Transcript No Slide Title

Residential Injury in US
Children and Adolescents
Kieran J. Phelan, MD, MSc
Assistant Professor of Pediatrics
Cincinnati Children’s Hospital Medical Center
“...it is less trouble and more satisfaction to bury two families
than to select and equip a home for one.”
Mark Twain’s Autobiography
Pen & Ink Illustration of Samuel Clemen’s
House in Hartford, Connecticut, circa 1890
Pediatric Injury
• Leading cause of morbidity and
mortality in US children after the first
year of life
• Leading mechanisms are motor vehicle
crashes and firearm-related injury
• Leading location of injury has not been
examined since mid-1980’s
Definition - Injury
• Damage to cells and organs from
energy exposure or depletion that
have sudden discernible effects
 exposures can be acute or chronic
 can result in varying degrees of cellular
and tissue dysfunction
Why Residential Injuries?
• Researchers have implicated the home
as the predominant location of injury
 Pollock 1984 Mortality Data Tapes
 Rivara 1989 King, Co. ED visits / Hosp.
 Scheidt 1995 Child Hlth Suppl to NHS
Fatal Injuries by place of occurrence, among
children < 15 years, United States, 1984
Home 61%
Unspecified 12%
* Pollock DA, MMWR 1988;37:13-20.
Fatal Injuries in U.S. Children
< 15 years of age, 1978-1984*
3500
Other
Residential
3000
2500
2000
1500
1000
500
0
1978
1979
1980
1981
1982
* Pollock DA, MMWR 1988;37:13-20.
1983
1984
Residential Injury & Haddon Matrix
Example: Residential Stairway Fall
Host:
young child
Agent:
stairway(s)
Environment:
Physical and social
characteristics of the home,
family, community
Access to stairwell at top
and bottom within the home
Pre-event
“Active” Child < 4 Clutter (clothing
yrs.
or toys) on
stairs or
Elevated Lead
stairwell
Event
Underdeveloped
ability to right
self after loss of
balance
Steep incline
with uneven
stair height, no
railings
State of repair of the
stairway
Lack of appropriate
supervision
Post-event
Untreated
Bleeding
diasthesis (VWD)
Genetic
disorders such
as osteogenesis
imperfecta
Presence of
cushioning on
landing (eg
carpetting)
Availability of EMSC
services and training in
pediatric management
Cement vs.
metallic vs.
wood
Focusing Injury Prevention
Efforts
• Frequent
• Severe
• Preventable
Injury Severity
• Death is the the most severe outcome of
energy transfer to human soft tissue and
represents ‘the tip of the iceberg’
• Hospital admissions and ED visits are less
severe subsets of the injury pyramid and
represent a substantial health services
burden for US children
• Severity scoring (AIS) by anatomic location of
tissue injury represents a means for
comparisons of injury and injury outcomes
over time and between location
Injury Pyramid
Deaths
Hospitalizations
Emergency Visits
Events, office calls, office visits
Emergency Visits and Hospitalizations for
US Children after Residential Injury
• National Hospital Ambulatory Medical
Care Survey (NHAMCS)
• Probability sample of US Hospitals,
emergency departments (EDs), clinics
within hospitals, and patient visits within
EDs / clinics
• National estimates of injury ED visits for
US children 1993 - 99
Average Annual Estimates of ED Visits for US Children <20 years by Ecoded intent and location, NHAMCS 1993-99.
Total Visits
N = 29,298,401
Injury Visits
N = 11,385,072
Unintentional
E800-929
N = 10,213,725
Home
N = 4,009,692
School
N = 810,971
Public
N = 2,210,444
Intentional
E950-978
N = 577,407
Other
N = 841,203
Undetermined
E980-999
N = 36,580
Unknown
N = 120,693
Unknown
N = 2,341,414
Phelan KJ et al. (unpublished data).
Average annual number (in thousands), rate (per 100), and 95% confidence intervals
(CI) for estimates of United States ED visits for residential injuries according to
demographics, location, season, and hospital admissions: NHAMCS, 1993-99.
Number
(95% CI)
Rate
(95% CI)
Age (years) *
<1
1-4
238
(191, 284)
1484
(1254, 1715)
5-9
936
6.22
(5.00, 7.44)
9.59
(8.09, 11.07)
4.85
(790, 1083)
(4.09, 560)
10-14
712
(625, 799)
3.75
(3.29, 4.21)
15-19
639
(546, 732)
3.43
(2.93, 3.93)
Gender **
Female
1685
(1439, 1930)
4.53
(387, 519)
Male
2325
(2002, 2648)
5.95
(5.12, 6.77)
Black
639
(529, 748)
5.41
(4.48, 6.33)
Race
White
3371
(2904, 3838)
5.40
(4.80, 6.34)
* p<0.0001, for <1 year and 1-4 year age
groups compared to 10-14 and 15-19 years
Average annual number (in thousands), rate* (per 100), and 95% confidence intervals (CI)
for estimates of United States ED visits for residential injuries according to
demographics, location, season, and hospital admissions: NHAMCS, 1993-99.
Number
(95% CI)
Rate
(95% CI)
Region
Northeast
781
(482, 1080)
5.64
(3.48, 7.80)
1297
(1096, 1498)
4.85
(4.10, 5.61)
Midwest
1192
(960, 1424)
6.63
(5.33, 7.91)
West
740
(422, 1057)
4.18
(2.38, 5.97)
January-March
954
(794, 1114)
1.25
(1.04, 1.46)
April-June
1127
(952, 1302)
1.49
(1.25, 1.71)
July-September
1010
(847, 1173)
1.32
(1.11, 1.54)
October-December
919
(806, 1032)
1.21
(1.06, 1.35)
3132
(2590, 3675)
5.16
(4.26, 6.05)
South
Season ***
Metro Area
MSA
Non-MSA
877
(785, 970)
6.60
(5.90, 7.29)
***p=0.03 April – June compared to October-December
Leading mechanisms of unintentional residential injury: US children < 20
years, NHAMCS 1993-99. Rate (per 100,000) by age group of emergency
department visits.
Age (years)
Mechanism
0-1
1-4
5-9
10-14
15-19 All Ages
3,108
4,425
1,716
1,161
1,478
1,108
530
241
70
1,003
728
197
82
28
1,301
2,582
1,235
773
799
368
730
697
676
656
**
285
207
152
91
369
520
132
113
99
261
443
41
38
360
88
36
All Falls
Rate
902
Fall, one level
to another
Rate
Fall from furniture
Rate
Struck / Strike
Rate
Cut / Pierce / Knives
Rate
Dog / Animal Bite
Rate
Submersion / suffocation
Rate
Poisoning
Rate
66
Burn / Hot liquid / Caustic
Rate
429
91
Number (in thousands), rate (per 100,000), and distribution of AIS scores for
Residential Injuries in US Children <20 years, NHAMCS 1993-1999.
1993
AIS Moderate-to-Severe
AIS >1, number
(95% CI)
AIS > 1, rate *
(95% CI)
% of visits
with AIS > 1
564
(292, 836)
1994
1995
1998
1999
354
(201,508)
412
(202, 614)
763
1012
740
811
591
(395, 1130) (474, 1550) (368, 1112) (416, 1206) (271, 910)
456
(258, 654)
521
(258, 784)
14.71
*p=0.03 decreasing trend from 1993 to 1999
14.88
620
(318, 922)
1997
455
(209, 701)
12.1
758
560
(355, 1,161) (278, 841)
1996
16.27
12.8
9.86
11.5
Number (in millions), rate (per 10, 000), and 95% confidence intervals (CI) of
residential Injuries according to body region: US ED visits NHAMCS, 1993-97
Number
(95% CI)
Rate
(95% CI)
Extremities
12.38
(9.36, 10.54)
232
(197, 266)
Head / Neck
9.33
(7.92, 10.72)
175
(148, 201)
Thorax / Abdomen / Pelvis
2.18
(1.74, 2.62)
41
(33, 49)
Number (in millions), rate (per 10, 000), and 95% confidence intervals (CI) of
residential injuries according to type of injury, NHAMCS 1993 - 99.
Number
(95% CI)
Rate
(95% CI)
12.61
(10.62, 14.58)
236.28
(198.95, 273.05)
Contusion / crush
4.44
(3.73, 5.15)
83.20
(69.80, 96.38)
Fracture / Dislocation
3.62
(3.01, 4.23)
67.78
(56.40, 79.17)
Sprain / strain
2.37
(2.03, 2.71)
44.54
(38.05, 50.67)
Internal
1.15
(9.68, 1.32)
21.42
(18.14, 24.69)
.94
(.73, 1.15)
17.67
(13.74, 21.60)
Open wound / superficial
Burn
Number (in thousands) and rate (per 100,000) for
hospitalizations for residential unintentional injury:
US children <20 years NHAMCS 1993-99
Hospital Admission
Admit
Not Admitted
.52
(.418, .614)
27.56
(23.71, 31.39)
10
(8, 11)
516
(444, 588)
Residential Injury-related Mortality in
US Children & Adolescents
• NCHS Mortality data tapes 1985 - 97
• Collaborative effort with Batelle Institute
(Columbus, OH)
• Jyothi Nagaraja, John Menkedick
(Battelle)
• Bruce Lanphear, Jane Khoury,
Kieran Phelan (Cincinnati Children’s)
Place of Occurrence of Death for US Children
and Adolescents, 1985 - 1997
Deaths
no. (%)
Place of Death
Total
4,362
(100)
Home
2,822
(64.7)
Recreation and Sports
327
(7.50)
Farm
123
(2.81)
Public Building
101
(2.32)
Street or Highway
84
(1.93)
Industrial
73
(1.67)
Residential Institution
29
(0.67)
Mine and Quarry
15
(0.34)
Other Specified Place
841
(19.3)
Place not Specified
687
(15.7)
* Nagaraja J et al. (in progress).
Proportion of Injury Deaths in the Home Among
U.S Children and Adolescents, by Age,
Percent Injured in Home
1985 to 1997
100
90
80
70
60
50
40
30
20
10
0
<1
1 to 4
5 to 10
10 to 14
15 to 19
Age of Children (years)
* Nagaraja J et al. (in progress).
Fatal Residential Injuries among U.S.
Children, 1985 to 1997
6
5
4
3
2
1
0
85 86 87 88 89 90 91 92 93 94 95 96 97
Year
* Nagaraja J et al. (in progress).
10
9
8
7
6
5
4
3
2
1
0
All Injuries
Residential Injuries
85 86 87 88 89 90 91 92 93 94 95 96 97
Year
* Nagaraja J et al. (in progress).
10
9
8
7
6
5
4
3
2
1
0
Black
White
Other
85 86 87 88 89 90 91 92 93 94 95 96 97
Year
* Nagaraja J et al. (in progress).
Average Annual Residential Injury Outcomes in
US Children & Adolescents <20 yrs. 1985 - 99
Deaths
N=
2, 822
N=
74, 285
Vital Stats
Hospitalizations
NHAMCS
Emergency Department Visits
N = 4,009,692
NHAMCS
Events, Office calls, Clinic Visits
NHIS
N = 13, 592, 000
Conclusions
• Injury is a residential hazard with HUGE
attributable risk
 Accounts for 40% of all ED visits for US
Children <20 yrs.
 The home environment accounts for 40%
of all unintentional injuries
 25% of US children and adolescents will
have an ED visit for an unintentional
residential injury each year
 Interventions to reduce early childhood
injury should be targeted to the home
environment
Prevention of Morbidity and Mortality
from Residential Hazards
• Shift from over-reliance on educational to environmental
or more passive interventions.
•
•
•
Multi-disciplinary approach to research, evaluation, and
control of residential hazards
Controlled Trials are necessary to assess efficacy of
hazard controls on child health outcomes.
Health-based standards are needed to protect children
from residential hazards.