Asthma ChildEngland’s Chief Medical Officer, Public Health England and accident prevention organisations including the Child Accident Prevention Trust are all united in their call to ask health professionals to help them reduce the number of preventable childhood accidents in the under-5s every year. JFHC & JSH editor Penny Hosie reports:

Nearly every week there is a story in the press about the death or injury of a child due to a serious accident. These unintentional injuries are often preventable, but the impact can be immense. A childhood death, acquired disability and serious injury can have a devastating effect on the whole family. There are also significant costs for the NHS and for local authority social care services, something England’s Chief Medical Officer Professor Dame Sally Davies highlighted as an area of concern in her own report Our children deserve better: prevention pays (DoH, 2012).

Reducing unintentional injuries
Public Health England, working with the Child Accident Prevention Trust (CAPT) and supported by the Royal Society for the Prevention of Accidents (RosPA), produced a document earlier this year called Reducing unintentional injuries in and around the home among children under five years (PHE, 2014), setting out actions local authorities and their partners can take to help reduce the numbers of children injured and killed.

Their report highlights that every year across England:
● 62 children under five die following accidents
● 40,000 under-5s are admitted to hospital
● around 450,000 under-fives attend A&E.

Viv Bennett referenced the report recently, explaining how it identifies five factors which influence accidents happening. Health professionals, she said, should be aware of these factors when working with parents and visiting homes as they have a ‘vital part to play in helping parents take action to reduce injuries in the home’.

She cites the factors as being:
● The child’s development – one example is that we can easily underestimate how quick (and curious!) new crawlers and walkers can be, and as children become more mobile their exposure to new risks changes, requiring health and early years professionals to adapt their advice to families.
● The physical environment in the home – including any overcrowding.
● The knowledge and behaviour of parents and other carers – do they understand the vulnerability of young children as they become more mobile, but also hazards such as leaving children unattended, even for a moment, when they are being changed from a height, or safely storing nappy sacks to avoid suffocation hazards?
● Safety equipment – are these available and are they being used correctly?
● Consumer products in the home – the risks posed by unattended established products such as hair straighteners and irons, as well as newer products such as e-cigarettes and especially liquid refills.

Health inequalities
Tellingly, the report itself identifies unintentional injuries as a major health inequality, based on the fact that for the under-fives, the emergency hospital admission rate for unintentional injuries is 45% higher for children from the most deprived areas compared with children from the least deprived areas.

It says: ‘There is a persistent social gradient for unintentional injuries and inequalities have widened. Children of never employed or long-term unemployed parents are 13 times more likely to die from an unintentional injury than children whose parents are employed in higher managerial and professional occupations. Our own analysis shows that the emergency hospital admission rate for unintentional injuries among the under-fives is 45% higher for children from the most deprived areas compared with children from the least deprived. Emergency hospital admissions among the most deprived children under five in 2012-13 were close to 1,400 per 100,000. For the least deprived children the rates were under 1,000 per 100,000.’

The cost of injuries
Public Health England doesn’t pull any punches when they describe the devastating costs of an injury on the whole family, not just the individual. They provide examples, including a toddler’s severe bathwater scald that will require years of painful skin grafts and a fall at home that can result in permanent brain damage. The injuries, they say, can have major effects on education, employment, emotional wellbeing and family relationships.

The report also points out the high financial costs. It details the short-term average healthcare cost of an individual injury (all types) is £2,494 and the wider costs of a serious home accident for a child aged 0 to four years has been estimated at £33,200. It adds, ‘There are also significant costs to local authorities and to society as a whole. For example, a traumatic brain injury (TBI) to a child under five from a serious fall may result in acquired disabilities which lead to high education and social care costs as well as loss of earnings to families and benefit costs to the state. The approximate lifetime costs for a three-year-old child who suffers a severe TBI is £4.89m.’

The role of health professionals
PHE recognises the key role health professionals can play in accident prevention and says it wants local authorities and their partners to develop child accident prevention strategies and programmes. The challenge for organisations lies in the basic fact that children under five experience many different kinds of accidents. This can make it hard for organisations to focus their work for maximum impact. PHE commissioned CAPT to analyse the data on deaths and hospital admissions for the five years between 2008–12.

This analysis showed that, when the main causes are considered carefully, five injury types deserve priority for the under-5s – and all occur in and around the home. The five key injury issues for children under five include choking, suffocation and strangulation, falls, poisoning, burns and scalds, and drowning.

However, they believe Injury reductions can be achieved at low cost and that local authorities can strengthen their existing work by prioritising the issue and mobilising existing programmes and services through leadership, co-ordination and training. They reference NICE guidance PH29 and PH30 (2010a; 2010b) and the evidence update (NICE, 2013) as offering a valuable framework for shaping the work.

They recognise the fact that the early year’s workforce will need support and training to enable it to strengthen its central role in helping to reduce unintentional injuries by, saying: ‘Health visitors lead and support delivery of the Healthy Child Programme (HCP), which has injury prevention at its core, and children’s centres are key partners. Further opportunities will arise when public health commissioning responsibilities for under-5s transfer from NHS England to local authorities in October 2015. Staff training to further develop confidence and competence in this area is important. With appropriate training and supervision, voluntary and community organisations will also be able to focus more explicitly on injury prevention in their work with families.

Practical prevention
On a practical level practitioners who work with parents and carers are best placed to help raise awareness as they have the knowledge of the biggest injury risks at different stages of a child’s development, and can provide clear, practical and accurate safety advice to parents. With this support, parents can anticipate the risks that can arise as their child grows and develops, and understand what they can do to keep their child safe from serious harm.

For example, the 12-month check provides an opportunity for health visitors to alert parents to accidents at this developmental stage – for instance hot drink scalds as babies grab at mugs left on coffee tables – to advise parents on simple changes to routines and suggest useful safety equipment. Katrina Phillips, Chief Executive of CAPT said: ‘We know that health visitors face increasingly demanding and complex workloads, but we also know that they are one of the most trusted professionals in touch with parents whose children are most vulnerable.

That’s why we want to do all we can to support health visitors to engage with parents about accident prevention. ‘Accident prevention isn’t about wrapping children up in cotton wool, it’s about protecting them from serious accidents – those which can hospitalise, disable or even kill. Some common accidents can have a lifelong impact on the child and their family, and put them under enormous pressure.

Five key issues for the under-fives
The PHE report highlights the importance of providing leadership, mobilising existing services, working in partnership, focusing on what works and addressing inequalities in tackling leading, preventable causes of death and serious long-term harm for children under five. Here, with the help of CAPT, we provide details on the five main causes of serious unintentional injury for the under-5s in England Choking, suffocation and strangulation Choking, suffocation and strangulation is one of five principal causes of serious injuries for the under‑5s. These injuries lead to the highest number of deaths for the under-5s – 28 each year – though hospital admissions are low.

There are three main causes:
● Inhalation of food and vomit – over eight underfives die in England each year. There are low numbers of emergency hospital admissions but stays in hospital are much longer than average. The injuries primarily affect children under the age of two.
● Hanging and strangulation – results in low numbers of hospital admissions but on average six under-fives in England die each year. Blind cords are a major hazard.
● Suffocation in bed – over seven under-5s die in England each year.

Food is the most common cause of choking. Babies and young children are learning how to chew, swallow and breathe in the right order and sometimes get them mixed up, causing choking. Babies and small children explore by putting things into their mouths, so small objects and toys can also be risky.

Young children are at risk of strangulation if they catch themselves on looped blind cords or chains, often when exploring or climbing. Also, some children have died from strangulation in cots or beds (including bunk and cabin beds), where straps, cords and ribbons from bags or toys are a hazard. Action PHE shows that injury prevention does not require major new investment – much can be achieved by coordinating existing services and programmes, building on strengths and developing capacity. Support and training for the early years’ workforce is key. Injury prevention initiatives can include home safety equipment schemes that supply and fit blind cord cleats, and educational campaigns and resources on threats to breathing.

Falls
Falls lead to the most accident-related admissions for the under-fives – nearly 20,000 each year in England. Ninety per cent of the admissions are for less than two days. However, even a fall from a low height can have serious consequences including brain damage. About 700 under-5s stay in hospital for more than three days a year. Falls are also the third most common cause of death for this age group but these are still rare – about five a year.

There are four broad groups of serious falls for the under‑5s:
● Falls from furniture including beds and chairs lead to most of the hospital admissions but few deaths. They result in average lengths of emergency admissions.
● Falls on and from stairs and steps continue to be a leading cause of hospital admissions for the under‑5s – especially for one and two year olds. Deaths are very rare.
● Falls while being carried have resulted in five deaths in the past five years. These injuries primarily affect children under the age of one.
● Falls from/out of buildings such as from windows or balconies led to five deaths during 2008–12.

Falls are an inevitable part of growing up for babies and young children – initially their heads are a large proportion of their body mass which makes them unstable. Their centre of gravity gradually changes as they develop and begin to roll, crawl and walk. However, much can be done to prevent serious falls with long-term consequences for children and their families. Injury prevention can be low cost and there is a tremendous return for young children in terms of disability adjusted life years. For example, the lifetime educational and social care costs for a three-year-old child who suffers a severe traumatic brain injury from a serious fall at home total £1.43m.

Action
PHE shows that injury prevention does not require major new investment – much can be achieved by coordinating existing services and programmes, building on strengths and developing capacity. Support and training for the early years workforce is key. Injury prevention initiatives can include home safety equipment schemes that supply and fit safety gates and window restrictors, and educational campaigns and resources on falls prevention.

Poisoning
About 21,000 under-fives in the UK go to A&E annually following poisoning incidents. These injuries lead to about 4,000 emergency hospital admissions each year in England, 95% of them for less than two days. But some poisonings can be very serious. About 100 children stay in hospital for more than three days each year. There are very few deaths.

The two main risks to under-5s are medicines and household chemicals:
● Medicines are the cause of over 70% of poisoning admissions – particularly common painkillers.
● Household chemicals account for nearly 20% of the admissions.

Emergency admissions following poisoning are on the increase. They peak when the child is age one for household chemicals and age two for medicines. Safe storage is essential as child-resistant packaging is not child-proof. Other products that can result in serious poisoning include small button/coin batteries and nicotine products such as electronic cigarette refills. There have been several fatalities recently following the ingestion of button batteries.

Who is most at risk?
Babies and toddlers are particularly at risk of accidental poisoning because they explore by putting things into their mouths. They are attracted by bright colours and attractive packaging. Some products, such as liquid detergent capsules (‘liquitabs’) and blister packs of medicines, look similar to sweets. Young children are at higher risk of harm from poisoning than adults – their small body size means that harmful substances make a greater impact. Children living in the most disadvantaged areas have a 50% higher risk of being poisoned resulting in primary or secondary care attendance than those in the most advantaged areas.

Action
PHE shows that injury prevention does not require major new investment – much can be achieved by coordinating existing services and programmes, building on strengths and developing capacity. Support and training for the early years workforce is key. Injury prevention initiatives can include home safety equipment schemes that supply and fit cupboard locks, and educational campaigns and resources on poisoning prevention.

Burns and scalds
Burns and scalds are the fourth highest cause of hospital admissions for under-5s, though deaths are rare. Twelve percent of burns and scalds admissions are for more than three days, compared with an average of five per cent for all unintentional injuries. These injuries are expensive to treat and serious burns and scalds are disfiguring and disabling for young children. Children living in the most disadvantaged areas have a 50% higher risk of suffering burns and scalds resulting in primary or secondary care attendance than those in the most advantaged areas. The peak age for hospital admissions is one year, with hot drinks causing the most injuries, followed by scalds from pots and pans and from hot bath water.

The risks come from five main sources:
● Scalds from hot drinks lead to moderate numbers of admissions, though with longer than average hospitalisations.
● Contact with hot household appliances cover a range of hazards. In recent years the number of children being treated for burns from hair straighteners has doubled. They now account for up to one in ten burns injuries to children.
● Contact with other hot fluids including water heated on a stove remains a serious hazard.
● Burns from hot heating appliances including radiators and pipes.
● Bath water scalds lead to relatively low numbers of admissions. Deaths are rare but the injuries can be severe. They result in a higher proportion of long hospital stays: 21% of admissions are for over three days. Bath water scalds are very expensive injuries to treat.

Action
PHE shows that injury prevention does not require major new investment – much can be achieved by coordinating existing services and programmes, building on strengths and developing capacity. Support and training for the early years workforce is key. Injury prevention initiatives can include work with housing providers to fit thermostatic mixing valves to bath taps, home safety equipment schemes that supply and fit fire guards, the provision of heat-proof pouches for hair straighteners, and educational campaigns and resources on burns and scalds prevention.

Drowning
The lethal nature of drowning – 12 deaths a year for the under-5s – means the rate of deaths is very high in comparison to hospital admissions. There are eight admissions for every death. For babies and young children, the main risk is the bath, although the circumstances of a third of deaths caused by drowning and submersion are unspecified. Babies cannot control their movements so cannot get themselves out of trouble if they slip under the water in the bath. As babies begin to crawl and then walk, they are more likely to explore.

While they may have more control over their limbs, they still cannot get themselves out of trouble if they go under the water in the bath or fall into the garden pond. Babies and toddlers can drown in as little as 5cm of water. They do not make any noise and do not struggle, but just drown silently, so there is no warning if this is happening. Action PHE shows that injury prevention does not require major new investment – much can be achieved by coordinating existing services and programmes, building on strengths and developing capacity. Support and training for the early years’ workforce is key. Injury prevention initiatives can include home safety equipment schemes that supply bath mats and educational campaigns and resources on drowning prevention.

Further information
Health visitors are encouraged to access further information at www.capt.org.uk. CAPT’s information leaflets, flyers, DVDS and website aim to offer flexible solutions which can help health visitors to facilitate accident prevention interventions with parents in a wide variety of settings.

References
NICE (2010a) Strategies to Prevent Unintentional Injuries to the Under-15s [online]. Available at: http://www.nice.org.uk/guidance/ph29 (December 2014)
NICE (2010b) Preventing Unintentional Injuries Among the Under-15s in the Home [online]. Available at: http://www.nice.org.uk/guidance/ph30 (December 2014)
NICE (2013) Consideration of an update of three pieces of public health guidance on: Preventing unintentional injuries among under 15’s: Strategies (PH29); Home (PH30) and Road (PH31) [online]. Available at: https://www.nice.org.uk/guidance/ph31/documents/prevent-unintentional-injuries-among-under15s-strategies-ph29-home-ph30-and-road-ph31-review-proposal-document-2 (accessed December 2014)
Public Health England (2014) Reducing unintentional injuries among children and young people – a suite of resources from Public Health England 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322210/Reducing_unintentional_injuries_in_and_around_the_home_among_children_under_five_years.pdf  
Our children deserve better: prevention pays DoH (2012). https://www.gov.uk/government/publications/chief-medical-officersannual-report-2012-our-children-deserve-better-prevention-pays