Pediatric injuries, epidemiology, risk, and prevention

1. Pediatric Injuries:
Risks and Prevention Among Ages
<1-15 in Los Angeles County
James M. DeCarli, PhD Candidate, MPA, MPH, CHES
Research Analyst III/Behavioral Sciences
Injury & Violence Prevention Program
Department of Public Health, Los Angeles County

2. Overview
Background: Overall Childhood Injury Among
Children Ages <1-15 in Los Angeles County
Specific Age Category (<1, 1-4, 5-12, 13-15):
Leading Causes of Injury Fatality & Hospitalization
Anatomical injuries Associated with Injury Mechanisms
Contributing & Protective Factors
Injury Prevention Planning Tools

3. Childhood Injury
in Los Angeles County
Data Sources
Fatalities:
California Department of Health Services, Vital Statistics
Death Statistical Master File
Hospitalizations:
California Office of Statewide Health Planning and
Development, Patient Discharge

4. Childhood Injury
in Los Angeles County
Injuries are the leading cause of death among
1-44 year olds in Los Angeles County
Injuries are the leading causes of death among
2.5 million children in Los Angeles County
(2006)
In 2006, among ages <1-15:
159 injury deaths
5,830 injury hospitalizations

5. Leading Causes of Injury–All Child Ages <1-15
Los Angeles County, 2006
Fatalities Hospitalizations
Pedestrian
11%
Struck by Obj
9%
MVT Ped
MV
10%
Occupant
MVT Ped
16% MVT 10%
MTV Occup
Occupant
MVT 35%
10%
Unspec
20% Suicide Fall
11% 60%
Unint. Falls
Drowning Drown Pedestrian
15% 29% 11% 61%
MV Occupant
17%
Sources:
[Fatalities] California Department of Health Services, Vital Statistics Death Statistical Master File
[Hospitalizations] California Office of Statewide Health Planning and Development, Patient Discharge

6. Infants Age <1
Leading Causes of Injury
Los Angeles County, 2006
Fatality (Freq) Hospitalization (Freq)
Assault/Homicide 13 Fall 158
Untint-Suffocation 2 Assault/Homicide 42
MVT Occupant 1 Unint-Burn, Hot Obj. 30
Untint-Suffocation 30
Unint-Nat Env 19

7. Fatal Injuries
Infants Age <1
Los Angeles County, 2006

8. Fatal Assault/Homicides by Cause
Infants Age <1
Los Angeles County, 2001-2006

9. Hospitalizations
Infants Age <1
Los Angeles County, 2006
100%

10. Where are infants falling from?
(Hospitalizations by Cause)
Los Angeles County, 2006
45
40
35
30
25
20
15
10
5
0
Stairs Bed Other Furniture One Lever to Another Other

11. Most common anatomical
fall-related hospitalization among infants: TBI’s
(Hospitalizations)
Los Angeles County, 2004
Traumatic Brain Injury (TBI)
100% 90%
80% 77%
80%
60%
60%
40%
20%
0%
Stair Chair Bed From different level

12. Toddler Ages 1-4
Leading Causes of Injury
Los Angeles County, 2004
Fatality (Freq) Hospitalization (Freq)
Drowning 10 Fall 718
Assault/Homicide 9 Unint-Burn, Hot Obj. 145
MVT Occupant 6 Poisoning 116
MVT Pedestrian 4 MVT Pedestrian 107
MVT-Unspecified 3 Unint-Nat Env 106
Pedestrian-Other 3

13. Fatal Injuries
Toddlers Ages 1-4
Los Angeles County, 2004
Fatalities
MVT Pedestian-
Unspecified Other Drowning
9%
9% 28%
Pedestrian
11%
Occupant Homicide
17% 26%

14. Where are toddlers drowning?
(Fatalities)
Los Angeles County, 2000-2004
70% 63%
60%
50%
Percent
40%
30%
20% 14%
11%
10% 6%
2% 2% 2%
0%
Unspec
Pool
Reservoir
Bathtub
Fall into
Fall into
Bathtub
Water
Open
Pool

15. Fatal Assault/Homicides by Cause
Toddler Ages 1-4
Los Angeles County, 2000-2004
50 46%
45
40
35
29%
30
Percent
25 20%
20
15
10 5%
5
0
Abuse & Cut/Pierce Firearm Other
Neglect

16. Hospitalizations
Toddlers Ages 1-4
Los Angeles County, 2004
Hospitalizations
Nautral-Env
MVT Ped 9%
9%
Poisoning
10%
Falls
60%
Burns
12%

17. P e r c e n ta g e
0
5
10
15
20
25
30
1
E s c a la t o r
7
S t a ir
2
Ladder
6
B u ild in g /S t ru c t u re
1
In t o H o le
P la y g ro u n d
11
E q u ip m e n t
0.1
C lif f
11
C h a ir
(Hospitalizations)
Los Angeles County, 2004
24
Bed
6
O t h e r F u rn it u re
Where are toddlers falling from?
13
D if f e re n t L e v e l
18
Sam e Level

18. Common anatomical fall-related hospitalizations:
Upper Extremity & TBI
Toddler Ages 1-4
Los Angeles County, 2004
80 71
68 69
70
60 54
Upper Extremity
Percentage
50
40 36 39 TBI
30
20
10
0
Level-Trips
Chair
Playground
Bed
Equipment
Different
Level
Same

19. Children Ages 5-12
Leading Causes of Injury
Los Angeles County, 2004
Fatality (Freq) Hospitalization (Freq)
Assault/Homicide 11 Fall 1033
Drowning 8 MVT Pedestrian 236
MVT Occupant 7 MVT Occupant 191
MVT Pedestrian 7 Unint-StruckByObject 154
MVT-Unspecified 6 Bicyclist, Other 144

20. Fatal Injuries
Children Ages 5-12
Los Angeles County, 2004
Fatalities
MVT
Unspecified
15% Homicide
28%
Pedestrian
18%
Occupant Drowning
18% 21%

21. Fatal Assault/Homicides by Cause
Children Ages 5-12
Los Angeles County, 2000-2004
80
69%
70
60
50
Percent
40
30 24%
20
10 5%
2%
0
Abuse & Cut/Pierce Firearm Other
Neglect

22. Where are children drowning?
Children Ages 5-12
Los Angeles County, 2000-2004
50
44%
45
40
35
Percentage
30
25
19% 18%
20
13%
15
10 6%
5
0
Bathtub Pool Open Reservoir Unspec
Water

23. Hospitalizations
Children Ages 5-12
Los Angeles County, 2004
Hospitalizations
Bicyclist,
Struck by
other
object
8%
9%
MTV
Occupant
11%
Fall
MVT Ped
59%
13%

24. Where are children falling from?
Children Ages 5-12
Los Angeles County, 2004
40% 35%
35%
30% 25%
Percent
25%
18%
20%
15% 8%
10% 6%
1% 3% 1% 2% 2%
5%
0%
Building/Structure
Into Hole
Stair
Chair
Playground
Bed
Equipment
Other Furniture
Ladder
Same Level
Different Level

25. Common anatomical fall-related hospitalizations:
Upper & Lower Extremity
Children Ages 5-12
Los Angeles County, 2004
90 84%
80
70 61%
57%
60
Upper Extremity
Percent
50
Lower Extremity
40
TBI
30 21%
18%
20 10%
8%
10 4% 6%
0
Playground From Different Same Level-Trip
Level

26. Adolescent Ages 13-15
Leading Causes of Injury
Los Angeles County, 2004
Fatality (Freq) Hospitalization (Freq)
Assault/Homicide 10 Fall 718
MVT Occupant 9 Suicide 145
MVT-Unspecified 6 Assault/Homicide 116
Suicide 4 Struck-By-Object 107
Drowning 3 MVT Occupant 106

27. Adolescent Ages 13-15
Leading Causes of Injury
Los Angeles County, 2004
Fatalities
Drowning
4% Fall
Pedestrian
4%
Suicide 4%
MVT 9%
Unspecified
9%
Homicide
57%
Occupant
13%

28. Common weapon of choice
(Fatal Assault/Homicides)
Adolescent Ages 13-15
Los Angeles County, 2000-2004
90 84%
80
70
60
P ercent
50
40
30
20 7%
10 1% 1% 4% 3%
0 Riflt/S hotgun
(m urder,
Handgun
S harp Object
Hang/S trangul,
Unspec
Other Firearm
m ansl)
S uffocat.

29. Hospitalizations
Adolescent Ages 13-15
Los Angeles County, 2004
Hospitalizations
Occupant
Struck by 10% Fall
object 38%
13%
Homicide
Suicide
18%
21%

30. Percent
0
5
10
15
20
25
30
35
40
Curb
1%
Stairs
6%
Ladder
.5%
Building/Structure
Into Hole 4%
Storm Drain
1% .5%
Playground
7%
Chair
Los Angeles County, 2004
Bed
Adolescent Ages 13-15
Other Furniture
.5% .5% .5%
Different Level
24%
Where are adolescents falling from?
Same Level-Trip
36%
Sports Activity
19%

31. Common anatomical fall-related
hospitalizations: Upper & Lower Extremity
Adolescent Ages 13-15
Los Angeles County, 2004
45 42 42%
40%
40
34%
35 30 29
30 Upper Extremity
Percent
25
Lower Extremity
20
13% 14% 13% TBI
15
10
5
0
Sports From Same Level-
Activity Different Trip
Level

32. Common methods of choice for suicide-
related hospitalizations: pain relievers
Adolescent Ages 13-15
Los Angeles County, 2004
70 59%
60
50
Percent
40
30
18% 16%
20
10 2% 1% 2% 1% 1%
0
Analgesics/Antipyretics
Corrosive Agents
Tranquilizers
Chemicals
Other Drugs/Chemicals
Hanging
Gas Vapor
Cut/Pierce

33. Review
Leading Causes of Injury
Ages Fatality Hospitalization
<1 Assault/Homicide Falls
1-4 Assault/Homicide Falls
Drowning
5-12 Assault/Homicide Falls
Drowning
13-15 Assault/Homicide Falls
Suicide

34. Contributing Factors
Assault/Homicide & Suicide
Intimate Partner Violence/Domestic Violence
Parental abuse of alcohol & drugs
Use of alcohol & drugs among youth
Personality Disorders/Mental Health
Depression
Lack of resources/access to care
Gang Activity
Malnutrition-aggression & violence behaviors

35. Childhood Exposure to IPV
Children observe traumatic events (IPV-family
violence) to varying degrees:
Home Environment:
May see mothers use violence in self-defense or see both
parents trading self-defense
See parents occasionally slap, shove, and throw things
Observes violence or threats, while the victim does not
leave the home or report to police or public agencies
(Straus & Gelles, 1990)

36. Symptoms of Children
Exposed to IPV
29 different studies of children who witnessed
IPV
Behavioral
Emotional
Social
Cognitive
Physical
(Kolbo, Blakely, & Engleman, 1996)

37. Behavioral Effects
Aggression
Tantrums
"acting out"
Immaturity
Truancy and
Delinquency
(Davies, 1991; Dodge, Pettit, & Bates, 1994; Graham-Bermann, 1996c; Hershorn &
Rosenbaum, 1985; Hughes & Barad, 1983; Jouriles, Murphy, & O'Leary, 1989;
Sternberg, Lamb, Greenbaum, Cicchetti, Dawud, Cortes, et al., 1993)

38. Emotional Effects
Anxiety
Anger
Depression
Withdrawal
Low self-esteem
(Carlson, 1990; Davis & Carlson, 1987; Graham-Bermann, 1996c; Hughes, 1988;
Jaffe, Wolfe, Wilson, & Zak, 1986)

39. Social Effects
Poor social skills
Peer rejection
Inability to empathize with others
(Graham-Bermann, 1996c; Strassberg & Dodge, 1992)

40. Cognitive Effects
Language lag
Developmental delays
Poor school performance
(Kerouac, Taggart, Lescop, & Fortin, 1986; Wildin, Williamson, & Wilson, 1991).

41. Physical Effects
Failure to thrive
Problems sleeping
Eating problems
Regressive behaviors
Poor motor skills, and
Psychosomatic symptoms (eczema, bed
wetting, etc.)
(Jaffe, et al., 1990; Layzer, Goodson, & Delange, 1986)

42. Specific Signs & Symptoms:
Toddler/Preschooler (<5)
Become more aware of their environment (easily aroused)
Sleeping & Eating Disorders
Somatic Complaints
Stomachaches
Headaches
Separation Anxiety (clinging to mother/victim)
Speech, motor skill & cognitive delays
Depression & anxiety
Difficulty in expressing emotions-but anger
(National Resource Center on Domestic Violence, 2002)

43. Specific Signs & Symptoms:
Childhood (5-12)
Poor in School-Exhibit few options/low success
Self esteem limitations
Frequent mood swings
Erratic attendance
Inability to concentrate
Poor social skills
Conflicts with classmates & teachers
Excel in School-Try to overcome & suppress family dysfunction
Seek approval by doing well in structured school environment
Perfect student
Making many friends
However:
Live with unpredictable home environments
Conflict-loving/hating their parents
Experience guilt, depression, sadness, powerlessness
Unable to relax/sleep
Signs of PTSD
(National Resource Center on Domestic Violence, 2002)

44. Specific Signs & Symptoms:
Adolescence (13-15)
Eating difficulties resulting in
anorexia, bulimia, or obesity
Academic difficulties-leading to dropping out
Feeling powerless, fear, delinquency, substance
abuse, suicide
Intimate partner relationships
Without proper intervention-exhibit sex roles and
communication patterns learned from dysfunctional home
environment-contributing to the generational cycle of
violence
(National Resource Center on Domestic Violence, 2002)

45. Contributing & Protective Factors
Falls
Risks:
Infant changing and sleeping locations
Preschool aged children-greatest risk of fall-related fatalities
50% occurring among children <4
80% fall related injuries among children <4 occur at home
and mostly during noontime and early evening (playtime)
Prevention:
Supervision (home & playground)
Changing tables & beds-use of rails
Use of safety gates leading to different levels/stairs
Avoid asphalt, concrete, grass or soil surfaces under
playground equipment-use of mulch, rubber, etc.

46. Contributing Factors
Drowning
Seasonal: 72% occur during summer months
Location: 51% occur in private swimming pools
Age: Infants and toddlers:
88% occur in private swimming pools
70% of these children were not expected to be in or at the
pool, but somewhere in the home
Lack of “Active” Supervision: SAFE KIDS Worldwide
study: 90% of children who had drowned, had been
supervised by an adult
Child wading and inflatable pools: Carry similar risks

47. Protective Factors
Drowning
“Active” Supervision (Lifeguard)
Barrier Fencing
Self-closing/Self-latching gates (open outward)
Locks and Alarms on all windows/doors
(leading to pool area)
Wading/Inflatable pools:
Smaller: Empty/turn over after use
Larger: Require fencing/Electrical requirements

48. Contributing & Protective Factors
MVT-Occupant
Riding improperly restrained-greatest risk factor
Currently 85% misuse rate (Child Passenger Safety)
63% seat belt not anchored tightly
33% harness straps not snug
20% harness straps improperly routed
11% forward-facing before age 1 and 20 lbs
More than 80% of the children under 4 years old killed in car
crashes in California since 1990, would have survived if buckled
properly
When used properly CPS can reduce the risk of fatal injury by
70% for infants, 55% for toddlers, and 59% booster seats

49. Contributing & Protective Factors
Bicycle
Poorly fitted helmets=twice the risk of head
injury in a crash compared with children whose
helmet is properly fitted
Children who wear their helmets tipped back on
their heads have a 52% greater risk of head
injury than those who wear their helmets
centered on their heads.
Bicycle helmets have been shown to reduce the
risk of TBI by as much as 88%

50. Contributing & Protective Factors
Pedestrian
Walking too close to a school bus at drop
off zones
Walking between cars and school busses
Not obeying traffic pedestrian laws
Children <12 not to walk without an adult

51. Contributing & Protective Factors
Seasonal-Summer Months
Childhood injuries increase during summer months
both nationally and in Los Angeles County
51% childhood injuries in Los Angeles County occur
between June-August
72% drowning
56% bicycle
41% pedestrian
38% MVT-occupant

52. Summary
Leading causes of injury fatality &
hospitalizations
Specific pediatric ages at-risk of injury
Contributing & Protective Factors

53. Conclusion
Five Handouts (Injury Prevention Planning
Tools):
1. Behavioral & developmental factors by age
2. Review of anatomic and physiologic factors that
contribute to pediatric injury
3. Pediatric Injury Prevention Project Planning
Worksheet
4. Haddon Matrix sample
5. Haddon Matrix template

54. Preventive Resources
Injury & Violence Prevention Program (IVPP) Website:
www.lapublichealth.org/ivpp
Contact Information:
jdecarli@ladhs.org
(213) 351-7888