and to describe factors influencing child restraint use from the perspectives of clinicians, representatives of non-government agencies, and academics in Cape Town, South Africa. (2) Methods: Qualitative interviews were conducted with 13 experts from government, academic and clinical backgrounds. Findings were analyzed using the COM-B component of the Behaviour Change Wheel and were grouped by the layers of the social-ecological model (individual, relational, community and societal). (COM-B is a framework to explain behaviour change which has three key components; capability, opportunity and motivation), (3) Results: Experts believed that there was a need for a child restraint program that should be staged and multifactorial. Participants described knowledge gaps, perceptions of risk, mixed motivations and limited enforcement of child restraint legislation as key influences of restraint use. (4) Conclusions: The results demonstrate potential areas on which to focus interventions to increase child restraint use in Cape Town, South Africa. However, this will require a coordinated and consistent response across stakeholder groups.

Categorizing mothers' and fathers' conceptualizations of children's serious play-related injuries: "You won't grow a finger back"

BACKGROUND

There is inconsistency across child development and care literature in operationalizing serious play-related injury and also a lack of understanding of how mothers and fathers conceptualize serious play-related injury. The current study explores parents' perspectives of their 2- to 7-year-old children's serious play-related injuries in urban and rural areas of British Columbia and Québec, Canada, and provides an urban/rural and gender analysis of the results.

METHODS

We conducted semistructured interviews with 41 mothers and 63 fathers from 57 families, a total of 104 participants, in urban and rural locations in British Columbia and Québec, Canada. We used a social constructionist approach to the research and reflexive thematic analysis to construct themes from participant responses and to inform the consequent categorizations of serious play-related injury.

RESULTS

The results indicate four categories of parents' conceptualizations of serious play-related injury: (a) injury requiring medical intervention, (b) injury resulting in head trauma, (c) injury resulting in debilitation, and (d) broken bones.

CONCLUSIONS

Child development and care advocates can use these categories to strengthen their communications with parents and to improve understanding of parents' conceptualizations of children's serious play-related injury.

School safety assessment in Bengaluru and Kolar districts, India

Ensuring optimum safety in schools to prevent injuries and promote safety of children is a mandate by the Constitution of India. However, there is limited evidence regarding safety and injury prevention in schools. This safety appraisal was conducted on a sample of 131 schools, selected by stratified random sampling in Bengaluru and Kolar districts in India. Trained investigators collected data using smart phone-assisted interview, observational methods and record review between 1 January and 31 March 2019. Safety was assessed across the domains of macro areas (policy, guidelines, committee, budget, coordination and training), physical infrastructure, road and transport safety, fire safety and first-aid services. Safety level (%) at each school was computed based on scores obtained in each domain. Overall safety level was at 50.8% of the assessment criteria and was relatively better in private schools (54%). Most schools scored less than 30% in domains of transport safety, fire safety and macro areas. Results highlight the need for implementing and augmenting safety measures in schools.

Affordability and Availability of Child Restraints in an Under-Served Population in South Africa

Background: Child road traffic injuries are a major global public health problem and the issue is particularly burdensome in middle-income countries such as South Africa where injury death rates are 41 per 100,000 for under 5′s and 24.5 per 100,000 for 5–14-year-old. Despite their known effectiveness in reducing injuries amongst children, the rates of use of child restraint systems (CRS) remains low in South Africa. Little is known about barriers to child restraint use especially in low- and middle-income countries. Methods: We carried out observation studies and parent/carer surveys in 7 suburbs of Cape Town over a three month period to assess usage rates and explore the knowledge and perceptions of parents towards child restraint legislation, ownership and cost; Results: Only 7.8% of child passengers were observed to be properly restrained in a CRS with driver seatbelt use and single child occupancy being associated with higher child restraint use. 92% of survey respondents claimed to have knowledge of current child restraint legislation, however, only 32% of those parents/carers were able to correctly identify the age requirements and penalty. Reasons given for not owning a child seat included high cost and the belief that seatbelts were a suitable alternative. Conclusions: These findings indicate the need for a tighter legislation with an increased fine paired with enhanced enforcement of both adult seatbelt and child restraint use. The provision of low-cost/subsidised CRS or borrowing schemes and targeted social marketing through online fora, well baby clinics, early learning centres would be beneficial in increasing ownership and use of CRS.

Children's experience of physical harms and exposure to family violence from others' drinking in nine societies

AIM

To study caregiver reports of children's experience of physical harm and exposure to family violence due to others' drinking in nine societies, assess the relationship of harm with household drinking pattern and evaluate whether gender and education of caregiver affect these relationships.

METHOD

Using data on adult caregivers from the GENAHTO (Gender and Alcohol's Harm to Others) project, child alcohol-related injuries and exposure of children to alcohol-related violence (CAIV) rates are estimated by country and pooled using meta-analysis and stratified by gender of the caregiver. Households with and without heavy or harmful drinker(s) (HHD) are compared assessing the interaction of caregiver gender on the relationship between reporting HHD and CAIV, adjusting for caregiver education and age. Additionally, the relationship between caregiver education and CAIV is analysed with meta-regression.

RESULTS

The prevalence of CAIV varied across societies, with an overall pooled mean of 4% reported by caregivers. HHD was a consistent correlate of CAIV in all countries. Men and women in the sample reported similar levels of CAIV overall, but the relationship between HHD and CAIV was greater for women than for men, especially if the HHD was the most harmful drinker. Education was not significantly associated with CAIV.

CONCLUSION

One in 25 caregivers with children report physical or family violence harms to children because of others' drinking. The adjusted odds of harm are significantly greater (more than four-fold) in households with a heavy or harmful drinker, with men most likely to be defined as this drinker in the household.

Monitoring Injuries Associated with Mandated Children's Products in Australia: What Can the Data Tell Us?

Mandatory standard regulation is used within Australia to ensure the safety of consumer products, preventing product-related injury. Standard regulation is particularly important for products designed for use by children, who are highly vulnerable to sustaining product-related injuries due to their small size and inability to identify product hazards. This project aims to investigate how effectively information regarding product-related injuries is able to be captured within Australian health and coronial data. Further, it aims to investigate the extent to which child injury occurs for products for which mandatory safety standards exist through the review of available data. This study highlights significant limitations in injury surveillance data for identification and monitoring of child product-related injuries. This in turn limits the evidence base to assess the efficacy of existing regulations. Available data show baby walkers, cots, prams, nightwear, and bunk beds to be associated with a considerable number of child hospital presentations, admissions, and deaths. A significant scope for improvement in current product injury recording practices in the health sector exists.

The Cellie Coping Kit for Children with Injury: Initial feasibility, acceptability, and outcomes

PURPOSE

Physical and psychological challenges can arise from paediatric injury, which can impact child health outcomes. Evidence-based resources to promote recovery are limited. The low cost, portable Cellie Coping Kit for Children with Injury provides evidence-based strategies to help children manage injury-related challenges. This study aimed to describe intervention feasibility and explore initial outcomes (learning, quality of life [QOL], and trauma symptoms).

METHODS

Three independent pilot studies were conducted. Child-parent dyads (n = 61) participated in the intervention; ~36% completed a 4-week follow-up assessment.

RESULTS

Results suggested that the intervention was feasible (e.g., 95% of parents would recommend the intervention; >85% reported that it was easy to use). Over 70% of participants reported learning new skills. No statistically significant differences were detected for children's QOL or trauma symptoms preintervention to postintervention.

CONCLUSION

Preliminary research suggests that the Cellie Coping Kit for Children with Injuries is a feasible, low-cost, preventive intervention, which may provide families with strategies to promote recovery from paediatric injury. Future research, including a randomized controlled trial, ought to further examine targeted long-term intervention outcomes.

Parental Factors Associated with Child Post-traumatic Stress Following Injury: A Consideration of Intervention Targets

Post-traumatic stress disorder (PTSD) symptoms are relatively common following pediatric traumatic injury and are related to poor long-term child outcomes. However, due to concerns regarding the efficacy of early child preventive interventions, and difficulty intervening with injured and medicated children soon after the event, it is not feasible to provide early psychological interventions to children exposed to traumatic injury. Parental PTSD symptoms and reactions to the child’s traumatic injury impact child outcomes and provide potential targets for early intervention to reduce child symptom development without involving the child. The authors conducted a review of the literature using Psycinfo and Pubmed research databases (publication years = 1990–2017) and identified 65 published studies relevant to the topic of the review. The present review considers parent factors [parenting styles, parental post-traumatic pathology (PTS), adaptive and maladaptive coping strategies, and communication regarding the traumatic injury] and their impact on child PTS. We focus specifically on factors amenable to intervention. We further review moderators of these relationships (e.g., child age and gender, parent gender) and conclude that it is unlikely that a one-size-fits-all approach to treatment will be successful. Rather, it is necessary to consider the age and gender of parent child dyads in designing and providing targeted interventions to families following the traumatic injury of a child.

Impact of participant attrition on child injury outcome estimates: a longitudinal birth cohort study in Australia

BACKGROUND

Longitudinal research is subject to participant attrition. Systemic differences between retained participants and those lost to attrition potentially bias prevalence of outcomes, as well as exposure-outcome associations. This study examines the impact of attrition on the prevalence of child injury outcomes and the association between sociodemographic factors and child injury.

METHODS

Participants were recruited as part of the Environments for Healthy Living (EFHL) birth cohort study. Baseline data were drawn from maternal surveys. Child injury outcome data were extracted from hospital records, 2006-2013. Participant attrition status was assessed up to 2014. Rates of injury-related episodes of care were calculated, taking into account exposure time and Poisson regression was performed to estimate exposure-outcome associations.

RESULTS

Of the 2222 participating families, 799 families (36.0%) had complete follow-up data. Those with incomplete data included 137 (6.2%) who withdrew, 308 (13.8%) were lost to follow-up and 978 families (44.0%) who were partial/non-responders. Families of lower socioeconomic status were less likely to have complete follow-up data (p<0.05). Systematic differences in attrition did not result in differential child injury outcomes or significant differences between the attrition and non-attrition groups in risk factor effect estimates. Participants who withdrew were the only group to demonstrate differences in child injury outcomes.

CONCLUSION

This research suggests that even with considerable attrition, if the proportion of participants who withdraw is minimal, overall attrition is unlikely to affect the population prevalence estimate of child injury or measures of association between sociodemographic factors and child injury.

Vitamin D and Fracture Risk in Early Childhood: A Case-Control Study

The objective of this study was to evaluate the association of vitamin D intake and serum levels with fracture risk in children under 6 years of age. A case-control study was conducted in Toronto, Ontario, Canada. Cases were recruited from the fracture clinic at the Hospital for Sick Children, and matched controls were obtained from the TARGet Kids! primary-care research network. Controls were matched to cases on age, sex, height, and season. Fracture risk was estimated from conditional logistic regression, with adjustment for skin type, fracture history, waist circumference, outdoor free play, neighborhood income, soda consumption, and child's birth weight. A total of 206 cases were recruited during May 2009-April 2013 and matched to 343 controls. Serum 25-hydroxyvitamin D concentration (per 10-nmol/L increment: adjusted odds ratio (aOR) = 0.95, 95% confidence interval (CI): 0.88, 1.03) and intake of cow's milk (<2 cups/day vs. 2 cups/day: aOR = 0.95 (95% CI: 0.60, 1.52); >2 cups/day vs. 2 cups/day: aOR = 1.39 (95% CI: 0.85, 2.23)) were not significantly associated with reduced odds of fracture. A statistically significant association was observed between child use of vitamin D supplements and decreased odds of fracture (yes vs. no: aOR = 0.42, 95% CI: 0.25, 0.69). Vitamin D supplementation, but not serum 25-hydroxyvitamin D level or milk intake, was associated with reduced fracture risk among these healthy young children.

Effect of a model-based educational program for mothers, on home-related injury prevention among under-five-year children in rural Twiserkan, Iran

Afshari M, Moghimbeigi A, Hazavehei SMM, Rezapur-Shahkolai F. Effect of a model-based educational program for mothers, on home-related injury prevention among under-five-year children in rural Twiserkan, Iran. Turk J Pediatr 2017; 59: 648-656. Children under 5 years of age are most vulnerable in terms of home-related injuries. As a majority of these injuries are predictable and preventable, it is important to design preventive intervention programs that can be utilized as models of health education. The aim of this study was to determine the effect of an educational program, using the PRECEDE model, for rural mothers, on home-related injury prevention among under-five-year old children. This quasi-experimental study was conducted on 72 mothers, with at least one under-five-year old child, in the rural areas of Twiserkan (Toyserkan) County in Iran. The intervention and control groups (36 participants in each), were interviewed in pre/post-test study by trained interviewers, using the questionnaire. The intervention group participated in four educational sessions. The questionnaire included the questions on demographic information, mothers` beliefs and caring in relation to child-injury prevention, based on the PRECEDE model and focusing on predisposing factors (knowledge and attitudes), enabling factors; reinforcing factors; and mothers` preventive behaviors. According to the results of the study, the mean scores of predisposing factors (knowledge), enabling and reinforcing factors and also mothers` behaviors on injury prevention, did not have significant differences between two groups before intervention, whereas they had significant differences after intervention. This study showed that the educational program, using the PRECEDE model, can be effective on promoting knowledge and performances of mothers in relation to home-related injury prevention among their under-five-year old children.

Qualitative analysis of emergency department reports applied to a pilot project for the prevention of pediatric burns

Accidents and burns are a major problem in Italy and in industrialized countries, due to the consequences they have on health, especially in children aged 0-4 years. In Italy, about 400 people die each year from burns, with over 70% of these occurring in the home. In the European Union, burns are one of the top five causes of death from accidents, accounting for 3% of all deaths from accidents and violence in those age groups. One percent of all deaths in children are due to burns. In this paper, we illustrate the results of qualitative analysis, conducted according to the methodology of content analysis, on narratives included in the anamnesis of clinical papers at the ED in 738 cases of burns in children (0-14 years) observed in a sample of Emergency Departments in the years 2005-2009. The results of content analysis show that the most frequent mechanism that leads to burns is contact with hot liquids and heating surfaces. Much of preventive action should be directed at controlling the child. The accidental event descriptions for the younger age group (0-4 years) reveal an unequivocal responsibility of the parents. The qualitative analysis of narratives was carried out to produce scientific evidence to identify the more frequent and severe burn accidents for specific target/age groups and to establish specific preventive measures. The study of qualitative analysis of burns observed at the ED was introductory to the pilot project PRIUS (Preventing burns among school-aged children). The objective of PRIUS is to increase awareness of the risks of burns in children and adults through a learning path tailored towards their prevention, and the promotion of appropriate standards of personal safe behaviour and first aid actions.

Epidemiology of Unintentional Child Injuries in the Makwanpur District of Nepal: A Household Survey

Secondary sources of information indicate that the proportion of child deaths due to injuries is increasing in Nepal. This study aimed to describe the epidemiology of unintentional injuries in children, explore risk factors and estimate the burden faced by families and the community in the Makwanpur district. We conducted a household survey in Makwanpur, covering 3441 households. Injuries that occurred during the 12 months before the survey and required treatment or caused the child to be unable to take part in usual activities for three or more days were included. We identified 193 cases of non-fatal unintentional child injuries from 181 households and estimated an annual rate of non-fatal injuries of 24.6/1000 children; rates for boys were double (32.7/1000) that for girls (16.8/1000). The rates were higher among the children of age groups 1–4 years and 5–9 years. Falls were the most common cause of non-fatal child injuries followed by burns in preschool children and road traffic injuries were the most likely cause in adolescence. Mean period of disability following injury was 25 days. The rates and the mechanisms of injury vary by age and gender. Falls and burns are currently the most common mechanisms of injury amongst young children around rural homes.

Injuries among children with autism spectrum disorder

OBJECTIVE

We compared risk of injury among children with autism spectrum disorder (ASD) to those without ASD, adjusting for demographic and clinical characteristics.

METHODS

We used claims data from 2001 to 2009 from a commercial health plan in the United States. A validated ASD case identification algorithm identified 33,565 children (ages 0-20 years) with ASD and 138,876 children without. Counting process models tested the association between ASD status and injury episodes with separate regressions run for children during different age periods.

RESULTS

Unadjusted results demonstrated that children with ASD had a 12% greater injury risk than children without ASD (hazard ratio [HR] = 1.119; P < .001). After including demographic variables, the HR was 1.03 (P < .05); after controlling for co-occurring conditions, such as seizures, depression, etc, HR decreased to 0.889 (P < .001). For the age period analysis, HR values were as follows: for 0 to 2 years, HR 1.141; 3 to 5 years, HR 1.282; 6 to 10 years, HR not significant; and 11 to 20 years, HR 0.634 (P < .05 for all significant results).

CONCLUSIONS

Children with ASD have more injuries than children without ASD. After controlling for demographic factors and co-occurring conditions, children with ASD are at lower risk of injury, suggesting that co-occurring conditions or the ways these conditions interact with ASD is related to injuries. Clinicians should understand that injury risk in children with ASD may be driven by co-occurring conditions. Treating these conditions could thus decrease injury risk as well as have other benefits. Injury prevention interventions are especially warranted for younger children with ASD and those with seizures, depression, visual impairment, or attention-deficit disorders.

Baby walker injury awareness among grade-12 girls in a high-prevalence Arab country in the Middle East

Baby walkers (BWs) are a consumer product frequently associated with infant injuries. With little research in the Middle East and few population studies anywhere, female students in grade 12 in the United Arab Emirates were surveyed, assessing the prevalence of use, perceived safety, and interventions. The study population included grade-12 students in a large UAE city. Multistage random sampling selected 4/8 female Arab government schools and 3 classes each from science and arts tracks for interview by self-administered questionnaire. Response was 100%, with a total of 696 students, 55% (n = 385) of whom were Emirati citizens; 90% (n = 619) of the families used/had used BWs. Among the reasons for use, 92% reported "keeping baby safe," with 11% perceiving BWs as very safe and 74% as moderately safe. Only 16% perceived that BWs could cause injuries. Despite causing many injuries, including fatalities, BWs were perceived to be safe and used by nearly all families. Effective education of professionals, patients, the public, and decision makers is needed. Governments should consider countermeasures such as prohibiting importation, sales, and advertising, together with public education and provision of stationary activity centers.

Epidemiology of unintentional child injuries in the South-East Asia Region: a systematic review

All the 11 members of the South-East Asia Region (SEAR) of the World Health Organization are categorised as low- and middle-income countries. This region has over a quarter of the world's total population but comprises about one-third of the world's unintentional injury-related deaths. There is a paucity of good-quality mortality and morbidity data from most of these countries. This is the first systematic review of community-based surveys on child injuries that summarises evidence from child injury studies from the SEAR countries. The included papers reported varying estimates of overall non-fatal unintentional injury rates across the countries, from 15/1000 children in Thailand to as high as 342/1000 children in India. The fatal injury rates were also found to be varying. This review revealed a need for strengthening child injury research using standard methodologies across the region and for promoting the dissemination of the results.

Preventing posttraumatic stress following pediatric injury: a randomized controlled trial of a web-based psycho-educational intervention for parents

OBJECTIVE

The study objective is to evaluate the feasibility and efficacy of a web-based intervention for parents (AfterTheInjury.org [ATI]) in promoting emotional recovery following pediatric injury.

METHODS

100 children with injuries requiring medical attention and their parents were randomly assigned to the intervention or usual care. Efficacy outcomes included parent knowledge and child and parent posttraumatic stress symptoms (PTSS).

RESULTS

All parents in the intervention group completed the intervention (directed use of ATI) in the hospital. 56% reported using ATI online post-discharge, and 100% of these parents found it helpful. Parent knowledge increased immediately post-intervention, but there was no significant intervention impact on parent knowledge or PTSS at a 6-week follow-up. Relationships between knowledge and PTSS were identified.

CONCLUSIONS

Brief web-based interventions introduced during child hospitalization are a feasible strategy to reach many parents following pediatric injury. Preventing psychological symptoms may require more than parental education alone.

Home safety and low-income urban housing quality

OBJECTIVES

Living in substandard housing may be one factor that increases the risk of fire and burn injuries in low-income urban environments. The purposes of this study are to (1) describe the frequency and characteristics of substandard housing in urban homes with young children and (2) explore the hypothesis that better housing quality is associated with a greater likelihood of having working smoke alarms and safe hot water temperatures.

METHODS

A total 246 caregivers of children ages 0 to 7 years were recruited from a pediatric emergency department and a well-child clinic. In-home observations were completed by using 46 items from the Housing and Urban Development's Housing Quality Standards.

RESULTS

Virtually all homes (99%) failed the housing quality measure. Items with the highest failure rates were those related to heating and cooling; walls, ceilings, and floors; and sanitation and safety domains. One working smoke alarm was observed in 82% of the homes, 42% had 1 on every level, and 62% had safe hot water temperatures. For every increase of 1 item in the number of housing quality items passed, the odds of having any working smoke alarm increased by 10%, the odds of having 1 on every level by 18%, and the odds of having safe hot water temperatures by 8%.

CONCLUSIONS

Many children may be at heightened risk for fire and scald burns by virtue of their home environment. Stronger collaboration between housing, health care, and injury prevention professionals is urgently needed to maximize opportunities to improve home safety.

Home and other nontraffic injuries among children and youth in a high-income Middle Eastern country: a trauma registry study

A trauma registry in the United Arab Emirates was used to ascertain nontraffic injuries of 0- to 19-year-olds. The registry's value for prevention was assessed. A total of 292 children and youth with nontraffic injuries were admitted for >24 hours at surgical wards of the main trauma hospital in Al Ain region during 36 months in 2003-2006. Injuries were analyzed by external cause, location, body part, and severity. Nontraffic represented 60% (n = 292) of child and youth injuries. Incidence/100 000 person-years was 91 for males, 43 for females. Unintentional included falls 65% (n = 191), burns 17% (n = 49), animal-related (mainly camel) 3% (n = 10), and others 10% (n = 29). Intentional accounted for 4% (n = 13). Falls affected all ages, burns mainly 1- to 4-year-olds. Of the injuries, 70% occurred at home. Most frequent and severe injuries measured by the Injury Severity Score and Abbreviated Injury Scale involved extremities. Prevention of home falls for all ages and burns of 1- to 4-year-olds are priorities. Registries should cover pediatric wards and include data on fall locations and hazardous products.

Protecting children: a survey of caregivers' knowledge of Georgia's child restraint laws

Introduction

The leading cause of injury and death among children in the United States is motor vehicle crashes. Even though restraint laws are in place and public awareness campaigns and educational interventions have increased, many children are still improperly restrained or not restrained at all. When correctly used, child restraints significantly reduce risk of injury or death.

Methods

The purpose of the study was to elicit caregiver baseline knowledge of car seat installation and regulation before receiving car seat education from certified technicians at Inspection Station events. Inspection Station is a program whereby staff assists parents in correctly positioning car seats in participants’ vehicles. Over an 8-week period, Safe Kids Cobb County Car Seat Technicians distributed a 16-item survey, with 10 knowledge-based questions and six demographic questions to Inspection Station participants. Descriptive statistics and t-tests were conducted to assess relationships between participant age, ethnicity, and gender with overall knowledge scores. Regression analysis was run to determine the association between participant education level and total child restraint knowledge.

Results

One hundred sixty-nine surveys were completed. Participant knowledge of vehicular child restraint ranged from 0% to 90% on all items. Only 29.6% of caregivers understood the proper tightness of the harness system. Less than half of the caregivers (43.8%) were aware of the Georgia law requiring children aged 6 years and younger to be in some type of child restraint. Only 43.2% of caregivers surveyed knew that children need to ride in a rear-facing child restraint until 1 year of age and 20 pounds. No significant correlations between participant knowledge and age were found. Statistically significant associations were found between total knowledge scores and education level, ethnicity, and gender.

Discussion

The results from this study describe baseline knowledge among a sample of participants at Inspection Station activities held in Cobb County, Georgia. These results can help inform tailoring of future programming so that the impact of enhanced health education/prevention messages for intended populations can be maximized and health child injury risk related to improper restraints can be minimized.