NPTR
October 1993, Fact Sheet #2Injuries Among Children
Professionals, parents and other family members have experience with injured children at different stages. Hospital staff, especially those working in trauma units and intensive care units, treat children shortly after they have been injured. They are involved directly in the medical and emotional crises of life-threatening injuries. They rarely see the child's long-term recovery. It is often educators in local schools who become directly involved in helping children adjust to the effects of injuries on their functional skills and learning abilities.
A child's injury affects every member of a family in some way. However, until it happens to their child, many parents are unaware of the epidemic of injuries to children. More than 20,000 children will die this year in the United States as a result of injuries. More than 30,000 children will have permanent disabilities as a result of injuries to the brain.
The development of children
Age is not simply a number. It reflects how the child perceives and reacts to the world. Children are constantly changing as they grow. Their abilities to react and respond to others, coordinate their bodies, plan ahead, and judge the consequences of their actions are factors that change predictably and frequently as children's physical, communicative, social and intellectual abilities develop. The causes and consequences of injuries vary by children's ages. The Registry uses the following age categories to reflect major developmental stages of children's growth and abilities.
- Infants are grouped in the less than one year category (<1) and are entirely dependent on adults for their care and supervision.
- Toddlers and preschool children are included in the 1-4 year range. Children in this range usually grow rapidly in weight and height. They become increasingly active and mobile. Communication with others grows as their speech and language skills develop. They gradually require less physical care and assistance, but still need major supervision despite increasingly assertive efforts at independence.
- The years of 5-9 are marked by a child's participation in school as learning and education become primary goals. Physical abilities continue to mature into increasingly complex skills and activities. Children become less reliant on adults, especially parents for physical assistance, emotional support, and supervision. They gradually explore the world beyond their homes as their judgement and self-reliance develop.
- The middle years of 10-14 bring dramatic physical and emotional changes as children prepare for and enter adolescence. Appearance becomes very important as do relationships among friends. Direct parental supervision decreases.
- Years 15-19 confront adolescents with the challenges of leaving childhood and taking on the roles and responsibilities of young adults. Experimenting with sex, drugs and alcohol increases. Motor vehicles serve the dual purpose of transportation and recreation. Challenging authority and breaking the rules are familiar patterns to worried parents.
Brief overview of pediatric trauma
The following brief overview of pediatric trauma is based on the findings of the National Pediatric Trauma Registry (NPTR) as of spring, 1993. It is intended to give the reader basic information on the major patterns of injuries and their consequences for children.
This summary is based on the records of 28,692 children who were admitted to 61 children's hospitals or trauma centers that participate voluntarily in the Registry. The ages of children range from birth through 19 years.
Sex
Boys were injured about twice as often as girls. The difference between sexes increases after infancy and continues through adolescence.
Age
The largest group of injured children was between ages 5-9 years (29%). This was followed by children ages 1-4 years (25%) and children 10-14 years (24%). Infants under one year have the lowest rate (5%). Adolescents 15-19 years represented 17% of all children.*Note: The upper age limit that defines a pediatric patient varies among participating centers in the NPTR. Consequently, adolescent data recorded for the NPTR is lower than national data on injuries for this age group. Not all centers admit adolescents through age 19.
Time
The vast majority of injuries occurred between noon and midnight when children are most likely to be out of the structured school environment.
Scene
The two most common sites of injuries were the road (43%) and home (34%). Other places included recreation areas, public places, schools, farms, and workplaces.The most common emergency treatments given at the scene of the injuries were placement of cervical collars, positioning devices for immobilization, insertion of intravenous lines, airway management, skeletal immobilization and hemorrhage control.
Admission to trauma center
Almost all children were alive upon arrival at the trauma center (99.7%). Slightly more than half were transported directly from the scene of the injury. Close to a third were transported from emergency rooms at other hospitals. Ambulance transportation was the most frequently used method at 57%. Helicopters transported 14% of the children and a small percentage arrived by plane. Only a quarter of the children admitted arrived by car. Professional transport was assisted by medical personnel. Paramedics or emergency medical technicians attended 77% of the children during transport to the trauma center.
From the emergency room, over half the children (62%) were taken to beds on a hospital ward. However, 22% of the children were taken to intensive care units and 15% to operating rooms directly from the emergency room.
Causes and mechanisms of injuries
Falls are the leading cause of injuries (26%). Falls among young children are often from furniture such as changing tables, couches, cribs or down stairs in walkers. As toddlers begin to explore, they increasingly fall from heights. Examples are falls down stairs, off balconies, from porches or out of windows. Nearly 20% of the children admitted after falls had fallen 8 feet or more.
The next major mechanism is motor vehicle crashes with children as occupants (19%). Most crashes involved collisions with other vehicles. Only 27% of those children injured were using some kind of protective restraints such as child safety seats or safety belts. Many unrestrained children were hurled around inside the car during a collision or thrown out of the car through windows or doors. Breast feeding in the car or holding a child in one's lap is dangerous as the child is unprotected during a crash.
The third leading mechanism is pedestrian injury (16%) where children are struck by motor vehicles. These children are most frequently hit while walking along the side of the street, during play in the street, or while darting into or crossing the street.
Children are frequently hit by motor vehicles while bicycling, but they may also be injured bicycling by falling after hitting objects such as trees, curbs, or walls. Close to 9% of the children were injured while bicycling. Only 31 children, or 1% of the 2,468 children admitted to trauma units after bicycling- related injuries, were wearing helmets.
Other motor vehicle-related injuries include motorcycles (1.4%) and all-terrain vehicles and recreational vehicles (1%). The use of helmets among those injured in motorcycle collisions was much higher than bicyclists at 30%. Use of restraints by riders of all terrain vehicles and recreational vehicles was 46%.
Falls separately appear to be the leading cause of injuries. However, when the motor vehicle related event includes children injured as occupants, pedestrians, and riding on bicycles, motorcycles and all terrain and recreational vehicles, then motor vehicle-related injuries become the leading mechanism (46%).
Violence
While the number of children injured by violence is lower than by other means, the motives and consequences are severe. Five percent of the children were injured by gunshots; however, 68% of these shootings were intentional. The highest death rate was for children who had been shot.Another 5% of the children were stabbed, 24% of these intentionally. Injuries by stabbings ranged from minor to severe depending on whether major organs or arteries were involved.
Additional violence includes beating and assaults with blunt objects. The second highest risk of death was associated with beatings, mainly child abuse.
Consequences
Many injuries occur while a child is engaged in some kind of activity such as running, playing, climbing or bicycling. Even when the child is in a more stationary position such as riding in a car, the child is part of an activity involving motion and speed. The child may also be the object or target of violent activities such as gunshots, beatings, or stabbings.
The combined effects of motion, speed and impact can injure many regions of a child's body. Two or more body regions were affected in 44% of the children recorded in the Registry. Children typically had multiple injuries that resulted in several diagnoses. Head injury is the most frequent diagnosis among children recorded in the Registry. This is followed by fractures to the bones of extremities and torso. The third most frequent diagnosis is open wounds.
Outcomes of Injuries to Children
The Registry categorizes the consequences of injuries by looking at the child's ability to perform routine activities and functions. this includes abilities to see, hear, communicate, feed oneself, bathe, dress, and walk. Additional areas of cognition and behavior are critical to the child's ability to develop self-awareness and to relate to others. Cognition refers to the child's mental awareness and ability to take in and use information. this is essential for learning. Behavior describes the child's ability to monitor and control emotional and physical impulses and actions.
Measuring these changes in children is more complex than in adults. Children are constantly changing because they are still growing and developing while they are recovering from their injuries. Whether a functional limitation exists after an injury can not be measured by a simple ability or inability to perform a specific task. The child's ability to do the activity at the level appropriate for his/her age is a key consideration. Therefore, the Registry documents if the child is able to perform tasks at an age appropriate level or whether the child is limited or unable to function in specific areas. The Registry also identifies if the child has a preexisting condition that limits function and if the injury has caused that condition to worsen.
1-3 functional limitations at discharge
Fortunately, over half the children (56%) were discharged from the trauma centers with no functional limitations in activities. Over a third had 1 to 3 functional limitations (38%). A very small percentage (4%) of children discharged had four or more functional limitations at discharge. This number is significant because these children have serious injuries that are likely to result in long-term limitations in their activities.
Four or more functional limitations at discharge
The diagnosis of head injury is three times more likely to result in four or more functional limitations. Children with four or more functional limitations also had more chest and abdominal injuries. It is the children with 4 or more functional limitations who are likely to have long-term consequences and even permanent disabilities. The complexity of these children's injuries is evident by the average of 5 diagnoses per child compared to an average of 2 diagnoses in the 1 to 3 functional limitation group. Fractures of the extremities, open wounds, superficial injuries, and bruises more often result in 1-3 functional limitations.
The severity of injuries is directly linked to how the children were injured. Children injured in motor vehicle crashes and as pedestrians were more likely to have four or more functional limitations. The force and speed of collisions are factors in the severity of injuries. Children injured by falls and stabbings were less seriously injured and had fewer functional limitations.
Discharge from hospital
Ninety-seven percent of the children admitted to trauma centers participating in the Registry survived. The vast majority of children went home from the hospital (93%). Only 653 children, or 6% of those with at least one functional limitation, were discharged to in-patient rehabilitation settings. Of those children injured by child abuse, mostly infants and toddlers, 61% were discharged under foster care arrangements.
Upon the child's discharge from the hospital, follow-up appointments were recommended for 91% of the children. Almost a third of the children were advised to restrict their activities and nearly a quarter of the children were given recommendations for short-term medications.
Over half of the children (56%) were not expected to have any functional limitations upon discharge. Among children with at least one functional limitation at discharge, referrals for out-patient services were limited. Only 14% had physical therapy recommended, 6% occupational therapy, and 3% speech therapy. Recommendations for psychological services were made for only 2% of the children discharged, although family counseling was recommended for slightly more at 3%. Recommendations for special education were very low at 1 percent, although home tutors were recommended for 2 percent.
Discharge destination from the trauma center varied according to the child's condition. Among the 11,539 children discharged with functional limitations, home was the primary destination. This included children with limited abilities in self-feeding, bathing, dressing, walking, cognition, or behavior. While this was overwhelmingly the case for the children with 1-3 functional limitations, 44% of the children with 4 or more functional limitations also went directly home. Only 40% of children with four or more functional limitations were discharged to in-patient rehabilitation programs. Even among the children with four or more functional limitations, more were discharged directly home than to rehabilitation facilities or units.