Residential Injury in US Children and Adolescents

Kieran J. Phelan, MD, MSc

Assistant Professor of Pediatrics

Cincinnati Children’s Hospital Medical Center

Pen & Ink Illustration of Samuel Clemen’s House in Hartford, Connecticut, circa 1890

“...it is less trouble and more satisfaction to bury two families than to select and equip a home for one.”

Mark Twain’s Autobiography

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%Other 26%

Unspecified 12%

* Pollock DA, MMWR 1988;37:13-20.

Fatal Injuries in U.S. Children< 15 years of age, 1978-1984*

0

500

1000

1500

2000

2500

3000

3500

1978 1979 1980 1981 1982 1983 1984

OtherResidential

* Pollock DA, MMWR 1988;37:13-20.

Residential Injury & Haddon MatrixExample: Residential Stairway Fall

Host:young child

Agent:stairway(s)

Environment:Physical and socialcharacteristics of the home,family, community

Pre-event “Active” Child < 4yrs.

Elevated Lead

Clutter (clothingor toys) onstairs orstairwell

Access to stairwell at topand bottom within the home

Event Underdevelopedability to rightself after loss ofbalance

Steep inclinewith unevenstair height, norailings

State of repair of thestairwayLack of appropriatesupervision

Post-event UntreatedBleedingdiasthesis (VWD)Geneticdisorders suchas osteogenesisimperfecta

Presence ofcushioning onlanding (egcarpetting)

Cement vs.metallic vs.wood

Availability of EMSCservices and training inpediatric management

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

H om eN = 4,009,692

SchoolN = 810,971

PublicN = 2,210,444

O therN = 841,203

U nknow nN = 2,341,414

U nintentiona lE800-929

N = 10,213,725

Intentiona lE950-978

N = 577,407

U ndeterm inedE980-999

N = 36,580

U nknow nN = 120,693

T ota l V isitsN = 29,298,401

Injury V isitsN = 11,385,072

Phelan KJ et al. (unpublished data).

Average Annual Estimates of ED Visits for US Children <20 years by E-coded intent and location, NHAMCS 1993-99.

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 Rate(95% CI) (95% CI)

Age (years) *

<1 238 6.22(191, 284) (5.00, 7.44)

1-4 1484 9.59

(1254, 1715) (8.09, 11.07)

5-9 936 4.85

(790, 1083) (4.09, 560)

10-14 712 3.75(625, 799) (3.29, 4.21)

15-19 639 3.43(546, 732) (2.93, 3.93)

Gender **

Female 1685 4.53(1439, 1930) (387, 519)

Male 2325 5.95(2002, 2648) (5.12, 6.77)

Race

Black 639 5.41(529, 748) (4.48, 6.33)

White 3371 5.40

(2904, 3838) (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 Rate(95% CI) (95% CI)

Region

Northeast 781 5.64(482, 1080) (3.48, 7.80)

South 1297 4.85(1096, 1498) (4.10, 5.61)

Midwest 1192 6.63(960, 1424) (5.33, 7.91)

West 740 4.18(422, 1057) (2.38, 5.97)

Season ***

January-March 954 1.25(794, 1114) (1.04, 1.46)

April-June 1127 1.49(952, 1302) (1.25, 1.71)

July-September 1010 1.32(847, 1173) (1.11, 1.54)

October-December 919 1.21(806, 1032) (1.06, 1.35)

Metro Area

MSA 3132 5.16(2590, 3675) (4.26, 6.05)

Non-MSA 877 6.60(785, 970) (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

All Falls

Rate 3,108 4,425 1,716 1,161 902

Fall, one levelto another

Rate 1,478 1,108 530 241 70

Fall from furniture

Rate 1,003 728 197 82 28

Struck / Strike

Rate 1,301 2,582 1,235 773 799

Cut / Pierce / Knives

Rate 368 730 697 676 656

Dog / Animal Bite

Rate ** 285 207 152 91

Submersion / suffocation

Rate 369 520 132 113 99

Poisoning

Rate 261 443 41 38 66

Burn / Hot liquid / Caustic

Rate 429 360 88 36 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 1994 1995 1996 1997 1998 1999

AIS Moderate-to-SevereAIS >1, number 564 758 560 620 455 354 412(95% CI) (292, 836) (355, 1,161) (278, 841) (318, 922) (209, 701) (201,508) (202, 614)

AIS > 1, rate * 763 1012 740 811 591 456 521(95% CI) (395, 1130) (474, 1550) (368, 1112) (416, 1206) (271, 910) (258, 654) (258, 784)

% of visitswith AIS > 1 12.1 14.71 14.88 16.27 12.8 9.86 11.5

*p=0.03 decreasing trend from 1993 to 1999

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 Rate(95% CI) (95% CI)

Extremities 12.38 232(9.36, 10.54) (197, 266)

Head / Neck 9.33 175(7.92, 10.72) (148, 201)

Thorax / Abdomen / Pelvis 2.18 41(1.74, 2.62) (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 Rate(95% CI) (95% CI)

Open wound / superficial 12.61 236.28(10.62, 14.58) (198.95, 273.05)

Contusion / crush 4.44 83.20(3.73, 5.15) (69.80, 96.38)

Fracture / Dislocation 3.62 67.78(3.01, 4.23) (56.40, 79.17)

Sprain / strain 2.37 44.54(2.03, 2.71) (38.05, 50.67)

Internal 1.15 21.42(9.68, 1.32) (18.14, 24.69)

Burn .94 17.67(.73, 1.15) (13.74, 21.60)

Number (in thousands) and rate (per 100,000) for hospitalizations for residential unintentional injury: US children <20 years NHAMCS 1993-99

Hospital Admission

Admit .52 10(.418, .614) (8, 11)

Not Admitted 27.56 516(23.71, 31.39) (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

Place of DeathDeathsno. (%)

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).

0102030405060708090

100

< 1 1 to 4 5 to 10 10 to 14 15 to 19

Per

cen

t In

jure

d in

Ho

me

Age of Children (years)

Proportion of Injury Deaths in the Home Among U.S Children and Adolescents, by Age,

1985 to 1997

* Nagaraja J et al. (in progress).

Fatal Residential Injuries among U.S. Children, 1985 to 1997

0

1

2

3

4

5

6

85 86 87 88 89 90 91 92 93 94 95 96 97

Mo

rtal

ity

Rat

e (/

100,

000)

* Nagaraja J et al. (in progress).

Year

0123456789

10

85 86 87 88 89 90 91 92 93 94 95 96 97

All Injuries

Residential Injuries

* Nagaraja J et al. (in progress).

Mo

rtal

i ty

Rat

e (/

100,

000)

Year

0123456789

10

85 86 87 88 89 90 91 92 93 94 95 96 97

BlackWhiteOther

* Nagaraja J et al. (in progress).

Mo

rtal

ity

Rat

e (/

100,

000)

Year

Average Annual Residential Injury Outcomes in US Children & Adolescents <20 yrs. 1985 - 99

Deaths

Vital Stats

Hospitalizations

NHAMCS

Emergency Department Visits

NHAMCS

Events, Office calls, Clinic Visits

NHIS

N = 2, 822

N = 74, 285

N = 4,009,692

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.