Unintentional injury is ranked number one among the 10 leading causes of death in children. In fact, injuries, ranging from car and bike crashes to poisonings and gunshot wounds, kill more children than anything else, starting at age 1 year to age 44 years.
Unintentional injury is ranked number one among the 10 leading causes of death in children. In fact, injuries, ranging from car and bike crashes to poisonings and gunshot wounds, kill more children than anything else, starting at age 1 year to age 44 years.1
Wendy J Pomerantz, MD, MS“We spend all this time thinking about cancer and heart disease and all this stuff, and, in kids, injury is the number one cause of mortality over the age of 1 [year]. It’s responsible for more deaths than all diseases combined, which is pretty staggering,” says Wendy J Pomerantz, MD, MS, professor of Pediatrics at the University of Cincinnati, Cincinnati Children’s Hospital, Ohio.
Pomerantz is president-elect of the Injury Free Coalition for Kids (www.injuryfree.org/), a national effort created and led by front-line doctors, including pediatricians. With funding from the Robert Wood Johnson Foundation, Injury Free Coalition for Kids has more than 42 independently run sites based in hospital trauma centers in the United States. Each site is headed by a physician and a community coordinator charged with addressing the injuries that are the most prevalent in their community.
This is a long-running coalition, started in 1981 by Barbara Barlow, MD, then chief of pediatric surgery at New York City’s Harlem Hospital. After noting that kids were falling from multistory apartment buildings in Harlem, Barlow established the “Children Can’t Fly” program in New York City, mandating window guards in buildings. She established the program in 1979 and by 1983 her paper on the effort, published in the Journal of Pediatric Surgery, showed a 96% decrease in falls from windows requiring hospitalization in Harlem.2
Since then, the coalition has blossomed into sites in cities from San Diego and Seattle to Ann Arbor and Miami. Its members have published outcomes in many peer-reviewed publications. The coalition’s persistence has resulted not only in saved lives and quality of life, but also with new laws designed to protect children, as well as design modifications in products such as the microwave.3
To start a coalition site, pediatricians or pediatric trauma surgeons and other team members use a model the coalition refers to as the “ABCs of injury prevention.”4
The key to the coalition’s work is program diversity according to the needs of each community, notes Pomerantz. “This isn’t like big brother going in and saying this is what we see; we need to fix this. [Often,] we don’t have any idea what’s really going on in the community,” she explains.
She uses the example that emergency department (ED) and trauma staff might see that kids are getting hit by cars. However, the children might be getting hit by cars because they’re running to get away from drug dealers on one side of the street. “The root of the problem is to get rid of the drug dealers, so people don’t have to cross the street,” Pomerantz says. “People in the neighborhoods know these things, so it’s helpful to have both sides.”
When Pomerantz and colleagues started a coalition in Avondale, a community just up the street from Cincinnati Children’s, the data revealed a high percentage of African American school-aged children, most below poverty level, were getting injured in the after-school hours. “We found out they had nothing to do other than hang out in the streets. So, what we did in that community was start an after-school program, to give kids something to do,” she says. “In another community we went into, we figured out the kids that were getting injured were mostly under [age 5 years] and it was happening in the home. So, we started a home safety program.”
Part of the model is to do something tangible in Injury Free Coalition for Kids’ communities, according to Pomerantz. An example: Injury Free sites around the country have built more than 50 playgrounds, to give children safe places to play.
Sometimes, it’s a particularly emotional issue that prompts people to want to do something about injury prevention.
Michael P Hirsh, MDMichael P Hirsh, MD, pediatric surgeon, chief of Pediatric Surgery and Trauma at the University of Massachusetts (UMass) Memorial Children’s Medical Center, Worcester, and co-principal investigator of the Injury Free of Worcester, was a surgical resident at Columbia-Presbyterian Hospital, New York City, in the 1980s when something happened that put gun violence front and center.
“I lost my best friend to gunfire. He was a resident with me and asked me to hold onto his beeper for a minute. He stepped out in front of the building and got shot right in front of the building,” Hirsh says.
To make some sense of it all, the hospital brought in speaker and gun control advocate Sarah Brady, whose husband, White House press secretary James S. Brady, was shot and partly paralyzed in the attempted assassination of President Ronald Reagan in 1981. Brady’s message, according to Hirsh who was in attendance for the lecture, was that the one thing that raised most confrontations from nonlethal to lethal was the handgun.
Hirsch kept that in mind and made note of the work Barlow was doing in Harlem. When he moved to Pittsburgh, Pennsylvania, to take a post at Allegheny General Hospital, Hirsh says he studied the data and got community input to see which injuries were most lethal for kids there. He found that although pedestrian fatalities topped the list, the public was clamoring for help with something else.
“You can’t take the public out of public health, and the public was clamoring for violence control,” Hirsh says. “This was 1993. The entire Pittsburgh scene had been taken over by the crack cocaine epidemic. Gangs were setting up turf wars . . . with gun fights. We were seeing many gunshot wounds coming in each week to the pediatric trauma service . . . . Finally, in 1994, a child was killed in front of the mayor’s house in Pittsburgh with an AK-47.”
Hirsh and a pediatric intensivist colleague had heard about a New York City carpet store owner who was so disgruntled with neighborhood gun violence that he offered free carpet in exchange for people bringing in their firearms. “He got almost 2000 weapons in a single day,” Hirsh says. “We adapted the idea to Pittsburgh.”
Allegheny County’s “Goods for Guns” program was born. Instead of carpet, the site, based out of Allegheny General Hospital, gave gift certificates to local department stores. It was around Christmas when the group did its first gun buy-back. Word got out, and that first day people were lined around the block with their weapons in hand, giving them peacefully in exchange for a gift certificate. “We retrieved in 1400 weapons that first year. [That program in Pittsburgh has gone on since 1994 to this date, and they’ve collected over 12,000 weapons in the 22 years,” Hirsh says.
Hirsh has since started a Goods for Guns program in Worcester, which collected more than 2900 guns between 2002 and 2016, removing unwanted guns from homes and raising community awareness about firearm safety.5
Although Hirsch doesn’t have the data to directly correlate Goods for Guns with statistics that show Worcester County has the lowest penetrating trauma rate of any county in Massachusetts, he says that the program, which also has distributed about 1400 free gun safety trigger locks, has raised awareness about gun safety and is contributing to the county’s lower gunshot fatality rate.
“The total cost for us of doing these 14 years of gun buybacks is about $150,000, and that’s less than the costs of caring for gunshot wound victims,” Hirsh says.
Like other coalition sites, Worcester offers more than 1 safety initiative. Hirsh says others include a mobile safety street, which goes to locations to show kids how to be safer on the street, as well as a mobile driving education unit for high school kids, which simulates bad weather and distracted driving. Worcester also offers a child passenger safety checkpoint, for people who need a free car seat or need one installed properly.
Still another local program takes first-time driving offenders through an all-day experience in the trauma center. The reality dose was associated with a big drop in the recidivism rate, which was 6% at 6 months for kids in the program versus 56% at 6 months in the control group.6
Microwave injuries stood out when pediatrician Kyran Quinlan MD, MPH, FAAP, helped to launch an Injury Free site at the University of Chicago, Illinois, to protect children from severe scald burns related to microwave ovens.
Quinlan, who today is associate professor of Pediatrics, Rush University Children's Hospital, Chicago, and chair, the American Academy of Pediatrics Council on Injury, Violence, and Poison Prevention, has authored 3 studies on the safety issue.7-9
“Young children are able to open the doors of microwaves and access the heated contents, pull them out, and are burned as they spill what was cooked onto themselves,” Quinlan says. “Over 6000 children [nationwide] have required ED visits for burns from exactly this mechanism over the past decade. Sometimes these require burn unit care, skin grafting, inpatient time for pain management, and dressing changes. They can have lifelong cosmetic complications, which can be life changing, since the scars are permanent and often involve the face, head, neck, and chest . . . . Our latest published report showed that two-thirds of all microwave-related burns to young children happen when a child is able to open the door and access the contents of the microwave in this way.”7
The work of Injury Free Chicago at the University of Chicago, and now Rush, involves changing the way microwaves are made, so they are child resistant, according to Quinlan. “This will involve a design change so that young children are not able to open the microwave door. We are part of a task group organized by Underwriters Laboratories (Northbrook, Illinois) working with the microwave manufacturers to change the standard by which microwaves are made, to incorporate this change for all microwaves sold,” he says.
Andrew W Kiragu, MD, interim chief of Pediatrics and medical director of Pediatric Intensive Care, Hennepin County Medical Center, Minneapolis, Minnesota, and assistant professor of Pediatrics at University of Minnesota, Minneapolis, says that the Injury Free Minneapolis bicycle helmet program does more than give away free helmets.
“For example, as part of a program we held in our ED one Saturday in May, helmets were given out to kids who completed the event as an incentive to attend. We had over 200 kids and fitted 175 helmets in 2hours,” Kiragu says. “We also provide helmets for several city-wide safety events that the hospital [public relations] staff attends. We conduct a yearly employee helmet sale and use the proceeds to help purchase helmets we stock in our impatient/clinics/ED to give to patients who come in after a bike/blade-related injury. We purchase the helmets for $7 and sell them for $15. Each year we provide 250 helmets for the program.”
The helmets are part of an overall awareness campaign. “My pediatrician colleagues also discuss helmet use during well-child checks, again stressing that the helmet is just as important to the child as immunizations and other health-related discussions,” Kiragu says. “In addition to offering the helmets through our various projects, we have also partnered with Safe Kids Minnesota and others and our local police and [emergency medical services] through a program called ‘I Got Caught,’ where [police] stop kids seen wearing their helmets and give them a ‘ticket’ for a free ice cream cone. This positive reinforcement message not only gets through to the kids, but to the parents, when [kids] bring the ‘ticket’ home.”
Research suggests that helmets reduce head injury risk by at least 45%, brain injury risk by a third, facial injury risk by 27%, and the risk of death by 29%. In addition, educational programs have been proven to increase children’s helmet use.10
Still, studying and monitoring each program is vital to its success because regardless of how logical the goal sounds, programs don’t always work.
“Somebody once told me that doing something is better than doing nothing. That’s not always true . . . . [I]f you’re going in to do an intervention and it’s not making a difference, then it’s pretty much a waste of time and money,” Pomerantz says.
Kiragu was among the authors who reported in 2009 on what doesn’t seem to work for educating children and families about booster seats. The study looked at how to increase booster seat knowledge and use in kindergarten-aged children. Possible interventions were written information; parent education class and a free booster seat; or student education and a free booster seat. They found that providing instructions to parent groups and teaching children in the classroom, along with providing an incentive booster seat, resulted in a boost to booster seat use. Providing information only wasn’t effective.11
Pediatricians and others can start by looking at local data. The Centers for Disease Control and Prevention National Center for Injury Prevention and Control (www.cdc.gov/injury/) has statewide data, and hospitals usually have trauma data. Even state Medicaid and Medicare claims data can help to determine what the most important things are in your area.
“Sometimes, [it starts with] what you’re seeing,” Pomerantz says. “We have a big problem with opiates and heroin here, and I don’t need data to tell me that. [W]e do need to think about how to prevent this in the kids.”
Pediatricians are the foundation of the effort because they’re on the front lines, charged with finding ways to prevent and treat illness and injury. Most hospitals already have associated injury prevention programs, and pediatricians can get involved with those by communicating what they see and taking part in educational and other programs for the community.
In most cases, a practicing pediatrician won’t have the time to spearhead and run a local coalition site, but that doctor can plant the seeds and get involved, as a coalition principal investigator, for example, Pomerantz says.
Pediatricians can make small adjustments to have an impact on injury prevention, according to Kiragu. “While there is never enough time during a clinic visit, I would like my colleagues to continue to give prominence to injury prevention as part of the anticipatory guidance they give children and their families during the well-child visit,” Kiragu says. “In addition, this message of safety should be provided at key points of interaction with other providers-for example, in the ED or in the hospital when kids are being cared for following an injury, and using this as a ‘teachable moment.’”
Whereas the successes of the Injury Free Coalition for Kids have been real and measurable, the work is incomplete, according to Joseph J. Tepas III, MD, FACS, emeritus professor in the Division of Pediatric Surgery, University of Florida Health Science Center, Jacksonville, whose forward on the program was published in October 2016 in the Journal of Trauma and Acute Care Surgery.3
“[We] must recognize that the system we seek to control is in continuous flux. The only constant is the vulnerable child,” Tepas writes.
Kids are the most important resource we have moving forward, and it’s incumbent on parents and physicians to make life safe for them, Hirsh says. “Doing something on the front end before those injuries occur is tremendously rewarding.”
1. National Vital Statistics System, National Center for Health Statistics, Centers for Disease Control and Prevention.10 leading causes of death by age group, United States-2010. Available at: https://www.cdc.gov/injury/wisqars/pdf/10lcid_all_deaths_by_age_group_2010-a.pdf. Accessed November 1, 2016.
2. Barlow B, Niemirska M, Gandhi RP, Leblanc W. Ten years of experience with falls from a height in children. J Pediatr Surg. 1983;18(4):509-511.
3. Tepas JJ 3rd. Twenty years of Injury Free Coalition for Kids: Precision focus on relentless problems. J Trauma Acute Care Surg. 2016;81(4 suppl 1):S1-S2.
4. Pressley JC, Barlow B, Durkin M, Jacko SA, Dominguez DR, Johnson L. A national program for injury prevention in children and adolescents: the injury free coalition for kids. J Urban Health. 2005;82(3):389-402.
5. Kasper RE, Green J, Damle RN, et al. And the survey said . . . . evaluating rationale for participation in gun buybacks as a tool to encourage higher yields. J Pediatr Surg. August 30, 2016. Epub ahead of print.
6. Manno M, Maranda L, Rook A, Hirschfeld R, Hirsh M. The reality of teenage driving: the results of a driving educational experience for teens in the juvenile court system. J Trauma Acute Care Surg. 2012;73(4 suppl 3):S267-S272.
7. Lowell G, Quinlan K. Not child's play: national estimates of microwave-related burn injuries among young children. J Trauma Acute Care Surg. 2016;81(4 suppl 1):S20-S24.
8. Robinson MR, O'Connor A, Wallace L, et al. Behaviors of young children around microwave ovens. J Trauma. 2011;71(5 suppl 2):S534-S536.
9. Lowell G, Quinlan K, Gottlieb LJ. Preventing unintentional scald burns: moving beyond tap water. Pediatrics. 2008;122(4):799-804.
10. American College of Surgeons. Bulletin: Statement on bicycle safety and the promotion of bicycle helmet use. Available at: http://bulletin.facs.org/2014/09/statement-on-bicycle-safety-and-the-promotion-of-bicycle-helmet-use/. Published September 1, 2014. Accessed November 1, 2016.
11. Philbrook JK, Kiragu AW, Geppert JS, Graham PR, Richardson LM, Kriel RL. Pediatric injury prevention: methods of booster seat education. Pediatr Nurs. 2009;35(4):215-220.
Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.