Unintentional injuries among infants and children
Lisa IrvingMPH, BSc(hons), RHV, RM, RGN Public Health Nurse, Northumbria Healthcare, PhD student
- Unintentional injury is one of the leading causes of infant and child morbidity and mortality
- Minor injuries are part of growing up and help children to understand and manage risk
- The term unintentional injury means that most injuries, and their precipitating events, are predictable and avoidable. Accident implies an unpredictable and unavoidable event
- A number of actions can be taken to reduce the risks of unintentional injuries taking place both in the home and the wider community
In the UK, unintentional injury is one of the leading causes of morbidity and mortality in children aged one to 141 and puts more children in hospital than any other cause2. Treating injury costs the NHS approximately ￡2 billion each year3 - yet many unintentional injuries are not inevitable and, in many cases are entirely preventable4.
The cost of injury can also be both life altering and expensive. Many injuries can result in disability or painful and lengthy hospital treatments, while many possible work and school hours are lost due to hospital attendances and ill health. The inability of injured or disabled children to participate fully in school and society could also lead to reduced achievement in education and lack of social and emotional well-being. Home accidents have been identified as a particular problem among pre-school age children1,5, and it has been estimated that one in five children under the age of five will attend an Accident & Emergency department every year due to an injury sustained in or around the home6. In older children, injuries in the external environment - and in particular at the roadside - are more common causes of injury7,8 as children begin to become more independent and spend more time away from the home. There are marked differences in risks of unintentional injury among children between different social groups.
The social gradient for deaths during childhood as a result from unintentional injury is steeper than that for any other cause of death9,10. Children from poorer backgrounds are five times more likely to die as a result of unintentional injury than children from more affluent backgrounds11. Factors which link social deprivation and increased risk of unintentional injury are complex and generally not well understood2,9, although the risk factors are generally acknowledged to be a combination of child, family and environmental characteristics5,9. It is worth noting that factors may interact or exacerbate each other, resulting in an even greater risk of unintentional injury.
It remains a key priority for healthcare professionals to receive training and support to help them if there is a suspicion of intentional/non-accidental injury. Safeguarding protocols should be in place for all those working with children and young people. Minor unintentional injuries are part of growing up and help children and young people to learn their boundaries and manage risks for themselves. There is a balance to maintain, which encourages young people to explore and develop, yet manages the risks to prevent serious injury. Such a dichotomy was recognised in a government review published in 200910.
The full suite of guidance, on preventing unintentional injuries among under-15s, comprises of three separate sets of guidance, which were developed using different methods. "Strategies to prevent unintentional injuries among under-15s" (PH29) was developed using the programme development process (PDG) and the other two pieces; "Preventing unintentional injuries among under-15s in the home" (PH30) and "Preventing unintentional injuries among under-15s: road design" (PH31), were developed using the NICE public health intervention process. Members on the PDG, which developed the "strategies" recommendations included people working directly in public health; people working in police and fire and rescue services, managers in the health service and other organisations; researchers; statisticians; economists; representatives from 'lay' groups such as charities or patient/carer organisations. When writing the recommendations, the PDG considered the evidence of effectiveness (including cost effectiveness), expert testimony, fieldwork data and comments from stakeholders. The guidance uses the term "unintentional injuries" rather than "accidents" as: "most injuries and their precipitating events are predictable and preventable"12. The term "accident" implies an unpredictable and therefore unavoidable event.
The recommendations in the guidance are relevant to commissioners and providers of health services, local authority children's services, local authorities and their strategic partnerships, local highway authorities, local safeguarding children boards, police, fire and rescue services, policy makers, professional bodies, providers of play and leisure facilities, and schools. They may also be useful guidelines for other public, private, voluntary and community organisations and services which have a direct or indirect role in preventing unintentional injuries among children and young people aged under 15.
There are a number of recommendations which are relevant to health visitors, school nurses and community nursery nurses, as well as others working in primary care. The guidance and recommendations are divided into six categories: general, workforce training and capacity building, injury surveillance, home safety, outdoor play and leisure, and road safety. General Despite the burden of unintentional injury on children, families and communities and the substantial economic costs, the prevention of unintentional injuries among children and young people may not be a priority to local organisations. In order to ensure prevention activities are given the importance they deserve, they need to be incorporated into both national and local strategies aiming to improve the children and young people's health and well-being.
This should include a commitment to prevent unintentional injuries among the most vulnerable groups in order to reduce inequalities in health. Plans and strategies should include clear guidance collaboration and partnership working, data collection and workforce development. An unintentional injury prevention coordinator should be appointed with the aim of promoting a strategic framework for action and encouraging local agencies to work together. This person could be employed by the local authority, an NHS organisation or another local partner, or posts could be funded by a number of local partners. There are currently a small number of these posts throughout the UK. It is acknowledged that in the current climate of resource cuts and reorganisation within public health and local authority that this may be a challenge, but the possible savings that could be gained from reduced hospital admissions, outpatients treatments and lost school and work hours are clear. A costing tool has been produced by NICE and this can be used to assess the cost and savings of implementing NICE recommendations, including appointing an unintentional injury prevention coordinator, and to build a case for investment.
A number of health professionals, including paediatric liaison health visitors, injury prevention coordinators, local safeguarding boards and emergency care staff, were identified as key to ensuring that appropriate responses are carried out following a child or young person's attendance at emergency departments (including minor injuries and walk-in centres). These people are required to ensure that health visitors, school nurses and GPs are aware of which families may benefit from injury prevention advice and home safety assessments. Local protocols could be used to identify children or young people at risk of unintentional injury; this may be following a number of attendances or may be following one attendance that raised concerns. Workforce training and capacity building
In order to ensure that the workforce is skilled in unintentional injury prevention, professional standards are needed to set out the knowledge and skills (or competencies) for a range of injury roles.
These include competencies to be incorporated into nursery nursing, nursing, midwifery and health visitor training and development of curricula and standards for those specialising in injury prevention such as injury prevention coordinators. These standards could be developed by Faculties of Public Health, professional bodies (for example the NMC, the CPHVA, the RCN etc), universities or sector skills councils. Training on injury prevention should involve the wider childcare workforce, including all those who work with children, young people and their families. There is also a recommendation that government departments, such as the Department of Health and the Department of Education, could allocate additional funding to develop these standards and curricula and to provide training.
In order to effectively monitor injury risks, target resources and assess effectiveness of prevention strategies, a robust national injury surveillance resource is needed. This could be provided by a network of agencies and will need coordination between public health observatories, colleges of emergency medicine, government departments, Office for National Statistics and the Information Centre for Health and Social Care. There may also be a role in injury surveillance for Health and Well-being Boards, which will include Directors of Public Health elected representatives and representatives of adult and children's social services as well as NHS clinical commissioning groups, as part of their role to promote public health. Currently all A&E departments (including minor injury units and walk-in centres) are required to submit data using the A&E commissioning dataset. In order to ensure that the data is collected and submitted to the required standard, commissioners of health services should stipulate that this standard is adhered to by hospital trusts.
There is recognition that the strategies designed to reduce the large number of injuries that occur in or around the home should be multi-faceted. The NICE guidelines for home safety attempt to address this with a range of recommendations. As families with children particularly vulnerable to unintentional injury may frequently live in social or rented accommodation, there is a recommendation that permanent safety equipment (such as smoke and carbon monoxide alarms, thermostatic mixing valves and window restrictors) should be installed and maintained in these properties. There was a great deal of evidence to support home safety assessments and safety equipment provision at many levels and this was reflected in a number of recommendations. In this guidance "home safety assessment" is described as the process of systematically identifying potential hazards in the home, evaluating the risks and providing information or advice on how to reduce them. Other terms commonly used to describe the same process include "home risk assessment" and "home safety check". These may be carried out by a trained assessor or by parents and other householders, using an appropriate checklist. Home safety equipment is any device used to prevent injury in the home. These could include door guards and cupboard locks, safety gates and barriers, smoke and carbon monoxide alarms, thermostatic mixing valves and window restrictors. Home safety assessments and installation of home safety equipment, either delivered separately or together, should be implemented as part of a broader strategy to reduce injury in the home. As well as home safety assessments, it is essential that education and advice on ways to reduce unintentional injury to children and young people is available to all families, this may be on a one to one basis or in a group situation. In many areas, home safety assessments and advice on safety issues are now part of routine practice for all practitioners who visit children and young people at home. Due to increasing community practitioner workloads, this may involve prioritising households at greatest risk of unintentional injuries and establishing partnerships to carry out home safety assessments, supply equipment and provide appropriate follow-up. These partnerships could include Children's Centres, fire and rescue services, local handyperson services and other statutory and voluntary organisations.
Outdoor play and leisure
During the development of these guidelines it was taken into account that children and young people learn, develop and mature when playing and taking part in activities that challenge them. Participating in regular physical activity and outdoor play is important for their growth, development and general health and well-being. For these reasons there is a need to address and balance risks against the benefits of activities for children. The type of hazards encountered during outdoor activities will vary for different age groups and according to where they take place.
At the strategic level, policies for public outdoor play and leisure should be developed by schools, local strategic partnerships, play and leisure providers and policy makers. These policies should insure that play and leisure provision is; inclusive of all children and young people, is compliant with safety standards, takes a balanced view when assessing risks and benefits of play and leisure environments, and takes into account children and young people's preferences about the play and leisure activities they would like to participate in. There was good evidence for action on particular types of leisure injuries. Health practitioners (among others) were identified as appropriate to provide education and advice on water safety, including providing age and developmental stage appropriate information and education to parents and carers. This included skills in identifying particular risks in their homes, gardens and local areas, the importance of supervision and advising on improving swimming and water skills for all family members. It was also recommended that all swimming lessons incorporate specific water information for example; coastal warning flags and skills in identifying potential water hazards to children and young people. Recommendations were also made on advising on off road cycle safety (especially in relation to correctly fitted cycle helmets) and for relevant organisations to carry out local firework campaigns at appropriate times such as Bonfire Night, New Year and Diwali.
The final part of the guidance addressed recommendations for road safety. The majority of these recommendations were at a strategic level and include policy, enforcement and engineering interventions. There was a call for those responsible for road safety to focus on the needs of local children and young people. Proposals included maintaining and establishing effective road safety partnerships and ensuring that the health sector is represented on these partnerships. These partnerships should ensure that regular local child safety reviews and consultations are carried out and that local child safety policies are aligned to ensure that there is consistency between strategies for children and young people's safety, health and wellbeing, road safety strategies and community safety plans. There should also be active involvement of the police in driver education activities and initiatives to reduce traffic speed. There were also recommendations directed specifically at local highway authorities, local strategic partnerships and public health professionals with an injury prevention remit.
These include measures to reduce vehicle speed, including 20mph zones, thorough need assessment and planning and engineering modifications, and changes to road design on routes used frequently by children and young people. There was also a suggestion for a senior public health position to lead on the public health sector's involvement in injury prevention and risk reduction with particular emphasis given on increased involvement in risks in the road environment and strategies to address these risks.
Unintentional injury is a leading cause of death among children aged one to 14 years, and thousands are disabled or left with physical and psychological scars each year following serious injury. The majority of these injuries are preventable and there is an increasing body evidence of what strategies and interventions can be used to prevent unintentional injuries to children and young people. These recommendations provide a valuable set of guidance to practitioners and organisations on many levels on actions and strategies to reduce unintentional injury in children and young people. Many organisations are also voicing their concerns regarding the scale of cutbacks, which are affecting the most vulnerable in society13
For all guidance documents - including quick reference guides, please see:
1. Audit Commission & Healthcare Commission. Better safe than sorry. Preventing unintentional injury to children. London, 2007
2. Brown CE, Chishti P, Stone DH. Measuring socio-economic inequalities in the presentation of injuries to a paediatric A&E department: the importance of an epidemiological approach. Public Health 2005;119 (8): 721-725
3. Department of Health (DH). Preventing accidental injury: priorities for action. London, The Stationery Office, 2002
4. The Royal Society for the Prevention of Accidents. General accident statistics. 2002http://www.rospa.com [Accessed November 2011]
5. Kendrick D, Mulvaney C, Burton P et al. Relationships between child, family and neighbourhood characteristics and childhood injury: a cohort study. Soc Sci Med 2005; 61(9): 1905-1915
6. Ramsay LJ, Moreton G, Gorman DR et al. Unintentional home injury in preschool-aged children: looking for the key - an exploration of the inter-relationship and relative importance of potential risk factors. Public Health 2003; 117(6): 404-411
7. Department for Children, Schools and Families (DCSF). Staying Safe: action plan. London, DCSF,2007
8. Towner E, Towner J. The prevention of childhood unintentional injury. Curr Paediatr 2001; 11(6): 403- 408
9. Dowswell T, Towner E. Social deprivation and the prevention of unintentional injury in childhood: asystematic review. Health Educ Res 2002; 17(2): 221-237
10. Department for Children, Schools and Families (DCSF). Accident prevention amongst children and young people - A priority review. London, DCSF, 2009
11. Haynes R, Reading R, Gale S. Household and neighbourhood risks for injury to 5-14 year old children. Soc Sci Med 2003; 57(4): 625-636
12. Davis R, Pless B. BMJ bans 'accidents'. Accidents are not unpredictable. BMJ 2001; 322(7298): 1320- 1321
13. Action for Children, Red Book (2010/2011)