Injury Prevention for Young Children: A Research Guide (Bibliographies and Indexes in Medical Studies)

Injury Prevention for Young Children

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Injury Prevention for Young Children A Research Guide Compiled by

BONNIE L. WALKER

Bibliographies and Indexes in Medical Studies, Number 12

Greenwood Press Westport, Connecticut • London

Library of Congress Cataloging-in-Publication Data Walker, Bonnie L. Injury prevention for young children : a research guide / compiled by Bonnie L. Walker. p. cm.—(Bibliographies and indexes in medical studies, ISSN 0896-6591 ; no. 12) Includes bibliographical references and index. ISBN 0-313-29686-3 (alk. paper) 1. Children's accidents—Prevention—Bibliography. 2. Safety education—Bibliography. 3. Children—Wounds and injuries— Bibliography. I. Title. II. Series. [DNLM: 1. Accident Prevention—in infancy & childhood—abstracts. 2. Wounds and Injuries—in infancy & childhood—abstracts. 3. Wounds and Injuries—prevention & control—abstracts. ZWA 250 W177i 1996] Z7164.A17W27 1996 [HV675.72] 016.6136—dc20 DNLM/DLC for Library of Congress 95-46143 British Library Cataloguing in Publication Data is available. Copyright © 1996 by Bonnie L. Walker All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 95-46143 ISBN: 0-313-29686-3 ISSN: 0896-6591 First published in 1996 Greenwood Press, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. Printed in the United States of America

The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48-1984). P Portions of this book were prepared pursuant to the Centers for Disease Control Grant Number 1R43CE00052-01. The statements and conclusions herein are those of Bonnie Walker & Associates, Inc., and do not necessarily reflect the views or policies of the sponsoring agency. In order to keep this title in print and available to the academic community, this edition was produced using digital reprint technology in a relatively short print run. This would not have been attainable using traditional methods. Although the cover has been changed from its original appearance, the text remains the same and all materials and methods used still conform to the highest book-making standards.

To my grandchildren, Derek Mitchell Walker Cope and Amber Nicole Walker

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Contents Preface Acknowledgments 1. 2. 3. 4. 5. 6. 7. 8. 9.

General Injury Prevention Burns and Scalds Child Abuse and Firearms Choking and Asphyxiation Drowning Falls Infectious Diseases and Foodborne Illness Motor Vehicle, Pedestrian, and Riding Toys Accidents Poisoning, Chemical Burns, Bites, and Allergic Reactions

Author Index Subject Index

ix xi 1 43 65 93 99 109 119 133 147 157 169

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Preface

T

he purpose of this literature review is to provide information that could be used to develop an injury prevention training program curriculum for people who care for young children ages 0 to 4 in child care facilities as well as in the community. Unintentional injury is one of the leading causes of death to young children. The most common types of injuries to children under the age of 5 are motor vehicle crashes, drowning, fires and burns, falls, poisoning, and suffocation. Other types of health and safety issues that affect young children are child abuse, infectious diseases, and food poisoning. Understanding each of these problems, their causes, and model prevention techniques can lead child care providers and policymakers to adopt practices that will reduce needless deaths and injuries. The injury areas that are included in this book were identified as a result of a literature search and through discussions with experts in child care and injury prevention. The process of locating the most important and most current research was circular and involved literature searches, discussions of findings, more literature searches, and more discussions. Many references were located from searches of the Expanded Academic Index, ERIC, Medline, and Articleslst. Carol Kennedy from the National Center for Education in Maternal and Child Health and Susan G. Brink, President of HealthMark Associates, provided assistance in locating many of the materials used in this text. Bonnie Walker & Associates, Inc. used its own extensive reference library to locate information about burns and scalds. The National Fire Protection Association provided many items related to that topic from its research collection.

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Injury Prevention for Young Children: A Research Guide

References selected for each section were those which provided information about prevalence, risk factors, specific hazards, and prevention techniques related to that injury area. The articles that were included provided information useful to people who care for young children, who conduct research to better understand how to prevent injuries in young children, or who supervise or train people who care for the young children either in child care or home settings. The first chapter of this book includes references which address injury prevention in general or more than one injury class. Also included in Chapter 1 are curriculum guides and other training materials addressing more than one injury class. The remaining chapters are arranged alphabetically by injury class. A summary of the findings related to each injury prevention topic is presented at the beginning of each chapter. Resource materials such as videos or curriculum guides related to specific topics are included in the related chapters.

Acknowledgments

T

he following individuals assisted the author at various stages of this project in locating and selecting the materials that are included in this book: Betty Adler, National ChildCare Association, Kenneth H. Beck, Ph.D., University of Maryland, Mary Ann Bowie, Child Care Referral Circuit, Inc., Susan G. Brink, Dr.P.H., HealthMark Associates, Annette Ficker, M.D., Children's National Medical Center, Norma Goode, Goode's Family Day Care, Kay Hollestelle, The Children's Foundation, Janet A. Holden, Ph.D., University of Illinois, Lenora McDermott, Crofton Child Care Development Center, Joan Pankey, American Red Cross, Carol Kennedy, National Center for Education in Material and Child Health, Frederick Rivara, M.D., Harborview Injury Prevention and Research Center and University of Washington, Lana Smith, Childtime, Children's Centers, Holly Stilton, Country Day Care, Lynn White, National Child Care Association. The following individuals assisted the author in conducting the research and in editing the text: Lise M. Holliker, Ann Pitcher, Sheryl L. Fischer, Janice Terry, and April L. Walker. The author is especially appreciative of Lise M. Holliker's help in editing many of the entries, locating articles in libraries, and preparing the final manuscript.

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Injury Prevention for Young Children

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1 General Injury Prevention

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nintentional injuries account for a large number of fatalities to children ages 0 to 4 each year. Injury prevention for young children has been the focus of many studies and training programs. In some cases researchers focus on a specific injury class. In others the researchers examine many types of injuries at once. Child abuse, a problem area which includes many other types of injury, has also produced a great deal of interest for researchers. Chapter 1 lists books and articles about the prevalence of major kinds of injuries including incidence among young children, risk factors, prevention research, and the cost of injuries. These publications address injuries across types rather than a single class of injuries. 001

Allshouse, Michael J., Rouse, Thomas, & Eichelberger, Martin R. (June, 1993). Childhood injury: A current perspective. Pediatric Emergency Care, 9(3), 159-164. The authors discuss trends in childhood injury to highlight the need for several types of prevention efforts. Because the majority of childhood injuries are traffic-, fall-, or burn-related, the authors suggest that new standards be set to prevent the known causes of such injuries. Well-known strategies such as wearing bicycle helmets, using safety belts, securing firearms at home, and controlling water heater temperature will also help prevent these major causes of injury. Because childhood injury is different both in type of injury and response to injury than adult injury, the

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Injury Prevention for Young Children: A Research Guide authors suggest that the study of childhood injury patterns will highlight the areas most in need of prevention intervention.

002

Alperstein, Garth, Rappaport, Claire, & Flanigan, Joan M. (September, 1988). Health problems of homeless children in New York City. American Journal of Public Health, 78(9), 12321233. The authors studied outpatient medical records for 265 homeless children ages 5 and under who attended a New York City hospital. These records were compared to children ages 5 and under attending the same hospital who lived at home. Of the homeless subjects, 138 (52%) were black, 93 (35%) Hispanic, 21 (8%) white, 3 (1%) other, and 10 (4%) unknown. A majority (64%) of the children were ages 1 to 4. The proportions of homeless children with higher blood lead levels, reports of child abuse and neglect, hospital admissions, and delayed immunization were higher than those in the comparison groups. The authors suggest that some of the health problems experienced by homeless children may be prevented by adequate health care, b u t acknowledge that other problems may only be remedied by broader political, social, and economic changes.

003

Alwash, R., & McCarthy, M. (June, 1988). Measuring severity of injuries to children from home accidents. Archives of Disease in Childhood, 63(6), 635-638. This British study examined the severity of home injuries to 402 children ages 5 and under in a London hospital. Lacerations, burns and scalds, poisoning, fractures, head injuries, and foreign body injuries were classified as either mild, moderate, or severe based on a scale developed by the authors. Burns and scalds and poisoning caused more severe injuries than other accidents. D e m o g r a p h i c d a t a s h o w e d t h a t c h i l d r e n from lower socioeconomic backgrounds had more accidents, and that the injuries caused by these accidents were more serious. Ethnic background appeared to have no impact on the severity of injuries studied. The authors suggest that a study of injury severity based on a similar scale would help pinpoint prevention efforts at the groups most likely to suffer serious injuries, and at the types of accidents that cause more severe injuries.

004

American Public Health Association, & the American Academy of Pediatrics. (1992). Caring for our children: National health and

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safety performance standards: Guidelines for out-of-home child care programs. Washington, DC: Authors. The American Public Health Association and the American Academy of Pediatrics developed this book to provide standards of child care safety and health for child care programs in the United States. The standards cover staffing, activity and health programs, nutrition and food services, facilities, infectious diseases, children with special needs, and administration. The authors make recommendations for child care licensing and community action. The book also includes several appendices and a glossary of terms used in the book. 005 American Red Cross child care course. (1992). Washington, DC: American Red Cross. This program was developed by the American Red Cross to train child care workers. There are millions of these caregivers in the United States, but most have little or no training. The course includes seven units which are divided into two coursebooks. The coursebook titled Health and Safety Units includes chapters on the prevention of childhood injuries, infant and child first aid, preventing infectious diseases, and caring for ill children, as well as the American Red Cross First Aid Guides. The coursebook titled Child Development Units includes chapters on learning about child development, communicating with children and parents, and recognizing and reporting child abuse. Each chapter includes sample forms, checklists, and resource pages as appendices. 006

American Red Cross, & Handal, Kathleen A. (1992). The American Red Cross first aid and safety handbook Boston, MA: Little, Brown and Company. This book discusses basic emergency procedures, first aid, and injury prevention techniques. Emergency situations are described with detailed instructions for giving emergency care and contacting appropriate medical help. The first aid section describes 30 types of injuries, giving the most common signs and symptoms as well as first aid techniques to help stabilize the condition until medical help is provided. The last section discusses personal and family safety, giving lists of ways that the reader can eliminate home, fire, disaster, outdoor, sports, water, and motor vehicle safety hazards. The book also includes a list of resource organizations and available American Red Cross first aid courses.

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Injury Prevention for Young Children: A Research Guide

007

Aronson, Susan S. (1991). Health & safety in child care. New York: HarperCollins Publishers, Inc. This book is intended as a textbook on the management of health and safety in child care settings for child care professionals and early childhood education students. Topics include promoting general health; nutrition; adult health; the child care facility; riding, walking, and playground safety; indoor safety and preparation for emergencies; infectious diseases; illness; child abuse; and implementing regulations and standards in child care facilities. Appendices include resource materials and sample forms for child care professionals.

008

Aronson, Susan, & Smith, Herberta. (1993). Model child care health policies. Washington, DC: National Association for the Education of Young Children. This book contains sample policies for child care facilities. The policies have been designed to comply with standards from the American Public Health Association and the American Academy of Pediatrics. The material in the book is intended to be modified for compliance with individual facility and state regulations, and should be reviewed annually. Several appendices also provide information on health assessment, illness symptoms and other resources.

009

Baker, Susan P. (1975). Determinants of injury and opportunities for intervention. American Journal of Epidemiology, 101(2), 98102. This article explores the reasons why some groups of people experience more injuries than others. For example, elderly people have a high rate of pedestrian fatalities. This phenomena is not necessarily a direct result of age, but may result from ageassociated decreases in an elderly person's ability to perceive moving cars or respond quickly and appropriately in an emergency. Interventions should be directed at the risk factors of the group of people, rather than at the people themselves. The article discusses four categories of countermeasures: modification of the environment; perceptual aids, training and education; strengthening the individual who would otherwise be injured; and emergency response systems and medical treatment. Modification of the environment has the greatest potential as an effective intervention because it does not rely on human cooperation or behavior to prevent injuries.

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010

Baker, Susan P., O'Neill, Brian, Ginsburg, Marvin J., & Li, Guohua. (1992). The injury fact book. New York: Oxford University Press. This book gives an overview of injury and injury mortality in the United States and discusses the intentional or unintentional nature of these injuries. Categories of injuries include suicide, homicide, sports and recreation injuries, vehicle-related injuries, occupational injuries, falls, firearm-related injuries, fires and burns, drowning, asphyxiation by choking and suffocation, and poisoning. Each category is discussed according to the place of injury, the victims of the injury by age, gender, race, and per capita income, geographic differences, historical trends, and preventive measures.

Oil

Baker, Susan P., & Waller, Anna E. (1989). Childhood injury: State-by-state mortality facts. Baltimore, MD: The Johns Hopkins Injury Prevention Center. The authors compiled child injury mortality data for 1980 to 1985 to determine the numbers of deaths in each state and in the United States as a whole. These data are evaluated by age, race, and gender for 23 common causes of childhood injury. These causes include motor vehicles, air transport, poisoning, falls, house fires, drowning, aspiration, suffocation, firearms, electric current, farm machinery, medicine or surgery, suicide, homicide, and unknown intent. The authors suggest that state-specific data, such as the data in this book, will help state health agencies target the specific injury prevention needs in their area.

012

Bassoff, Betty Z., & The San Diego County Consortium for The California Child Care Health Project. (1991). Injury prevention & response: A manual for child care providers. San Diego, CA: San Diego State University. This book is a curriculum guide designed to provide instructors of day care providers with materials to teach a 3-hour course on injury prevention. The course begins with a description of child care injuries, how injuries happen, and basic injury prevention management, as well as the behavioral and developmental aspects of injury prevention in child care settings. The course material includes a wide range of injury topics, including falls, interpersonal violence, burns and fires, heat exhaustion and heatstroke, choking and suffocation, poisoning, child abuse, traffic and vehicle occupant safety, and drowning. Each topic is discussed with a definition of the problem, a list of

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Injury Prevention for Young Children: A Research Guide prevention interventions, and a discussion of what to do if the injury occurs. The book also includes student handouts and resource pages emphasizing the prevention and emergency techniques described in the course.

013 Bever, David L. (1992). Safety: A personal focus (3rd ed.). St. Louis, Missouri: Mosby-Year Book Inc. This book, which was designed for use as a introductory safety course textbook, discusses how people can protect themselves from injuries and injury hazards. The author defines safety and describes safety measures for many specific areas and types of hazards. The book discusses safety topics related to young children including poisoning, pedestrian accidents, motor vehicle accidents, and falls. 014

Bijur, Polly E., Stewart-Brown, Sarah, & Butler, Neville. (May, 1986). Child behavior and accidental injury in 11,966 preschool children. American Journal of Diseases of Children, 140(5), 487492. The authors studied the social and behavioral characteristics of 11,966 British children age 5 along with mothers' reports of the children's accidental injuries from birth to age 5. Aggressive behavior was positively associated with all accidental injuries, and overactivity was associated with injuries n o t r e q u i r i n g hospitalization. The association between injuries and behavioral factors was found to be stronger that the association between injuries and social factors, including social class and crowding. The authors suggest that intervention aimed at high-risk groups (aggressive a n d / o r overactive children) may be a successful addition to environmental injury prevention interventions.

015

Brink, Susan, Hammond, Maria V., O'Hara, Nancy, & Tortolero, Susan. (1991). Project PEACH. Houston, Texas: University of Texas, Health Science Center. Project PEACH is a self-paced home instructional package consisting of a guide, hazard check sheets, and a 15-minute videotape. The materials guide the user through a family day care home, identifying critical hazards and methods for changing these hazards. The self-instructional guide and hazard check sheets are directed toward owners, operators, and staff of family day care facilities. Arranged as a tour of a house, the materials describe hazards that may be found in each location. Areas discussed include the kitchen, bathroom, and outdoor play areas. The

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hazards described include household items, fans, furniture and rugs, heaters, electrical sockets and cords, fire and poisons, guns, stairs, doors and windows, toys, toy chests and art supplies, cribs and playpens, and outdoor equipment. The videotape shows how family child care providers have identified and dealt with the various hazards discussed in the guidebook. 016

Centers for Disease Control. (June, 1990). Childhood injuries in the United States. American Journal of Diseases of Children, 144(6), 627-646. Among children ages 1 to 19, injuries cause more deaths than all diseases combined and are a leading cause of disability. This article focuses on children ages 0 to 19 and groups them into 5-year age groups that correspond with four developmental stages: preschool (ages 0 to 4), early school (ages 5 to 9), preadolescence and early adolescence (ages 10 to 14), and late adolescence (ages 15 to 19). Emphasizing the injuries most common to each developmental level may help clarify the problem and pinpoint future injury prevention areas toward the groups at highest risk for certain injuries. The article also describes priority areas for injury prevention, including motor vehicle occupant injuries; homicide, assault, and abuse; suicide and suicide attempts; drowning and near-drowning; pedestrian injuries; head injuries; and minority groups.

017

Chang, Albert, Lugg, Marlene M., & Nebedum, Archibald. (February, 1989). Injuries among preschool children enrolled in day-care centers. Pediatrics, 83(2), 272-277. The authors studied 423 injury incidents among preschool children enrolled in Los Angeles, California day care centers. Both gender and age were factors affecting the risk and incidence of injury. The relative risk of injury between boys and girls was 1.5 to 1. Younger boys (ages 2 to 3) had the highest rate of injury, and older girls (ages 4 to 5) had the lowest rate of injury. The majority of the injuries were minor (only 12.8% required medical attention), and most of the incidents occurred from 9 a.m. to 12 p.m. Over half of the injuries (53.7%) involved a consumer product, such as playground equipment, bicycles, chairs, tables, or rope. The authors suggest that three out of four of the injuries could have been prevented, and conclude by providing specific intervention recommendations for the injuries reported in the study.

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Injury Prevention for Young Children: A Research Guide

018

Children's Defense Fund. (1995). The state of America's children yearbook. Washington, DC: Children's Defense Fund. This book is a review of current statistical data on the factors affecting the lives of children in America. Topics include family income, health, child care and early childhood development, hunger and nutrition, violence, housing and homelessness, children and families in crisis, teen pregnancy, and education. The book also includes many tables of national and state data concerning children in the United States.

019

Children's Safety Network. (1991). Children's Safety Network: A data book of child and adolescent injury. Washington, DC: National Center for Education in Maternal and Child Health. This book is an overview of injuries affecting children and adolescents. Childhood injury causes more deaths than all childhood diseases combined, claiming the lives of more than 22,400 children ages 19 and under in the United States during 1988. The leading causes of injury mortality differ among age groups, but in all age groups, males are at higher risk for death from injury than females. The book describes specific data on unintentional injuries, as well as injuries due to violence. Because the rates of specific injuries differ according to age group, prevention interventions should be similarly directed toward the groups at highest risk.

020

Christoffel, Tom. (May, 1989). The role of law in reducing injury. Law, Medicine & Health Care, 17(1), 7-16. This article discusses the recommendations of injury prevention experts from a legal point of view. The three most often recommended strategies to prevent injuries are to persuade persons at risk to alter their behavior for increased self protection, to adopt laws or administrative rules requiring individual behavior change, and to provide automatic protection through improved product design. Opponents of the second strategy (injury prevention laws) propose that the laws don't work to prevent injuries, that such laws pose too much of a restriction on individual liberty, and that the cost of enforcing the laws is too high. These objections should be either validated or refuted by future research. The author suggests that laws can only be an effective means of injury prevention if the general public understands and supports the need for them.

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021

Colver, A. F., Hutchinson, P. J., & Judson, E. C. (October 23, 1982). Promoting children's home safety. British Medical Journal, 285(6349), 1177-1180. This British study compared two methods of teaching people to reduce home safety hazards to determine which strategy would influence behavior to make homes safer. One group of families was told to watch a series of 10-minute safety programs on television. The other group was also told to watch the programs, but also received a home visit prior to the programs which provided safety advice specific to their homes at the time of the visit. Among families with children ages 5 and under in the study area, 55% did not watch any of the television programs. Only 9% of the group who were told to watch the safety programs took any action to remove home safety hazards, compared with 60% of the group who received the home visit. All of the families in the study group were aware of the importance and preventable nature of injuries to young children. The authors suggest that home safety education will most effectively change behavior if delivered in a home visit, where the advice can be customized for the individual hazards in the home.

022

Committee on Trauma Research. (1986). Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press. This book reviews the subject of injury epidemiology, prevention, treatment, and research. The authors illustrate the current magnitude of the injury problem in the United States with results of existing studies, and give specific recommendations for further research. General methods of injury prevention are described, with their specific applications to different types of injuries. The authors also review current funding for injury research and give recommendations for improved administration and funding.

023

Cost of injury in the United States: A report to Congress 1989. (1989). Atlanta, GA: Centers for Disease Control. This report discusses the incidence and cost of injury in the United States. It includes 1985 data on the number and rate of persons injured by gender, age, and class of injury, by cause and class of injury, and by intent and class of injury. It also includes information on injury morbidity and mortality losses by age and gender.

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Injury Prevention for Young Children: A Research Guide

024

Davis, W. S„ & McCarthy, P. L. (April, 1988). Safety in day-care centers. American Journal of Diseases of Children, 142(4), 386. This article outlines a study conducted to determine the safety of day care centers. Researchers made inspections of 60 day care centers. Half of the centers received an in-person educational intervention including site-specific feedback from the initial inspection. The remaining 30 centers received a written curriculum on preschool safety by mail. All 60 centers were reinspected 4 to 6 weeks later. After intervention, the mean total score for the written intervention group increased from 72.2% to 75.4%. In the in-person intervention group, the mean total score increased from 76.5% to 80.1%. The authors suggest that both written and in-person educational interventions are effective ways to improve safety practices in day care settings.

025

Department of Health and Human Services. (April, 1992). Position Papers from The Third National Injury Control Conference. Washington, DC: U. S. Government Printing Office. This book discusses the prevalence and prevention of major injuries in the United States. The topics include motor vehicle injury prevention, prevention of violence and injuries due to violence, home and leisure injury prevention, occupational injury prevention, trauma care systems, acute care treatment, and rehabilitation of people with injuries. Each topic is discussed according to present statistics, future goals, and plans to implement those goals.

026

Dershewitz, Robert A. (January, 1979). Will mothers use free household safety devices? American Journal of Diseases of Children, 133(1), 61-64. The author studied whether free safety devices, with or without additional safety education, would be used to safety-proof homes. An experimental group of 101 families received general health education on home safety proofing. The control group had 104 families. Both groups received two types of safety devices: Kindergards (plastic locking devices for cabinets) and covers for electrical outlets. The families were given identical instructions for use. There was a significant increase in the use of the outlet covers, by the experimental group as compared to the control group but not in the use of the Kindergards. The author suggests that passive interventions, such as products with built-in safety components, may be more effective than those that cause inconvenience or require constant monitoring.

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Dershewitz, Robert A., & Williamson, John W. (December, 1977). Prevention of childhood household injuries: A controlled clinical trial. American Journal of Public Health, 67(12), 1148-1153. The authors used a controlled clinical trial to determine whether an educational intervention program could improve the home safety practices of households with children ages 5 and under. The study population was divided into two groups, one of which received an educational intervention tutorial, safety assignments, and follow-up. Both groups were later evaluated by unannounced in-home assessments for the presence of 11 home safety hazards: cleaning agents, prescription drugs, waxes and polishes, non-prescription drugs, coins, jewelry, watches, or keys, appliances on counter tops, matches exposed, pins and needles, kitchen knives, and hazards on the floor. The mean home safety score for the two groups was almost identical. The authors conclude that the educational program stimulated interest and intentions to improve, but did not actually reduce household hazards. The authors suggest that passive safety measures requiring less behavior modification may be more effective.

028

Durkin, Maureen S., Davidson, Leslie L., Kuhn, Louise, O'Connor, Patricia, & Barlow, Barbara. (April, 1994). Low-income neighborhoods and the risk of severe pediatric injury: A smallarea analysis in northern Manhattan. American Journal of Public Health, 84(4), 587-592. The a u t h o r s investigated the relationship between socioeconomic status and the incidence of severe childhood injury by analyzing data on all injuries to residents ages 17 and under in Northern Manhattan, New York that resulted in hospitalization or death from 1983 to 1991. The average annual incidence of all causes of severe pediatric injury was 72.5 per 10,000 children, and the case-fatality rate was 2.6%. Low-income households, singleparent families, non-high school graduates, and unemployment were found to be significant predictors of risk for both unintentional and intentional injuries. Low income was the single most important socioeconomic predictor of all injuries. Compared with children living in areas with few low-income households, children in areas with predominantly low-income households were more than twice as likely to receive injuries from all causes and 4.5 times as likely to receive assault injuries. The authors conclude that socioeconomic factors have a significant impact on child health, and suggest that future injury prevention efforts target low-income neighborhoods as areas of high risk.

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Injury Prevention for Young Children: A Research Guide

029

Eggert, Russell W., & Parkinson, Michael D. (September 7,1994). Preventive medicine and health system reform: Improving physician education, training, and practice. Journal of the American Medical Association, 272(9), 688-693. This article discusses the issues related to the current need for and shortage of preventive medicine physicians. The leading causes of death in the United States —tobacco, diet and activity patterns, alcohol, diseases, firearms, sexual behavior, motor vehicles, and illicit drugs —can be attacked through preventive medicine and interventions. Current funding, however, tends to focus on high-tech interventions that have less clinical benefit than other interventions that have already been proven effective. The authors recommend that better training of preventive medicine physicians will provide more effective research and intervention in the causes of preventable deaths.

030

Eichelberger, Martin R., Gotschall, Catherine S., Feely, Herta B., Harstad, Paul, & Bowman, Leon M. (June, 1990). Parental attitudes and knowledge of child safety. American Journal of Diseases of Children, 144(6), 714-720. The authors used a national telephone survey to assess parents' attitudes and understanding of child safety. Subjects were 404 parents of children ages 13 and under. When asked about things that might happen to their children, most parents were more worried about kidnapping or drug abuse than about childhood injury. Eighty-severn percent of the parents believed that serious injuries were preventable, and 68% claimed to have acted to reduce the risk of their child being injured. Many of the parents were familiar with prevention methods for automobiles (seatbelts and car seats), but were unfamiliar with the risks and prevention of other types of injuries, including burns, pedestrian injuries, and drowning. The authors suggest that these data emphasize the need for passive prevention measures and for programs to educate parents about childhood injury and safety.

031

Elardo, Richard, Solomons, Hope C, & Snider, Bill C. (January, 1987). An analysis of accidents at a day care center. American Journal of Orthopsychiatry, 57(1), 60-65. The authors studied 1,324 accidents over a 42-month period among 133 children at a university day care center. Toddlers (ages 13 to 24 months) had the highest average number of injuries, most of them self-induced. Falls, collisions, and bites were the major causes of accidents, and a majority of injuries were head injuries.

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Accidents peaked during the morning, which was the busiest activity time at the center. September was the month with the highest accident rate. Despite the frequency of accidents, the injuries were minor, with only four children referred to a physician. The authors compare these data to other similar studies in day care settings. 032

Emerick, Sara J., Foster, Laurence R. & Campbell, Douglas T. (April, 1986). Risk factors for traumatic infant death in Oregon, 1973 to 1982. Pediatrics, 77(4), 518-522. A retrospective study of traumatic infant deaths in Oregon during 1973 to 1982 used vital records and medical examiner records to determine the risk factors associated with traumatic infant deaths. Factors found to be significantly associated with the 146 traumatic deaths (intentional or unintentional) during the study period were low maternal age, out-of-hospital birth, unwed mother, late or no prenatal care, low birth weight, and low maternal education. Race, sex, and birth order were not associated with traumatic infant death. The authors suggest that preventive measures such as car seats, safe cribs, and safety programs be targeted at the infants identified by this study to be at highest risk for trauma.

033

Finn-Stevenson, Matia, & Stevenson, J. John. (March-April, 1990). Child care as a site for injury prevention. Child Today, 19(2), 17-20,32. This article is a general review of the literature on childhood injury prevention, emphasizing the aspects of injury prevention unique to child care settings. The authors also describe Safe Care/Safe Play, a state-based program developed to use family day care as a setting for injury prevention training. The program is targeted at officials who license family day care homes, child care providers, and parents who use child care. The authors suggest that child care environments provide many opportunities for educating and creating awareness of injury prevention.

034

Fisher, Leslie, Harris, Virginia Goddard, VanBuren, John, Quinn, John, & DeMaio, Alison. (September, 1980). Assessment of a pilot child playground injury prevention project in New York State. American Journal of Public Health, 70(9), 1000-1002. The authors assessed the effectiveness of a 1977 New York State child playground equipment injury prevention project. Workshops for 1,500 people involved in the purchase, installation,

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Injury Prevention for Young Children: A Research Guide maintenance, and supervision of public playgrounds explained various hazards and inexpensive ways to correct hazards. The project also included volunteer training and public information. The authors selected 110 playgrounds to survey for hazards before and after the training. The average number of hazards per playground decreased 42% in the year following the project. There were also 22.4% fewer playground-related injuries in the year following the project.

035

Gallagher, Susan S., Finison, Karl, Guyer, Bernard, & Goodenough, Sandra. (December, 1984). The incidence of injuries among 87,000 Massachusetts children and adolescents: Results of the 1980-81 Statewide Childhood Injury Prevention Program Surveillance System. American Journal of Public Health, 74(12), 1340-1347. The authors describe the incidence of fatal and nonfatal injuries occurring in 87,022 Massachusetts children ages 0 to 19 during 1980 to 1981. The rate of injuries varied according to age, gender, cause, and level of severity. Injury rates were lowest for infants and elementary school children, and highest for toddlers and adolescents. Children ages 0 to 5 had the highest rate of falls, poisoning, burns, and foreign body injuries. The overall ratio of male to female rates of injury was 1.66 to 1. Falls, sports, and cutting and piercing instruments had a high incidence and low severity of injuries. Motor vehicles, burns, and drowning had a lower incidence, but greater severity of injuries. For each death from injury, there were 45 hospitalizations and 1,300 emergency room visits. The authors also discuss the implications of these data on injury surveillance systems, injury data gathering, and funding of injury prevention research.

036

Gallagher, Susan S., Guyer, Bernard, Kotelchuck, Milton, Bass, Joel, Love joy, Frederick H., McLoughlin, Elizabeth, & Mehta, Kishor. (October 14, 1982). A strategy for the reduction of childhood injuries in Massachusetts: SCIPP. New England Journal of Medicine, 307(16), 1015-1019. This article describes the Massachusetts Department of Public Health's Statewide Childhood Injury Prevention Program (SCIPP). The program includes a 3-year surveillance of childhood injuries and community-based injury prevention trials. The initial results obtained with the SCIPP surveillance system are presented as base-line epidemiological data, including mortality rates, hospitalizations, and emergency room treatment for unintentional

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injuries. The authors present SCIPP as a model for injury prevention strategies in other states. 037

Gallagher, Susan S., Hunter, Paul, & Guyer, Bernard. (February, 1985). A home injury prevention program for children. Pediatric Clinics of North America, 32(1), 95-112. This article describes the Home Injury Prevention Project (HIPP), which was pilot-tested in two Massachusetts cities during 1981 and 1982. The project was developed to incorporate injury prevention education and technology with the regulatory activities of local health departments. The goal of HIPP was to reduce home hazards related to burns, poisonings, falls, choking, and consumer products. Homes with children ages 6 and under were targeted for inspections. The inspector identified home hazards, gave the parents counseling on ways to eliminate the hazards, and, if necessary, installed or distributed safety devices in the home. None of the homes inspected were found to be free of hazards. At a follow-up visit, there was a significant reduction in the number of household hazards. The authors suggest that the study illustrates the feasibility of using local health departments to include injury prevention in their regular responsibilities, and recommend that health department staff, in addition to medical and home care professionals, become advocates for injury prevention during home inspections and visits.

038

Garbarino, James. (January, 1988). Preventing childhood injury: Developmental and mental health issues. American Journal of Orthopsychiatry, 58(1), 25-45. This article is a comprehensive review of child injury prevention concepts and programs. Based on the results of previous programs and studies, the author suggests developing a program to train and certify community professionals as child safety specialists, and gives recommendations for the methods, targets, and sources of risk to include in the program. The program could be integrated into already-existing training programs for nurses, social workers, early childhood educators, and other professionals dealing with children and child safety issues.

039

Glotzer, Deborah, & Weitzman, Michael. (November, 1991). Childhood injuries: Issues for the family physician. American Family Physician, 44(5), 1705-1716. The authors describe issues related to childhood injuries and injury prevention for family physicians. Nonfatal injuries occur at

16

Injury Prevention for Young Children: A Research Guide least 1,300 times more frequently than fatal injuries. One in every five children every year requires medical attention for an injury. Age, cognitive and motor skills, and environment have a significant influence on the risk of different types of injury for children. Because childhood injury prevention counseling by physicians can be effective in changing the behavior and environment of both parent and child, the authors recommend that family physicians make office-based injury prevention education a prominent part of their practices.

040

Greensher, Joseph, & Mofenson, Howard C. (February, 1985). Injuries at play. Pediatric Clinics of North America, 32(1), 127139. This article discusses the hazards associated with toys, playgrounds, skateboards, and infant walkers. Toy hazards include aspiration or ingestion dangers, burns and electrical shock, catch injuries, explosions and poisonings, lacerations, noise, puncture and piercing injuries, projectile injuries, and strangulation. The authors recommend several appropriate, safe toys for children in five age groups from infants to pre-teenagers. The majority of playground injuries are caused by falls, many of which could be prevented by using resilient, energy-absorbing surfaces under playground equipment, and by teaching safe play habits, some of which are listed in the article. Other play activities, such as skateboarding and using infant walkers, can also be dangerous. The authors give recommendations for precautions and ways to prevent injuries from these activities.

041

Grossman, David C, & Rivara, Frederick P. (June, 1992). Injury control in childhood. Pediatric Clinics of North America, 39(3), 471-485. The authors discuss behavioral and environmental aspects of unintentional and intentional injuries to children and adolescents. Efforts to prevent these injuries through persuasion or education have been less effective than legislative methods. Prevention interventions that have proven most successful, especially for unintentional injuries, have focused on modifying the environment to remove hazards and changing the agents most often associated with injury. The authors suggest that the pediatrician has three crucial roles in injury prevention: clinician, discussing concerns with patients and seeking to modify behavior or environments; investigator, conducting and supporting injury

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prevention research; and advocate, supporting legislative injury prevention initiatives. 042

043

Gunn, Walter J., Pinsky, Paul F., Sacks, Jeffrey J., & Schonberger, Lawrence B. (July, 1991). Injuries and poisonings in out-of-home child care and home care. American Journal of Diseases of Children, U5(7), 779-781. The authors used a national telephone survey to gather data on poisonings and injuries related to out-of-home child care. Of the 171 reported poisonings, none occurred during out-of-home child care. The rate of injury during out-of-home child care was 1.69 per 100,000 child-hours compared with 2.66 for home care (time spent at home). Overall injury rates were slightly higher for children who attended out-of-home child care than for those who did not, which may be because the children who attended out-ofhome child care had a higher injury rate during the time they spent at home than did the children who did not attend out-ofhome child care. The authors suggest that out-of-home child care does not appear to carry an increased risk of injury and, in fact, may confer a lower risk.

Guyer, Bernard, & EUers, Beth. (June, 1990). Childhood injuries in the United States: Mortality, morbidity and cost. American Journal of Diseases of Children, 144(6), 649-652. The authors present national estimates of the mortality, morbidity, and cost of childhood injuries. Motor vehicle-related injuries, homicide, and suicide are the leading causes of childhood injury deaths. Falls and sports-related injuries are the leading causes of hospitalizations and emergency department visits. Unintentional childhood injuries cost the nation approximately $7.5 billion in 1982. The highest direct costs per year for unintentional injuries are attributable to falls, sports, and motor vehicle occupant injuries. Pedestrian injuries, motor vehicle occupant injuries, and drowning were responsible for the majority of indirect costs. The pediatric age group at highest risk for injury mortality is adolescents (ages 15 to 19), among whom injuries account for 78% of total fatalities. The authors suggest that federal, state, and local agencies need a stronger commitment to support and promote research and programming for injury prevention. 044 Guyer, Bernard, Gallagher, Susan S., Chang, Bei-Hung, Azzara, Carey V., Cupples, L. Adrienne, & Colton, Theodore. (November, 1989). Prevention of childhood injuries: Evaluation

18

Injury Prevention for Young Children: A Research Guide of the Statewide Childhood Injury Prevention Program (SCIPP). American Journal of Public Health, 79(11), 1521-1527. The authors evaluated the effectiveness of a communitybased injury prevention program for children ages 0 to 5. The program targeted burns, falls in the home, motor vehicle occupant injuries, poisonings, and suffocations. The authors conducted five concurrent programs in nine Massachusetts areas over a 2-year period. Five sites were matched by demographic characteristics and used as a control group. Interventions included injury counseling for parents of young children, school and community burn prevention education, inspections for household injury hazards by the local board of health, community-wide promotion of poison prevention information, and promotion of automobile restraints. There was a decrease in the number of motor vehicle occupant injuries among children ages 0 to 5 in the intervention communities compared with control communities. Being exposed to the prevention messages was associated with safety behaviors for both burns and poisoning. The authors suggest that future intervention efforts include the active participation of local public health officials, media to increase awareness of the program, and more thorough evaluation.

045

Guyer, Bernard, & Gallagher, Susan S. (February, 1985). An approach to the epidemiology of childhood injuries. Pediatric Clinics of North America, 32(1), 5-15. This article is a review of injury prevention from an epidemiological perspective. Using a framework based on epidemiological data from the Massachusetts Department of Public Health's Statewide Childhood Injury Prevention Program (SCIPP), the authors identify the injury risks to children at various ages. Epidemiological data can be used both evaluate current knowledge about injuries and to target future prevention efforts toward those populations at highest risk.

046

Hall, John R., Reyes, Hernan, M., Meller, Janet L., & Stein, Robert J. (January, 1993). Traumatic death in urban children, revisited. American Journal of Diseases of Children, 147(1), 102107. The authors analyzed the causes of trauma deaths among children ages 16 and under in a large urban community over a 6year period to suggest means of prevention in urban settings. During the 6 years of the study, 3,121 autopsies were performed on children, 36.1% of whom died due to traumatic injuries. Of all

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trauma deaths, fire was the most common cause of death, followed by motor vehicle-related injuries, homicides, drowning, and falls. The authors found improved treatment of trauma injuries followed general trauma centers being established, with further improvement when specific pediatric trauma centers were established. The authors suggest that identifying the causes of pediatric trauma death enables researchers to suggest methods of prevention, and that the centralized care of seriously injured children through the establishment of trauma centers and, specifically, pediatric trauma centers might help to prevent pediatric trauma deaths. 047

Hallgren, Kathryn, & Micik, Sylvia. (1986). Safe kids: An injury prevention program for head start children. San Marcos, CA: North County Health Services. This book is intended to be used as a manual for Head Start, day care and/or preschool teachers and administrators to administer a childhood injury prevention program in their classroom or daycare center. The program is designed to be integrated into existing classroom activities utilizing existing personnel, and includes suggestions for implementing the injury prevention program, conducting safety activities for preschool children and their parents, and methods for evaluating the program. The goal of the program is to reduce the severity and number of injuries to children by teaching children, their parents, and child care personnel how to prevent and treat childhood injuries. While the emphasis of the materials is directed toward Head Start settings, the authors suggest that the program can be used in any setting with preschool children.

048

Holden, Janet A., & Presperin, Celeste, (undated). Safe home Illinois: An environmental health and safety manual for home daycare providers. Chicago, IL: University of Illinois at Chicago, Office of Publication Services. This manual is designed to help day care providers prepare a safe environment and reinforce safe behavior in day care children. The manual discusses hazards in the home including sources of burns, choking, drowning, falls, lead poisoning, and poisoning. Automobile and pedestrian hazards are also discussed. The manual provides information about child development and games and activities that teach safety, as well as listing safety supplies and resources, and emergency and first aid procedures.

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Injury Prevention for Young Children: A Research Guide

049

HoUestelle, Kay (Ed.). (1991). 1991 Day Care Center Licensing Study. Washington, DC: The Children's Foundation. This book contains the results of a nationwide survey of state and territorial regulatory agencies to gather child day care center licensing and regulatory information, listing the results state by state, noting whether the information has been verified or not, and providing the name, address, and phone number of the person contacted in each state.

050

HoUestelle, Kay (Ed.). (1992). 1992 Family Day Care Licensing Study. Washington, DC: The Children's Foundation. This book contains the results of a nationwide survey of state regulatory agencies to update family day care licensing information gathered in 1991. Information on both small and large family day care homes is included. The study reflects the many changes in the regulations in the states as a result of the guidelines for the Child Care and Development Block Grant.

051

HoUestelle, Kay (Ed.). (1993). 1993 Family Day Care Licensing Study. Washington, DC: The Children's Foundation. This book contains the results of an annual nationwide survey of state regulatory agencies to update family day care licensing requirements from the previous year, including information on both small and large family day care homes and a state by state breakdown of family day care regulations.

052

HoUestelle, Kay (Ed.). (1994). 1994 Family Day Care Licensing Study. Washington, DC: The Children's Foundation. This book contains the results of an annual nationwide survey of state regulatory agencies to update family day care licensing requirements from the previous year, including information on both small and large family day care homes and a state by state breakdown of family day care regulations.

053

Holroyd, H. James. (October, 1983). How to prevent accidents. Pediatric Annals, 12(10), 726-731. The author examines the primary prevention of injury, the aspect of childhood injury prevention that is still the most ineffective. The discussion focuses on three aspects: the host or victim, the injury-producing agent, and the hazardous environment. The author recommends that pediatricians put increased emphasis on prevention to protect children and young

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adults from what he describes as the number one preventable disease. 054

Hopkins, Richard S., Writer, James V., Mortensen, B. Kim, & Indian, Robert W. (January, 1990). Childhood injury mortality in Ohio, 1979 to 1986: Setting prio? ties for prevention. American Journal of Diseases of Children, 144(1), 79-82. This study calculated injury mortality rates by gender for three age groups (ages 1 to 5, 6 to 11, and 12 to 16) and three population groups (metropolitan white, metropolitan nonwhite, and nonmetropolitan). Fire was the leading cause of injury mortality for metropolitan children ages 1 to 5, while motor vehicle injuries and drowning were the leading causes of injury deaths for nonmetropolitan children in this age group. Fire was also the leading cause for metropolitan nonwhite children ages 6 to 11, while motor vehicle injuries were the leading cause for nonmetropolitan children, and pedestrian injuries were the leading cause for metropolitan white children. For nonmetropolitan and metropolitan white children ages 12 to 16, motor vehicle injuries were the leading cause, while for metropolitan nonwhite children, homicide was the leading cause. Based on these data, the authors suggest that highest priority for injury prevention should be placed on prevention of motor vehicle deaths in nonmetropolitan and metropolitan white children ages 12 to 16, of fire deaths in metropolitan nonwhite children ages 1 to 11, and of drowning deaths in boys ages 12 to 16 in all three population groups.

055

Hsu, James S. J., & Williams, Scott D. (November, 1991). Injury prevention awareness in an urban Native American population. American Journal of Public Health, 81(11), 1466-1468. Because the injury mortality rate for Native American children ages 1 to 4 is nearly three times that of the general population, the authors surveyed 50 Native American and 100 other families with children ages 1 to 4 to evaluate Native American awareness of injury prevention. Survey results showed that the Native American families were less likely to keep small objects, household products, and medicines out of children's access. The Native American families were also less likely to have and understand the use of ipecac than the other families surveyed. Even though the survey indicated a lack of injury prevention awareness, the authors suggest that the factors contributing to the

22

Injury Prevention for Young Children: A Research Guide higher risk of injuries and injury deaths are more related to Native Americans' low income, rather than cultural or ethnic differences.

056

Hu, Xiaohan, & Wesson, David E. (July-August, 1994). Fatal and non-fatal childhood injuries in Metropolitan Toronto, 1986-1991. Canadian Journal of Public Health, 85(4), 269-273. The authors used hospital and coroner's records to determine the distribution of the cause, rate, and nature of fatal and major non-fatal injuries to children ages 0 to 14 in Metropolitan Toronto from 1986 to 1991. There were 11,024 nonfatal injuries during the 6 years of the study, of which falls were the leading cause (45%). There were also 133 fatal injuries, of which intentional injury (21%) was the leading cause. The nonfatal injury rate dropped 23% from 1986 to 1991. Mortality rates also fell during the study period. Despite the decrease in injury and mortality rates, injuries to motor vehicle occupants and drowning increased considerably. The authors suggest that protecting children in motor vehicles by promoting the use of proper restraints and preventing injuries caused by falls and drowning should be high priorities for childhood injury prevention in Metropolitan Toronto.

057

Hu, Xiaohan, Wesson, David, & Kenney, Brian. (May-June, 1993). Home injuries to children. Canadian Journal of Public Health, 84(3), 155-158. To evaluate childhood injuries in the home, the authors collected information on home injuries to children in the emergency room of a pediatric trauma center. During the 1-year study period, there were 4,195 injured children (ages 18 and under) registered, of whom 1,538 were injured at home. Approximately two-thirds of the injuries to children ages 2 and under occurred at home, a rate much higher than that of older children. Falls were the leading cause of injury at home (51%); other causes included being struck by objects (18%) or sustaining cutting or piercing injuries (9%). Age was positively associated with the likelihood of being struck by objects, cutting or piercing, and overexertion, but negatively associated with falls. Playing was the most common activity at time of injury. Because most of the injuries occurred in a setting that seemed safe to parents, the authors suggest that a reduction in home injuries may require identifying potential hazards in light of the association between different types of injury and children's stages of development.

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058

Kelly, Barbara, Sein, Carmen, & McCarthy, Paul L. (May, 1987). Safety education in a pediatric primary care setting. Pediatrics, 79(5), 818-824. The authors studied parents' knowledge of safety hazards to determine whether a program of age-appropriate safety education could have a positive effect on knowledge of hazards and safety practices. Parents of 171 children at a Connecticut primary care center for their 6-month checkup were divided into an intervention group (n=85) and a control group (n=86). The intervention group was given a three-part individualized course in child safety at the 6-month, 9-month, and 12-month visits. The control group parents received routine safety information. A community health worker conducted follow-up visits at the parents' homes. Of 13 possible h a z a r d s , the mean number of hazards identified by the intervention group was 9.4, compared with 8.4 by the control group. The intervention group also had a lower mean score for hazards observed in the home. The authors suggest that a similar program of age-appropriate safety education that is repetitive, individualized, and requiring active participation by parents can increase parents' safety knowledge and improve some home safety practices.

059

Kendrick, Abby Shapiro, Kaufmann, Roxane, & Messenger, Katherine P. (1991). Healthy young children: A manual for programs. Washington, DC: National Association for the Education of Young Children. This book is a reference and resource guide for owners, operators, and staff of child care facilities to use in planning and developing health and safety p r o g r a m s . The text gives recommendations on keeping health records, teaching health education, creating a healthy and sanitary environment, diapering, and toilet learning. Safety recommendations include choosing safe equipment, keeping children safe inside and outside during winter and summer months, preventing insect stings, and transporting children. First aid procedures, preventive health care, nutrition, and special health issues such as children with special needs, child abuse and neglect, lead poisoning, and chronic health conditions such as allergies and asthma are also included.

060

King, Amy Suzanne. (October 27,1989). Accidents claim 96,000 lives, but rate declining for some types. Journal of the American Medical Association, 262(16), 2195.

24

Injury Prevention for Young Children: A Research Guide The author uses accident statistics from 1988 to describe accident and injury trends in the United States. Nearly half of all accidental deaths during this year occurred during traffic accidents. Home accidents were the second most common, for which the elderly and young children were at highest risk. Nearly 40% of falls resulting in death occurred at home, and more than 50% of these fall deaths involved the elderly (ages 75 and over). Residential fires were responsible for 75% of all burn fatalities. Other common accidental deaths resulted from poisoning, workplace hazards, and drownings.

061

Kraus, Jess F., Fife, Daniel, Cox, Pamela, Ramstein, Karen, & Conroy, Carol. (July, 1986). Incidence, severity, and external causes of pediatric brain injury. American Journal of Diseases of Children, 140(7), 687-693. The authors studied brain injuries causing death or hospitalization among children ages 15 under in San Diego County, California during 1981. The rate of brain injuries was 185 per 100,000 children (235 for boys and 132 for girls). The major causes of injury were falls (35%), recreational activities (29%) and motor vehicle crashes (29%). For every 100 children injured, there were 6 deaths. Of the children admitted to a hospital alive, 88% had a mild brain injury, and 44% had no evidence of losing consciousness. Two-thirds of children with mild brain injuries and one-third of those with serious brain injuries arrived at the hospital in non-emergency vehicles.

062

Landman, Petra Froehlich, & Landman, Gary B. (March, 1987). Accidental injuries in children in day-care centers. American Journal of Diseases of Children, 141(3), 292-293. The authors used a telephone survey of all licensed group day care centers serving children ages 2 to 6 in Maryland to determine the rate, nature, and circumstances of injuries. The centers reported 29 injuries in the previous 5 working days. The authors calculated a total yearly injury rate of 11.30%, which is similar to previous data from a non-day care center study. The authors suggest that this lack of improvement in injury rates in licensed day care should create concern about the regulations governing day care, and recommend that parents and physicians actively participate in the selection and maintenance of quality day care.

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063

Leland, Nancy Lee, Garrard, Judith, & Smith, Diane Klein. (August, 1993). Injuries to preschool-age children in day-care centers. A retrospective record review. American Journal of Diseases of Children, 147(8), 826-831. This retrospective study examined the epidemiologic nature of injuries to children in day-care settings. The authors used injury logs from four suburban day care centers in the upper Midwest to record the number of injuries during a 1-year period. More than 1,000 injuries were reported. Of the 527 children ages 2 to 6 in the study group, 275 experienced one or more injuries during the study period. Injury rates were calculated based on the number of hours spent in day care during the study year. The rate of injury ranged from 6 to 49 injuries per 1,000 children per 8 hours of exposure in a day care center. Most injuries were minor, and none resulted in a fatality or hospital admission. The authors suggest that future research should determine the child's exposure time based on the actual number of hours a child spends in day care, and that exposure time should also be carefully considered in determining product- and location-specific injury data.

064

Malek, Marvin, Chang, Bei-hung, Gallagher, Susan S., & Guyer, Bernard. (September, 1991). The cost of medical care for injuries to children. Annals of Emergency Medicine, 20(9), 997-1005. The authors combined injury incidence data from the Massachusetts Statewide Childhood Injury Prevention Project (SCIPP) with data on charges for medical care to estimate the mean cost of initial medical treatment for a variety of injuries and to project the national cost of initial medical care for injuries to children. The estimated mean cost of initial hospitalization for injury was $5,094, while emergency department (ED) care was $171. The projected national annual cost of injury-related initial medical care for children was $5.1 billion. There was little difference in mean cost between genders; however, mean cost increased with age. The projected initial cost of injuries to teenagers ages 15 to 19 was much higher than that of younger children, which is due to a higher incidence of injuries and a greater mean cost per injury. Because the cost of medical care for injured children, particularly adolescents, is great, the authors recommend that the prevention of childhood injuries should become a higher priority in the United States, and that a national surveillance system for nonfatal injuries should be developed.

26

Injury Prevention for Young Children: A Research Guide

065

Margolis, Lewis H., & Runyan, Carol W. (October, 1983). Accidental policy: An analysis of the problem of unintended injuries of childhood. American Journal of Orthopsychiatry, 53(4), 629-644. The authors provide a method of analyzing strategies to prevent unintentional childhood injury. After alternative strategies for injury prevention have been determined, choosing the preferred strategy is a process that should evaluate the efficiency of the strategy, assess the impact on freedom of choice, and determine the equity (or fairness) of the strategy to all parties involved. The authors use motor vehicle occupant injuries as an example of strategy development and evaluation. According to the criteria for selection described in this article, the authors suggest that the most efficient injury prevention strategies are those that change the agent of injury or environmental hazard, rather than changing the host.

066

Massachusetts Department of Public Health. (1986). Safe daycare. Boston, MA: Massachusetts Department of Public Health. This curriculum guide was developed by the Massachusetts Statewide Comprehensive Injury Prevention Program (SCIPP) for teachers of children ages 2 to 5. The program is intended to help caregivers prevent injuries to preschool children. The book discusses creating a safe day care environment, teaching children about safety, being prepared for emergency situations, and involving parents in the program. Checklists, resources, and references are also included to illustrate and supplement the suggestions and information in the book.

067

McCormick, Marie C , Shapiro, Sam, & Starfield, Barbara H. (February, 1981). Injury and its correlates among 1-year-old children. American Journal of Diseases of Children, 135(2), 159163. The authors studied factors associated with injury during the first year of life. Data were taken from a random sample of infants in eight regions in the United States. By age 1, 8.6% of the 4,989 infants whose parents were surveyed had sustained an injury requiring medical care. Most of the injuries reported were not severe. Achievement of independent mobility, crawling or walking, was a major factor in the risk of injury. Other risk factors included having very young or isolated mothers, but not socioeconomic status, illness in the infant, or low birth weight. The authors suggest that identification of small groups at very high

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risk is not possible, and recommend that health professionals should be prepared to counsel all new parents about injuries. 068

Micik, Sylvia H., & Miclette, Michelle. (February, 1985). Injury prevention in the community: A systems approach. Pediatric Clinics of North America, 32(1), 251-265. The authors describe a systems approach to childhood injury prevention. The program includes five phases. During the analysis phase, the problem is defined, the need to solve the problem is established, and the overall goal of the program is determined. The design phase involves identifying target populations and injuries, collecting additional information, evaluating and selecting strategies, and developing a plan to implement the program. The development phase includes identifying and committing key decision makers in the process, defining roles, revising strategies, establishing protocols, and creating tools. During the implementation phase, the designated agencies and personnel carry out the tools and protocols. The final phase is evaluation, which includes determining the markers to evaluate implementation and outcome, evaluating the overall program, and revising the program. The authors describe the various components of each phase in detail, and suggest that a similar systematic, national program is essential to dealing with childhood injury.

069

National Committee for Injury Prevention and Control. (1989). Injury prevention: Meeting the Challenge. New York: Oxford University Press. This report describes the process and substance of injury prevention, explaining how to plan, implement, and interpret data from injury prevention programs. Several specific injury topics are discussed: traffic injuries, residential injuries, recreational injuries, occupational injuries, violence and injury, assaultive injuries, child abuse, domestic violence, elder abuse, rape and sexual assault, suicide, and firearm injuries. For each of these topics, the authors include statistical data concerning the magnitude of the injury, the cost, at-risk groups and risk factors, currently used interventions, and the committee's recommendations for future research and interventions.

070

National Safety Council. (1992). Accident facts, 1992 edition. Itasca, IL: Author.

28

Injury Prevention for Young Children: A Research Guide This book has tables, charts, and graphs showing the ways people died from accidents in 1991. During this year, the number of accidental deaths (88,000) was the lowest reported in 70 years. Most types of accidental deaths decreased, except firearm injuries (+8%) and poisoning (+2%). The book classifies accidents by type, age, state, month, and other variables. Major classifications include all accidents, work accidents, occupational health, motor vehicle accidents, public accidents, home accidents, farm resident accidents, and environmental health. Information on the types and numbers of accidental deaths are reported in this publication. Deaths and death rates are presented by age and gender.

071

National Safety Council. (1993). Accident facts, 1993 edition. Itasca, IL: Author. This book contains statistics on deaths caused by accidents in 1992 by age, state, type, and other variables. The total number of accidental deaths (83,000) was the lowest reported since 1922. Motor vehicle accidents were responsible for nearly 50% of all accidental deaths.

072

National Safety Council. (1994). Accident facts, 1994 edition. Itasca, IL: Author. This book contains statistics on deaths caused by unintentional injuries in 1993 by age, state, type, and other variables. During this year, the number of unintentional injury deaths and the population death rate increased for the first time in five years. Motor vehicle injury deaths increased 3%, home injury deaths increased 7%, and public injury deaths increased 8%.

073

O'Connor, Mary Ann, Boyle, William E., Jr., O'Connor, Gerald T., & Letellier, Robert. (January-February, 1992). Self-reported safety practices in child care facilities. American Journal of Preventive Medicine, 8(1), 14-18. The authors conducted a telephone survey to determine the prevalence of safety hazards and current injury prevention practices in child care settings. Of the 130 facilities who responded, 26.8% of those who knew the temperature of their tap water stated that it was over 130°F; 14.1% had space heaters within a child's access; 30.3% of those with stairs accessible to children lacked safety gates; 61.4% of those with playgrounds did not have impactabsorbing surfaces under playground equipment; 16.9% had an unexpired bottle of ipecac; 55.8% had a poison control number available to them; 80% had a telephone number for the local

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ambulance. The authors suggest that potential and remedial injury hazards exist in some licensed child care centers and recommend that providers of child care within licensed facilities be targeted for childhood injury prevention interventions. 074

Ohio Department of Health, & Ohio Department of Human Services. (1993). Health and safety in family day care: An introductory course for family day care providers. Arlington, VA: National Center for Education in Maternal and Child Health. This training package was designed for family day care providers and other providers of group care for infants, toddlers, and preschool children in home settings. The six 1-hour modules are divided into three volumes. Volume One addresses communicable diseases, first aid, and home safety. Volume Two includes modules on nutrition and food safety. Volume Three addresses managing child behavior. Each module contains a trainer guide, class handouts, in-class activities, audiovisuals (including videotapes, slides, and an audiotape), and evaluation forms. The materials were originally developed to comply with Ohio day care regulations, but have been adapted in this printing to be used in other areas as well.

075

Pascoe, Delmer J., & Rodriguez, Juan G. (1988). Accidents and accident prevention. In Delmer J. Pascoe, & Moses Grossman, Quick reference to pediatric emergencies (pp. 61-66). Philadelphia, PA: J. B. Lippincott Company. This chapter reviews technical information about accidents and accident prevention. Accidents are the leading cause of death in the pediatric age group and cause more childhood deaths than the next five major causes of death combined. The leading causes and types of injuries discussed include bicycles, burns, cribs, electrical injuries, mouth burns from electrical cords, electrocution, falls, firearms, homicide, lightning, motor vehicle and pedestrian accidents, suffocation, and zipper injuries.

076

Pearn, J. H. (December, 1985). Current controversies in child accident prevention. An analysis of some areas of dispute in the prevention of child trauma. Australia and New Zealand Journal of Medicine, 15(6), 782-787. The author describes five controversial areas of injury prevention to illustrate the conflicts that often arise in injury prevention work: the inevitability of accidents, personal freedom of adults vs. safe environments for children, the effectiveness of

30

Injury Prevention for Young Children: A Research Guide "drown-proofing" infants, sports and recreation injuries among children, and the absence of reliable data on exposure to risk. The author discusses each topic and uses data from related studies to describe the problems inherent in each controversy.

077

Playground-related injuries in preschool-aged children—United States, 1983-1987. (1988). Morbidity and Mortality Weekly Report, 37(41), 629-632. From 1983 to 1987, nearly 6.72 million emergency room visits in the United States were caused by product-related injuries among preschool children ages 1 to 4. Approximately 305,000 of these injuries involved playground equipment. These playground equipment-related injuries occurred most frequently at home, in sports or recreation settings, or at school. Of the 82,108 injuries in preschool-aged children attending day care, 27,232 were related to playground equipment.

078

Pless, I. Barry, & Stulginskas, Joan. (1982). Accidents and violence as a cause of morbidity and mortality in childhood. Advances in Pediatrics, 29,471-495. This article is a review of trends and research data concerning childhood injuries and injury prevention with an emphasis on the pediatrician's role in prevention efforts. Specific injuries discussed include poisoning, falls, drowning, burns, motor vehicles, homicide, and suicide. Examples of successful injury prevention programs, both educational and legislative, illustrate the various theoretical and practical methods of injury prevention. The authors suggest that pediatricians become both advocates for legislative methods of injury prevention and counselors of both patients and parents.

079

Public Health Division. (1989). Safe daycare. Santa Fe, NM: New Mexico Department of Health. This curriculum guide contains materials originally prepared by the Massachusetts Statewide Comprehensive Injury Prevention Program (SCIPP). The recommendations and guidelines were modified to comply with New Mexico day care licensing and operating regulations. Information pertaining to New Mexico, including state resources and injury statistics, was also added.

080

Rice, Dorothy P., MacKenzie, Ellen J., & Associates. (1989). Cost of injury in the United States: A report to Congress 1989. San

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Francisco, CA: Institute for Health & Aging, University of California and Injury Prevention Center, The Johns Hopkins University. This book evaluates the impact of injury on individuals, government programs, and society at large, including both the economic cost and the effects of injury. The authors use comprehensive data on incidence, cause, severity, lifetime cost, and life year and productivity losses from leading causes injury to provide the foundation for recommendations concerning future injury prevention research and funding. The leading causes of injury include motor vehicles, falls, firearms, poisonings, fires and burns, drownings and near-drownings. 081

Rivara, Frederick P., Bergman, Abraham B., LoGerfo, James P., & Weiss, Noel S. (June, 1982). Epidemiology of childhood injuries: II. Sex differences in injury rates. American Journal of Diseases of Children, 136(6), 502-506. The authors explored gender differences in children's injury rates by using data from 197,561 consumer product-related injuries to children ages 18 and under over a 1-year period. The children were grouped into developmental categories: infants ages 1 and under, 1 to 2, 3 to 6, 7 to 12, and 13 to 18. Gender differences appeared during the first year of life for most injuries. Exceptions included burns, ingestions, and poisonings. Among children ages 2 and over, males had a significantly higher rate of injury than females, a difference that became more pronounced with increasing age. Some of these gender differences may be due to different levels of exposure to risk, gender differences in motor skills, or differences in behavior. The authors suggest that injury prevention efforts should recognize the higher risk of injury among males and explore ways to discourage risk-taking behavior.

082

Rivara, Frederick P., Calonge, Ned, & Thompson, Robert S. (August, 1989). Population-based study of unintentional injury incidence and impact during childhood. American Journal of Public Health, 79(8), 990-994. This prospective study evaluated medically-treated unintentional injuries among 8,603 children ages 19 and under over a 1-year period. The overall rate of medically-treated injuries was 247 per 1,000, Of those injuries, 147 per 1,000 were treated in the clinic, and 100 per 1,000 were treated in the emergency room. Overall, 2.5% of patients were hospitalized. The highest rates of injury were for falls (60 per 1,000), recreational activities (57 per

32

Injury Prevention for Young Children: A Research Guide 1,000) and competitive sports (49 per 1,000). Sprains and strains, fractures, and injuries due to play and sports were most often treated in the clinic. Overall, 55.9% of injuries resulting in restricted activity, 10.6% resulted in 2 or more missed school days, and 6.7% resulted in 2 or more days spent in bed. The authors suggest that a large proportion of childhood injuries requiring medical attention are treated in clinic settings, and recommend that both clinic and emergency room settings be targeted as sites for injury prevention programs.

083

Rivara, Frederick P., DiGuiseppi, Carolyn, Thompson, Robert S., & Calonge, Ned. (December, 1989). Risk of injury to children less than 5 years of age in day care versus home care settings. Pediatrics, 84(6), 1011-1016. The authors conducted a population-based study to asses the incidence of injuries in day care and home care according to the level of exposure to each environment. The rate of injuries in day care was 2.50 per 100,000 child-hours of exposure compared with a rate of 4.88 per 100,000 child-hours of exposure at home. There were no differences in overall severity of injuries in the two groups. The authors conclude that children are at no greater risk of injury in day care than at home.

084

Rivara, Frederick P. (March, 1985). Traumatic deaths of children in the United States: Currently available prevention strategies. Pediatrics, 75(3), 456-462. The author discusses the causes of traumatic deaths of children ages 14 and under in the United States. Specific injury categories include motor vehicle injuries, poisoning, drowning, fire and flames, firearms, choking or suffocation, and falls. The author suggests that if 12 currently available prevention strategies were implemented for these injuries, childhood injury deaths could be reduced by 29% in the United States. Injuries for which there are few effective strategies include pedestrian injuries, injuries to older children in motor vehicles, and drowning. The author suggests that the prevention strategies suggested in this article are realistic goals for the medical community, and that future research should focus on finding new solutions to injury prevention problems.

085

Rivara, Frederick P. (May, 1982). Epidemiology of childhood injuries. American Journal of Diseases of Children, 136(5), 399-405. The author reviews the literature on childhood injury and uses the data to explain a conceptual framework for injury

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prevention. This framework has two phases: pre-event, the elements leading u p to the injury; and event, the elements of what actually happens when the injury occurs. Each phase is then analyzed according to the h u m a n factors, vectors, physical environment, and sociocultural environment. The author concludes with questions and recommendations to be answered and met by future research. 086

Robertson, Leon S. (1992). Injury Epidemiology. New York: NY: Oxford University Press. The author discusses epidemiological methods for studying injuries and evaluating prevention interventions, suggesting that the nature of research questions and research methods may be the key to conducting accurate epidemiology research. Injury prevention programs can be improved with the help of relatively simple descriptive studies, but some necessary elements can only be evaluated by more sophisticated analysis. The book describes m e t h o d s of injury surveillance, epidemiological analysis, determining behavioral factors and interventions, researching laws concerning behavior, and other issues related to injury epidemiology and data analysis.

087

Robertson, Leon S. (August, 1994). Child injury control: Surveillance and research questions. American Journal of the Medical Sciences, 308(2), 88-91. The author describes research objectives and priorities for the goal of child injury prevention. By asking the question, "What do we need to know to control injuries?" the author suggests several objectives for future research: 1. Select the most important injuries for study or detailed surveillance, 2. Apply known countermeasures efficiently, 3. Find changeable factors that will reduce injury and quantify the reduction expected, 4. Develop causal models of subsets of injury, 5. Evaluate the effectiveness of an intervention, and 6. Evaluate the cost-effectiveness of alternative interventions. The author concludes by recommending that injury prevention be placed on a higher priority by both the public and the research community.

088

Roybal, Charlotte. (1993). New Mexico, 1993: Injury. Santa Fe, NM: New Mexico Department of Health. This publication discusses injury categories as they relate to different age groups in New Mexico, and gives prevention techniques for each. Topics include falls, motor vehicle crashes,

34

Injury Prevention for Young Children: A Research Guide poisoning, and drowning, and intentional injuries like homicide, assault, abuse, and suicide, traumatic brain and spinal cord injuries, problem use of alcohol, and firearm injuries. Each topic is described with current statistical data on prevalence, risk factors, and costs incurred for each type of injury. The author also gives prevention recommendations for each type of injury.

089

Runyan, Carol W0, Gray, Diana E., Kotch, Jonathan B., & Kreuter, Matthew W. (August, 1991). Analysis of U. S. child care safety regulations. American Journal of Public Health, 81(8), 981-985. The authors assessed child care safety regulations from 45 states to determine whether the content included 36 selected injury-related criteria. Only five of the criteria were met by at least half of the states studied, and 15 of the 36 items were not mentioned by half or more of the states. For 24 of the 36 items, more than half of the states were below or did not mention the criteria. The most important areas neglected were playground safety, choking hazards, and firearms. The authors suggest that the uneven coverage of these regulations may be due to the nature of the regulatory process, where many different agencies share authority and the involvement of injury prevention specialists is minimal.

090

Runyan, Carol W., Kotch, Jonathan B., Margolis, Lewis H., & Buescher, Paul A. (December, 1985). Childhood injuries in North Carolina: A statewide analysis of hospitalizations and deaths. American Journal of Public Health, 75(12), 1429-1432. The authors studied injury-related hospitalizations and deaths of children ages 0 to 19 in North Carolina during 1980. The overall annual rate of injury-related hospitalizations was computed at 80 per 10,000. Children ages 15 to 19 had the highest rate of hospitalizations (119.4), followed by ages 0 to 4 (71.7), 10 to 14 (64.5), and 5 to 9 (56.0). The nature and cause of injuries also varied by age. The authors suggest that the similarity of this study's results compared to previous studies further confirms the importance of injury as a source of childhood morbidity and mortality.

091

Seattle-King County Department of Public Health. (1991). Child care health handbook. Seattle, WA: Author. This handbook was developed to provide information about child health, illness, and behavior to child care providers and staff. The guidelines described in the book are intended to comply with

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Washington State day care regulations. The topics discussed range from preventing injuries and illnesses to the health of child care providers. The book contains specific information about what to do for certain health and emergency situations, and includes listings of community and other resources for child care providers. 092

Sibert, J. R., Maddocks, G. B., & Brown, B. M. (1981). Childhood accidents —An endemic of epidemic proportions. Archives of Disease in Childhood, 56(3), 225-227. This British study used data on children who were taken to the hospital during a 6-month period. Nearly 10,000 children who lived in the study area were seen at the hospital. According to the authors, this indicates that 20% of children each year might be expected to go to the hospital after an accident. The majority (71%) of children needed only simple investigation, treatment, or reassurance, followed by outpatient surgery (23%). Falls were the most common cause of injury, responsible for 35% of the injuries. The authors recommend that special attention be given both to preventing and treating childhood injury.

093

Tatum, Pam S. (January, 1994). Promoting wellness: A nutrition, health and safety manual for family child care providers. Atlanta, G A: Save the Children Child Care Support Center. This manual contains guidelines for family child care providers to use in developing a health policy. The main focus of the materials is nutrition, but other topics covered include tips on purchasing, storing, preparing, and serving food safely, immunizations, exercise, dental health, lead poisoning, and the safe and proper use of car seats. The book also includes recipes for healthy meals and a health and safety checklist providers can use to check their family child care home for safety.

094

Taylor, B., Wadsworth, J., & Butler, N. R. (1983). Teenage mothering, admission to hospital, and accidents during the first 5 years. Archives of Disease in Childhood, 58(1), 6-11. The authors compared 1,031 children of teenage mothers to 10,950 children of older mothers in a national longitudinal cohort study. The children who were born to teenage mothers and who lived with them up to age 5 were more likely to have hospital admissions, especially after accidents and for gastroenteritis, than children born to and living with older mothers. Frequent accidents, poisonings, burns, and superficial injuries or lacerations were more often reported by teenage mothers. Even after

36

Injury Prevention for Young Children: A Research Guide controlling for social and biological factors, the authors found that the association of teenage mothers with greater a likelihood that children would have accidents or be hospitalized remained highly significant. The authors suggest that children of teenage mothers are not only at higher risk for socioeconomic disadvantages, but also for injuries or hospitalization.

095

Teret, Stephen P., & Jacobs, Michael. (1989). Prevention and torts: The role of litigation in injury control. Law, Medicine & Health Care, 17(1), 17-22. This article describes the legal aspects of injury control, especially those concerning product liability. Unfortunately, the product liability lawsuits (torts) that receive the most attention are not those which serve this purpose, and the negative publicity has led some to seek stricter regulation of these lawsuits. The authors suggest that if manufacturers and retailers are held financially responsible for unsafe products, there will be an incentive for them to participate in injury prevention. This concept may also applied to medical malpractice.

096

Teutsch, Steven M. (March 27,1992). A framework for assessing the effectiveness of disease and injury prevention. Morbidity and Mortality Weekly Report, 41 (RR-3), 1-12. This report gives an overview of a method used to evaluate disease and injury prevention programs. Any assessment of prevention programs should identify the effectiveness of the strategies used, determine the potential and practical consequences of those strategies, evaluate the economic impact of the program, determine the best way to implement the program, and evaluate the impact of the program.

097

Thacker, Stephen B., Addiss, David G., Goodman, Richard A., Holloway, Barbara R., & Spencer, Harrison C. (October 7,1992). Infectious diseases and injuries in child day care: Opportunities for healthier children. Journal of the American Medical Association, 268(13), 1720-1726. The authors reviewed current literature to provide background information on infectious diseases and injuries in child day care and to outline measures to address these health care needs. Compared to children ages 5 and under in home care, some children in day care were at a two to four times higher risk of some infectious diseases. In contrast, the children in day care settings appeared to have a lower risk of unintentional and intentional

General Injury Prevention 37 injuries than children at home. The authors suggest that because children are spending more and more time in structured day care, child day care is an ideal setting to enhance child development, create safer environments, provide better nutrition, increase vaccination coverage, and facilitate health promotion efforts. 098

The report of the lieutenant governor's trauma and injury prevention (TIP) task force for Wisconsin's children. (1990). Madison, WI: Wisconsin Department of Health and Social Services. This report is the result of meetings conducted by a 16member panel to assess the impact of injuries and injury deaths on children in Wisconsin. The panel made general injury prevention recommendations, which included continuing injury prevention programs on a permanent basis, providing additional funding, collecting new data, training professionals and the public, improving emergency medical services, and giving research attention to disabled and high-risk children. The panel also made 84 injury-specific recommendations addressing education, environment modification, and legislative efforts to prevent each type of injury.

099

U. S. Consumer Product Safety Commission. (February, 1988). The safe nursery: A booklet to help avoid injuries from nursery furniture and equipment. Washington, DC: U. S. Government Printing Office. This booklet outlines the major hazards associated with nursery furniture, including cribs and crib toys, gates and enclosures, high chairs, playpens, rattles and other toys, toy chests, and walkers. The book also includes safety tips for buying and using nursery furniture and toys.

100

U. S. Preventive Services Task Force. (July, 1990). Counseling to prevent household and environmental injuries. American Family Physician, 42(1), 135-142. This article discusses the effectiveness of physician counseling on the prevention of injuries. The authors suggest, even though there is no conclusive evidence of effectiveness, that physicians should counsel their patients about injury prevention because of the cost and suffering burden that injuries produce. Alcohol and drug use is a proven risk factor for injuries, so physicians should counsel their patients to avoid high-risk activities while intoxicated. The incidence of injuries such as falls,

38

Injury Prevention for Young Children: A Research Guide bicycle injuries, drowning, fires and burns, poisoning, and firearm injuries may also be reduced as a result of physician counseling, especially with patients in high-risk groups.

101

Viano, David C. (July-August, 1990). A blueprint for injury control in the United States. Public Health Reports, 105(4), 329333. The author describes a National Academy of Sciences' review of a Centers for Disease Control injury control program, which applauded the success of the program and made several recommendations for future programs. These recommendations include organizing the effort into an institute, seeking appropriate funding for further research, balancing the five areas of injury control (epidemiology, prevention, biomechanics, acute care, and rehabilitation), continuing the evaluation of existing programs, and establishing an advisory council to create a blueprint for future injury control programs based on the Centers for Disease Control model.

102

Wallace, Helen M., Nelson, Richard P., & Sweeney, Patrick J. (Eds.). (1994). Maternal and child health practices. Oakland, CA: Third Party Publishing Company. This book is a collection of articles which discuss a wide range of maternal and child health issues. The first section provides background information on legislative, health care, and socioeconomic issues related to women and children. The second section discusses the issues related to delivery of maternal and child health services. The following sections discuss maternal and child health at various stages of development, children with special needs, and children around the world. An appendix includes a listing of maternal and child health-related objectives for the year 2000.

103

Waller, Anna E., Baker, Susan P., & Szocka, Andrew. (March, 1989). Childhood injury deaths: National analysis and geographic variations. American Journal of Public Health, 79(3), 310-315. The authors used National Center for Health Statistics data to analyze 23 causes of injury mortality in children ages 0 to 14 in the United States by age, race, sex, and state of residence for the years 1980 to 1985. Motor vehicles caused 37% of all injury-related deaths and were the leading cause of injury mortality in every group except children ages 1 and under, for whom homicide was

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the leading cause of death. Death rates for males were four times female rates for suicide, unintentional firearm injuries, and injuries related to farm machinery or motorcycles. The drowning rate among whites was almost twice that of blacks ages 1 to 4, but for those ages 10 to 14, the drowning rate for blacks was over three times higher than whites. The highest injury death rates were in the mountain states and the south. The authors suggest that identifying the specific injury problems among certain geographic areas and population groups will help target injury prevention programs at these areas and groups, which will eventually lead to a reduction in injuries. 104

Waller, Julian A. (February, 1987). Injury as disease. Accident Analysis and Prevention, 19(1), 13-20. The author discusses the disease concept of injury as it relates to prevention measures, explaining the theory's advantages and limitations, and applying the theory to alcohol-related injuries. Viewing injury as a disease emphasizes the external sources of energy causing the injury, rather than the victim's behavior. For instance, disease-based methods of preventing motor vehicle crashes would be improvements in roads and motor vehicles that would decrease the environmental risk of crashing and subsequent injury. Traditional prevention methods would include education for drivers that emphasized safe driving practices. The author suggests that neither theory of prevention can be used exclusively; instead, prevention interventions should be selected based on which methods are not only theoretically sound, but are also effective and practical. Viewing injury as a disease can allow public health professionals the option to apply environmental interventions that may be more effective and less costly to society than behavioral methods. The author illustrates his argument by discussing the relationship of alcohol to injury, and the ways in which both behavioral and environmental interventions may be applied to prevent alcohol-related injuries and deaths.

105

Waller, Julian A. (1985). Injury control: A guide to the causes and prevention of trauma. Lexington, MA: D. C. Heath and Company. This book describes the three phases of injury (pre-injury, injury, and post-injury) and the pathways of injury: kinetic energy, thermal energy, chemical energy, electrical energy, and ionizing radiation. The book also describes specific injury events such as motor vehicle, bicycle, and pedestrian events; injuries at home; burns; scalds; hypothermia; falls, and poisoning. Construction

40

Injury Prevention for Young Children: A Research Guide features and tools for living such as stairs, doors, windows, tubs and showers, furnishings, appliances, and housewares can play a part in injury events. The book also describes high-risk populations such as children, youths, and the elderly, as well as several injury settings: hospitals, nursing homes, the workplace, and recreational areas.

106 Wasserman, R. C , Dameron, D. O., Brozicevic, M. M. & Aronson, R. A. (April, 1987). Injury hazards in home day care. American Journal of Diseases of Children, 141(4), 383. This abstract discusses the findings of a study to assess injury hazards in day care homes (DCHs). A total of 109 DCHs were inspected using a home safety checklist that rated 25 indoor hazards and 21 playground hazards. The authors found that 11% of DCHs had no smoke detector, 12% had no fire extinguisher, 33% had no syrup of ipecac, 51% had unlocked accessible cabinets containing dangerous materials, 51% had unprotected stairways, and 62% had tap water hotter than 130°F. The DCHs that were owned (vs. rented) or had higher-educated operators h a d significantly safer scores. The authors conclude that operators of DCHs need increased education and perhaps increased regulation to decrease hazards in DCHs. 107 Weesner, Carol L., Hargarten, Stephen W., Aprahamian, Charles, & Nelson, David R. (February, 1994). Fatal childhood injury patterns in an urban setting. Annals of Emergency Medicine, 23(2), 231-236. The authors conducted a retrospective chart review of medical examiner files, prehospital and hospital records, and police and fire personnel reports to describe patterns of fatal injuries in an urban county. There were 70 children ages 15 and under who sustained a fatal injury during 1989 or 1990 in the study area. House fires were the leading cause of death by injury (34%), followed by firearms (19%), drowning (11%), and motor vehicle injuries (7%). One-third of deaths were homicides (48% firearms, 30% assault). Twenty-four percent of deaths were pronounced at the scene, 12% were dead-on-arrival (no emergency department resuscitative efforts), and 37% were dead-on-arrival with emergency department resuscitations. Only 27% of victims survived to become inpatients, and 84% of these patients died within 72 hours. The authors conclude that fatal childhood injury patterns in this urban setting differed from reported national injury patterns. This study found a higher percentage of deaths

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from fire, gunshot wounds, and homicides, but a lower percentage of motor vehicle-related deaths. The authors suggest that prevention strategies should address the injury patterns of a particular community. 108

Widome, Mark D. (October, 1983). Occasional but serious accidents. Pediatric Annals, 12(10), 761-768. The author reviews a few of the less prevalent hazards that cause injury to children, emphasizing those recently reported in pediatric literature, including fireworks, air rifles, button batteries, hot tubs and whirlpool spas, domestic pets, electric garage door openers, and toy chests.

109

Wilson, Modena Hoover, Baker, Susan P., Teret, Stephen P., Shock, Susan, & Garbarino, James. (1991). Saving children: A guide to injury prevention. New York: Oxford University Press. This book discusses different types of injuries according to the environment in which the injury occurs: roadway, home, or school and recreation. The authors describe the effects of injury on different age groups: infants, toddlers, preschoolers, elementary school children, and young adolescents. The authors also make recommendations to different professionals concerning the possible contribution of each to prevent injury: schools and child care centers, health care providers, public agencies, legislators and regulators, law enforcement professionals, voluntary organizations, designers, architects, builders and engineers, business and industry, and the mass media. An appendix lists organizations that provide general information about childhood injury prevention.

110

Wisconsin Comprehensive Child Injury Prevention Project. (1988). Safe daycare: A teacher's guide for creating safe and healthy learning environments for preschool children. Madison, WI: Wisconsin Department of Health and Social Services. This book contains materials originally prepared by the Massachusetts Statewide Comprehensive Injury Prevention Program (SCIPP). The recommendations and guidelines were modified to comply with Wisconsin day care licensing and operating regulations. Information pertaining to Wisconsin, including state resources and injury statistics, was also added.

42

Injury Prevention for Young Children: A. Research Guide

111

Wols, Matthew, & Strange, Gary R. (March, 1993). Pediatric injury prevention annotated bibliography. Annals of Emergency Medicine, 22(3), 547-552. The authors provide a brief annotated bibliography of general articles related to pediatric injury prevention.

112

Yamamoto, Loren G., Wiebe, Robert A., & Matthews, Wallace J., Jr. (October, 1991). A one-year prospective ED cohort of pediatric trauma. Pediatric Emergency Care, 7(5), 267-274. The authors collected data on 4,623 pediatric patients visiting an emergency department with injuries (excluding burns) during a 12-month period. A majority of the patients (61%) were male. Common causes of injury included suspected child abuse (4%), organized sports (6%), nonorganized sports (4%), pedestrian motor vehicle accidents (MVAs) (3%), bicycle MVAs (2%), and automobile MVAs (3%). Incidents took place at home (41%), on the street (11%), at school (10%), and at a playground or park (10%). Injuries involved the external body (59%), extremity (26%), head or neck (13%), face (4%), chest (1%), and abdomen (2%) and were more common during the summer. Factors associated the most severe injuries included MVAs, water-related injuries, sports, streets, schools, parks, playgrounds, skateboards, skates, and alcohol. The authors suggest that the diverse nature of injury morbidity and mortality requires diverse prevention intervention strategies, and recommend a combined legislative, educational, and public effort to reduce childhood injuries.

113

Zuckerman, Barry S., & Duby, John C. (February, 1985). Developmental approach to injury prevention. Pediatric Clinics of North America, 32(1), 17-29. In this article the authors suggest how three components of children's behavior might contribute individually or in combination to the occurrence of an injury. The components are temperament, the "how" of behavior; motivation, the "why" of behavior; and competencies, the "what" of behavior. Each of these components are examined in light of the progressive development of children from infants to adolescents. The authors suggest that this information provides a framework for clinicians to individualize injury prevention counseling to patients and their parents and a set of goals for future research.

2

Burns and Scalds

F

ire and burn injuries are a leading cause of accidental death for young children ages 0 to 4. The majority of these deaths occur in house fires. Other causes of burn injuries are hot water scalds, contact burns from appliances, and mouth burns from hot foods. The articles in this chapter present information regarding prevalence of injuries in this category as well as prevalence of burns related to specific hazards. Many articles discuss fire safety issues. Articles and publications are also included that address injury prevention issues. 114

Banco, Leonard, Lapidus, Garry, Zavoski, Robert, & Braddock, Mary. (April, 1994). Burn injuries among children in an urban emergency department. Pediatric Emergency Care, 10(2), 98-101. The authors reviewed medical records of children under 18 who received emergency department treatment for burns during a 1-year period to determine the profile of burn injury among an ambulatory population. Of the 109 visits, contact burns were the most common (43.1%), followed by scalds (33.9%), flame or explosion (11.0%), cigarettes (5.5%) and electrical (2.8%). For children under age 11, contact burns caused over half of all burns. Irons accounted for 44.7% of contact burns and 19.1% of all burns. The next most frequent causes were beverages (14.7%), food (7.3%), tap or bath water (7.3%), and cooking (6.4%). Contact burns were more likely to be smaller and more localized than other burns. The causes and agents of injury for burns differed in frequency and relative importance according to the population

44

Injury Prevention for Young Children: A Research Guide studied and the level of medical care being provided. The authors suggest that specific burn prevention strategies should be directed toward particular patterns of injury within established at-risk populations.

115

Baptiste, Mark S., & Feck, Gerald. (July, 1980). Preventing tap water burns. American Journal of Public Health, 70(7), 727-729. Based on a 1974 to 1975 survey of hospital records in upstate New York, the authors estimate that 347 tap water burns will require inpatient treatment annually, with children and the elderly at the highest risk. The number and severity of burns from tap water makes this type of accident an important prevention priority. Reducing the temperature of household hot water supplies could be a practical and effective prevention measure.

116

Burn prevention and treatment tips. (March, 1992). American Family Physician, 45(5), 1331-1332. The American Academy of Family Physicians prepared this list of tips for family physicians to use and distribute to their patients. The recommendations include safe water heater temperatures, ways to treat minor burns, and tips for wound and dressing care. The tips may be reproduced free of charge for nonprofit, educational purposes.

117

Canter, David (Ed.). (1990). Fires & human behavior: Second edition. London: David Fulton Publishers. This text presents several chapters on the subject of human behavior in fire. Of special interest are the chapters on the concept of panic, a survey on behavior in fires, a studies of fire in hospitals, and fires in nursing homes. A chapter written by the editor provides suggestions in training people to avoid disasters.

118

Conley, Christopher J., & Fahy, Rita F. (May-June, 1994). Who dies in fires in the United States? NFPA Journal, 88(3), 99-106. The authors use statistics on fire deaths in the United States to identify those at highest risk and to find out what conditions decrease the risk. The very young and the elderly are at highest risk for fire deaths. The fire death rate for children ages 5 and under is more than twice the national average. For the elderly, the death rates increase with age: ages 65 and over, the rate is twice the national average; for those ages 75 and over, it is almost three times the national average; and for those ages 85 and over, it is four times the national average. Males, the physically and mentally

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handicapped, the homeless, those living in poverty, smokers, those using alcohol or other drugs, children playing with fire or setting fires, and residents of homes with security measures that hamper escape are also at high risk for fire deaths. Conditions that reduce the risk include public fire education programs, smoke detectors, and sprinklers. 119

Demling, Robert H. (November 28, 1985). Burns. New England Journal of Medicine, 313(22), 1389-1398. The author reviews the prevalence and epidemiology of burn injuries in the United States, which has the highest incidence of burns among all industrialized countries. A United States citizen has a 1 in 70 chance of being hospitalized for a burn injury in his or her lifetime. Only motor vehicle accidents cause more accidental deaths. Most burns occur among children ages 1 to 5, of which a majority are caused by scalds from hot liquids. The elderly are the second highest risk group. The author suggests that although little has been done to prevent burn injuries, much has been done to improve the victim's chance of survival and recovery. The article presents detailed information on treatment, including the immediate response, continuing care for infection, wound management, and skin grafting.

120

Duran, Victoria, Teplica, David, & Gottlieb, Lawrence J. (1992). Childhood burn injury. Chicago Medicine, 95(3), 14-17. This article discusses the seriousness of burns to young children. The types of burns most often received by young children are caused by hot liquids, flame, electricity, and direct contact with a hot surface. The average cost of burn injuries is estimated at $42,500 per patient. In 1985, the societal cost of burn injury to the nation was $3.5 billion. Burn abuse, an often unrecognized and underdiagnosed problem, is discussed. The authors describe how to distinguish intentional from unintentional burns, and suggest several ways to prevent the types of burns most often suffered by children.

121

Electric-blanket fires. (June 6, 1963). New England Journal of Medicine, 268(23), 1308. Electric blanket fires have been the cause of 7,000 fires in the United Kingdom. Sixty-one persons were injured and two of these died. The electric blankets were either defective or improperly used. Two of the many models of electric blankets on the market have built-in safety systems that make them safe to use, but they

46

Injury Prevention for Young Children: A Research Guide are relatively expensive. Standards are being revised for the making of the blankets. Reliable figures on electric blanket and heating pad fires are hard to obtain in the United States, because minor incidents are not usually reported by the local fire departments. There were 18 reported fires during May, 1955 to December, 1960; 2 were caused by heating pads, and 16 by electric blankets. Electric blankets and heating pads do not appear to cause the same amount of fires in the United States as they do in the United Kingdom, unless the system of reporting fires is more effective in United Kingdom than in the United States. However, these devices should be manufactured and used as carefully as other electrical equipment such as irons, heaters, or stoves.

122

Fire in the United States (7th Ed.). (1990). Emmitsburg, MD: U. S. Fire Administration. This book is a report from the United States Fire Administration giving a statistical overview of the fire problem in the United States. The report is designed to direct fire prevention programs, to serve as a model for local fire data gathering, and to provide a foundation from which to evaluate fire safety programs. The data are analyzed to identify fire risk factors and high-risk groups, and to predict trends in fire injury, loss, and death.

123

Feldman, Kenneth W., Schaller, Robert T., Feldman, Jane A., & McMillon, Mollie. (July, 1978). Tap water scald burns in children. Pediatrics, 62(1), 1-7. The authors used National Electronic Injury Surveillance System (NEISS) and other data from 1975 to determine whether the characteristics of victims or circumstances of injuries would suggest ways to prevent tap water scald burns. Tap water scald burns accounted for 7% to 17% of all childhood scald burns requiring hospitalization. Toddlers and preschool children were the most frequent victims. In 45% of the injuries, the unsupervised victim or a peer turned on the tap water; in 28% the cause was abuse. Eighty percent of homes tested had unsafe bathtub water temperatures of 54°C (130°F) or greater, exposing the occupants to the risk of full-thickness scalds with only 30 seconds of exposure to hot water. To prevent tap water scalds, the authors suggest that household water temperatures be limited to less than 52°C (125°F).

124

Hall, John R., Jr. (March-April, 1989). A look at juvenile firesetting and fireplay with special emphasis on the role of matches and lighters. NFPA Fire Journal, 83(2), 27-30.

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The author discusses the problem of firesetting and fireplay by children. Children under 10 are responsible for a higher percentage of arson than for any other crime. Playing with fire is the leading cause of death in residential fires among children ages 5 and under. The author describes two methods of prevention: changing children's behavior patterns through education and counseling and modifying the ignition and heat sources (focusing on matches and lighters) to reduce fireplay and injury severity. 125

Hall, John R., Jr. (January-February, 1989). The latest statistics on U. S. home smoke detectors. Fire Journal, 83(1), 39-41. This article discusses the importance of home smoke detectors in saving lives. Homes that are poor or headed by the elderly or less educated are less likely to use smoke detectors. The use of smoke detectors can cut the risk of death from fire in half. The most common factor influencing nonoperational smoke detectors is having dead or missing batteries. The author recommends that the public be educated to properly install, use, and test smoke detectors in their own homes.

126

Hibbard, Roberta A., & Blevins, Ronald. (September, 1988). Palatal burn due to bottle warming in a microwave oven. Pediatrics, 82(3), 382-383. This article discusses a case study of a child that was treated for palatal lesion. The child could not eat and needed to be hospitalized for poor weight gain. The authors discovered that the lesion was caused by a scald from formula in a microwave-heated bottle. The parents did not recognize the hazards of microwave heating, and the doctors did not immediately recognize the nature of the injury. The authors suggest that microwaving infant formula is not a safe practice, and recommend that physicians counsel parents about microwave scald hazards.

127

Johnson, Charles F., Ericson, A. Kyle, & Caniano, Donna. (March, 1990). Walker-related burns in infants and toddlers. Pediatric Emergency Care, 6(1), 58-61. The authors compared records from nine children hospitalized with walker burns to records from other hospitalized burned children. During one year, four (6.5%) of the 61 children who were hospitalized for burns at a children's hospital sustained their injuries in a walker. Patients who were burned while in a walker had a greater body surface area burned (11.6%) than those with burns from abuse (1.7%), neglect (2.5%), or other accidents

48

Injury Prevention for Young Children: A Research Guide (6.2%). A higher percentage of males were burned, and the burn patterns differed among all four groups. Seven of the nine walker burns resulted from scalds, three of which were from hot grease. Walker-related burn patients required more physical or occupational therapy and a longer mean hospital stay than other burn patients. The authors suggest that, in addition to falls, burns are another hazard associated with the use of baby walkers, and recommend that physicians discourage parents from putting their children in walkers.

128

Karter, Michael J., Jr. (February, 1992). Patterns offire casualties in home fires by age and sex, 1985-89. Quincy, MA: National Fire Protection Association. This report examines civilian casualties in homes for patterns by age and gender of victim, and looks at age and gender differences associated with various circumstances surrounding the casualty, such as the cause of the fire and the activity of the victim at time of the injury. Research indicates that preschool children under 5 and the elderly (ages 65 and over) have the highest rates of fire deaths in the United States. For the elderly, the rates increase dramatically with age, and the most common causes are smoking materials and heating. The author concludes that fire safety and education programs need to target these high-risk groups.

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Karter, Michael J., Jr. (March, 1986). Patterns of fire deaths among the elderly and children in the home. Fire Journal, 80(3), 19-22. The author uses statistics on fire deaths to illustrate the risk factors for young children and the elderly, and makes four conclusions: 1. The young and very old have a much higher risk of dying in a home fire; 2. Young and very old victims of fatal fires are more likely to have limited mobility prior to the fire; 3. Young children are most often victims of fires they started themselves by playing with fire or arson; and 4. The elderly are most often victims of fires caused by heating and cooking equipment or smoking materials.

130

Katcher, Murray L. (1992). Efforts to prevent burns from hot tap water. In Abraham B. Bergman (Ed.), Political approaches to injury control at the state level (pp. 69-78). Seattle, WA: University of Washington Press. This chapter discusses the problem of tap water scalds among children, senior citizens, and physically impaired people. A

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10-year retrospective review of hot tap water scalds in these highrisk groups showed that 17% were children under 5, 3% were ages 65 and over, and 10% were physically or mentally disabled. The author also describes a public prevention education program e n c o u r a g i n g testing and lowering unsafe water heater temperatures in Wisconsin. 131

Katcher, Murray L., & Delventhal, Stephen J. (February, 1982). Burn injuries in Wisconsin: Epidemiology and prevention. Wisconsin Medical Journal, 81(2), 25-28. A 2-year study of patients admitted to the University of Wisconsin Hospital Burn Center showed that gasoline fires involving a motor vehicle or the use of gasoline to start a fire were responsible for 39% of flame burns. Flammable gases were involved in 21% of the flame burns, the most common cause was lighting a pilot light. House fires accounted for 21% of the flame burns. The majority of the electrical burns resulted from contact with a high voltage wire. Chemical burns were caused by contact with cement, fertilizers, and ammonia. Other sources of burn injury were from a heating pad, hot wood stove, hot iron casting, space heater, exhaust pipe, a drive belt (friction burn), and smoke inhalation without burns. Of the 18 fatal burns, 12 were flame burns; four were scalds (three of which were from hot tap water and occurring in the bathtub), and two were from house fires. Children under 5 were most commonly burned from hot liquids; two of the four cases resulted from hot tap water scalds in the bathtub.

132

Katcher, Murray L. (September, 1987). Prevention of tap water scald burns: Evaluation of a multi-media injury control program. American Journal of Public Health, 77(9), 1195-1197. This prospective study evaluated the success of a tap water scald prevention program. The program included pamphlets sent through the mail, posters at doctors' offices and hospitals, and free brochures and thermometers, as well as television, radio, and newspaper announcements, and reached approximately two million people in Wisconsin. Findings indicated that the program increased the tap water scald danger awareness in the general population from 72% to 89%. However, there was no indication of any increase in the testing or lowering of water heater temperatures in this group. A sample of those who requested free thermometers showed a higher rate of testing than the general population, with 43% reporting dangerous water heater

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Injury Prevention for Young Children: A Research Guide temperatures. The author suggests that a safety education program that changes awareness of risks will not necessarily change the atrisk situation or behavior, but that programs demonstrating the desired changes in behavior are more likely to prove, effective.

133

Katcher, Murray L., Landry, Gregory L., & Shapiro, Mary Melvin (May, 1989). Liquid-crystal thermometer use in pediatric office counseling about tap water burn prevention. Pediatrics, 83(5), 766-771. The authors gave consecutive pediatric clinic clients, randomized to two groups, an informational pamphlet, a 1-minute discussion about tap water safety, and a questionnaire. The clients in the first group also received a liquid-crystal thermometer to test the temperature of their home tap water. A follow-up telephone interview showed that approximately 80% of each group read the pamphlet. Reading the pamphlet was associated with greater temperature testing in the thermometer (T) group but not in the pamphlet-only (P) group. Temperatures were checked by 46.4% of the T group but by only 23.0% of the P group. Among the households with water temperature over 54.4°C (130°F) and an accessible water heater, 77.3% reported lowering the temperature. The authors suggest that using devices such as thermometers may be used as an effective supplement to office counseling about hot water hazards.

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Katcher, Murray L. (September 11,1981). Scald burns from hot tap water. Journal of the American Medical Association, 246(11), 1219-1222. The authors reviewed charts of all patients hospitalized for tap water scalds in Dane County, Wisconsin, over a ten-year period. Of 33 patients, 29 (88%) had readily-identifiable risk factors: 17 (52%) were children under 5, 3 (6%) were over 65, and 10 (30%) were physically or mentally disabled. Of the five deaths, three occurred in children younger under 30 months, and two occurred in patients over 70. The authors suggest that almost all of the injuries could have been prevented by lowering the water temperature to between 120° to 125°F, and recommend that physicians counsel patients to lower water heater temperatures.

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Leadership in public fire safety education: The year 2000 and beyond. (June, 1993). Washington, DC: Federal Emergency Management Agency.

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This book is the result of a United States Fire Administration symposium to identify trends in fire prevention and safety education. This report identifies trends in society, in schools, in local government, in the fire service, and in the field of injury prevention and health. Based on analysis of the implications of these trends for public fire safety education, the book details future-oriented strategies and actions to maximize the impact of education on the nation's fire problem. 136

Learn Not to Burn Foundation. (1991). Learn not to burn preschool program. Quincy, MA: Learn Not to Burn Foundation and the National Fire Protection Association. This program includes a teacher's guide and audio tape designed as a fire safety unit for preschool children. Each lesson focuses on one of eight key fire safety behaviors for preschool children: 1. Stay away from hot things that can hurt, 2. Tell a grown-up when you find matches or lighters, 3. Stop, drop, and roll if your clothes catch on fire, 4. Cool a burn, 5. Crawl low under smoke, 6. Know the sound of the smoke detector or alarm, 7. Practice an escape plan, and 8. Recognize the fire fighter as a helper. The lessons are supplemented in the teacher's guide by suggested activities and reproducible pages, and in the audiotape by songs teaching the behaviors stressed in each lesson.

137

Levin, Bernard M., & Nelson, Harold E. (September, 1981). Firesaf ety and disabled persons. Fire Journal, 75(9), 35-40. The authors discuss the unique fire safety needs of disabled people. Safety regulations for the general population should the foundation for fire safety programs for the disabled. In addition to these general regulations, measures directly related to the individual's environment and disability should be added. The authors describe practical fire prevention techniques for these special populations, and suggest that such measures be implemented, and that the disabled people should be taught to take advantage of them.

138

Lewis, Jan. (April, 1992). Scalding tap water. Trial, 28(4), 74-78. This article describes the dangers of very hot tap water in various high-risk populations. In 1988, 5,000 United States children were scalded by hot tap water, most often in the bathroom. More than half of all fatal tap water scalds are sustained by people ages 75 and over. The very young, the very old, and the neurologically or mentally impaired may not react as quickly to hot water, and

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Injury Prevention for Young Children: A Research Guide may also lack the mental ability to escape the hazard. Children and elderly people also have thinner skin and will suffer more severe burns during shorter periods of exposure than other groups. The author discusses anti-scald devices, the Safe Kids Campaign, code requirements, and court cases about scalds.

139

Lovejoy, Frederick H., Jr. (September 6,1990). Corrosive injury of the esophagus in children. New England Journal of Medicine, 323(10), 668-670. This article describes ingestions of corrosive agents by young children. Despite the fact that poisoning events in young children are usually less severe than for adolescents or adults, this is not the cases with corrosive agents. Drain or oven cleaners, detergents, and batteries are common sources of corrosion injury. Signs of corrosive burns may include dysphagia (difficulty swallowing), excessive salivation, refusal to drink, and pain. Injuries to the esophagus may also exist in the absence of any mouth or throat injury. Because current treatment of severe corrosive esophagus injuries is limited, the author suggests that interventions such as reducing the availability and toxicity of corrosive agents are essential to preventing serious injury in young children.

140

MacKay, Annette, Halpern, Judith, McLoughlin, Elizabeth, Locke, John, & Crawford, John D. (November, 1979). A comparison of age-specific burn injury rates in five Massachusetts communities. American Journal of Public Health, 69(11), 1146-1150. The authors measured burn incidence rates for residents of five Massachusetts cities by examining all non-occupational burn injuries and cases of smoke inhalation requiring treatment on an inpatient or outpatient basis in a hospital during a 3-year period. The patterns of burn injuries were similar for all five cities, indicating that different types of burn injuries correlate with certain age groups consistently. If these findings can be generalized to other geographic areas, the authors suggest that there may be behavioral or developmental factors that predispose certain age groups to certain types of burns, and that these factors may subsequently be used to form the basis for prevention efforts directed at these risk groups.

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141

McLoughlin, Elizabeth, & Brigham, Peter A. (July, 1992). Stop carelessness? No, reduce burn risk. Pediatric Annals, 21(7), 423428. In this article, the authors address four questions: How have rates of burn deaths and injuries changed during this century, and what is the situation for children today? What are the current estimates of costs of childhood burn injuries? How do burn prevention messages and strategies of the 1990s compare with those of the 1920s? and How can clinicians further reduce the risk of burn injury for children in their care? In detailing burn prevention messages from past and present, the authors compare different messages for cause of injury, matches, tap water scalds, kitchen scalds, house fires, and cigarettes. The authors conclude by describing ways clinicians can reduce the risk of burn injury for children, as well as ways to achieve safer environments and reductions in the number and severity of injuries through architects, builders, designers, and manufacturers who devise structures and products that will prevent burn injuries.

142

McLoughlin, Elizabeth, Clarke, Nicola, Stahl, Kent, & Crawford, John D. (October, 1977). One pediatric burn unit's experience with sleepwear-related injuries. Pediatrics, 60(4), 405-409. The authors reviewed the records of 678 children with acute injuries during an 8-year period. The records indicated that flame burns from a single ignition source (50%) outranked scalds (27%) or house fires (12%) as causes of injury. The majority of these single-source flame injuries were severe and involved ignition of the child's clothing. From 1969 through 1973, sleep wear was the clothing involved in 32% of the incidents. The authors found that the number of sleepwear-related injuries declined substantially after the institution of strict federal and state standards for the flammability of children's sleepwear, and suggest that the regulations were largely responsible for the decline in sleepwearrelated burn incidents.

143

McLoughlin, Elizabeth, & Crawford, John D. (February, 1985). Burns. Pediatric Clinics of North America, 32(1), 61-75. This article discusses the six categories of burn injuries: flame, scald, contact, electrical, chemical, and ultraviolet radiation. Burns can occur from a number of sources: match play, cigarettes, tap water scalds, kitchen scalds, electrical cords, and others. The authors recommend that pediatricians take four steps to prevent fire and burn injuries: 1. Collect detailed information on the

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Injury Prevention for Young Children: A Research Guide circumstances and products involved in burn injuries, 2. Insist on evaluation to provide evidence on effective prevention programs, 3. Cooperate with local fire departments, and 4. Become an advocate for legislative prevention efforts.

144

McLoughlin, Elizabeth, & McGuire, Andrew Qune, 1990). The causes, cost, and prevention of childhood burn injuries. American Journal of Diseases of Children, 144(6), 677-683. This article describes the incidence of burns to children ages 0 to 19. In 1985, fire and burn injuries caused the deaths of 1,461 children in the United States. In addition, an estimated 23,638 were hospitalized, and 440,000 were treated for injuries. Young children ages 0 to 4 in house fires accounted for 47% of the deaths. The authors suggest that preventing fire deaths through residential sprinklers, smoke detectors, fire-safe cigarettes, and child-resistant lighters would prevent more than 75% of all childhood fire and burn deaths.

145

Miller, Alison L. (January-February, 1991). Where there's smoking there's fire. NFPA Journal, 85(1), 87-93. Statistics from 1988 showed that 25% of civilian fire deaths were traced to fires caused by smoking materials. The risk of death or injury from these fires increases consistently with age. Previous attempts to prevent these fires has focused on the ignited material (such as mattresses and upholstery). The author suggests that smoking material-related fires cannot be reduced further without modifying the smoking materials or reducing the use of these materials by smokers.

146

Miller, Robert E., Reisinger, Keith S., Blatter, Mark M., & Wucher, Frederick. (April, 1982). Pediatric counseling and subsequent use of smoke detectors. American Journal of Public Health, 72(4), 392-393. This study compared the effects of a brief educational and purchase program concerning home fires and smoke detectors by two pediatricians to routine counseling without such a program. Subjects were two groups of 120 parents of well children. An inspection performed 4 to 6 weeks after the office visits showed that of 55 experimental group parents without detectors prior to the program, 26 purchased and 19 installed them correctly. None of the control group parents did so. The authors suggest that even brief counseling by pediatricians, when supplemented by written

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information and improved access to safety devices, can produce effective changes in patient behavior. 147

National Commission on Fire Prevention and Control. (1989). America burning. Washington, DC: U. S. Fire Administration. This report summarizes the findings and recommendations of the National Commission on Fire Prevention and Control concerning the fire problem in the United States. The report gives statistical data about fire injuries and deaths, as well as the hazards and existing prevention efforts. The Commission recommends that an organization called the United States Fire Administration be established to meet several fire safety and prevention needs in conjunction with local governments: more emphasis on fire prevention, better training and education for fire services, fire safety education for the general public, reduced hazards in the home and workplace, improved building fire protection, and more research on firefighting and fire hazards. The United States Fire Administration would also develop a national fire data system to aid research, monitor and encourage fire research, provide firerelated bloc grants to local governments, establish a national fire academy, and coordinate a national fire safety education program.

148

Othersen, H. Biemann. (October, 1983). Burns and scalds. Pediatric Annals, 12(10), 753-760. The author examines the prevention of three major causes of injury —scalds, flame burns, and inflicted burns (child abuse) —for which effective prevention methods were published in 1830. The Book of Accidents: Designed for Young Children was published in 1 as an aid for parents and guardians of young children. The author compares excerpts from this book with information from the American Academy of Pediatrics' The Injury Prevention Program (TIPP) to show that, despite past and present knowledge of ways to prevent these injuries, burns and scalds continue to be a major source of injury among children.

149

Parker, Douglas J., Sklar, David P., Tandberg, Dan, Hauswald, Mark, & Zumwalt, Ross E. (March, 1993). Fire fatalities among New Mexico children. Annals of Emergency Medicine, 22(3), 517522. This retrospective study analyzed fire deaths among children ages 0 to 14 in New Mexico during 1981 to 1991. There were 57 children who died in fires during the study period, twothirds of whom were male, and three-fourths of whom were

56

Injury Prevention for Young Children: A Research Guide under 5. The mortality rate of children living in mobile homes was three times that of children in houses or apartments. The mortality rate of children in homes without plumbing was more then ten times that of other children, and two-thirds of the victims in these homes were Native American. More than half of the deaths were associated with parental errors or negligence, and only 11% of the children reached a hospital burn center. The authors suggest that future prevention strategies emphasize improving housing conditions and educating adults about safety practices.

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Ramanathan, C , Ekpenyong, L., Stevenson, J. H. (April, 1994). Scald burns in children caused by hot drinks—The importance of the type of cup. Burns, 20(2), 111-114. This prospective study evaluated 36 consecutive scald injuries in children caused by hot beverages. Nearly one-third of these were deep or full skin thickness, most resulted in injury to the upper chest region. The study further investigated the cooling characteristics in different types of cups. The authors found that the potential for a full thickness burn can exist for up to 11 minutes from the time the drink is poured into a cup, and that plastic or polystyrene cups retained more heat for longer periods of time than ceramic cups.

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Rossignol, Annette MacKay, Boyle, Catherine M., Locke, John A., & Burke, John F. (November, 1986). Hospitalized burn injuries in Massachusetts: An assessment of incidence and product involvement. American Journal of Public Health, 76(11), 1341-1343. This study assessed the frequency and of hospitalized burn injuries by age, gender, and race and identified the various consumer products that were involved in these injuries. The authors reviewed hospital inpatient records and emergency room logbooks for 240 acute-care hospitals in Massachusetts. During a 1year period, there were 1,237 recorded burn incidents. Children under 2 had the highest burn rates for both males and females. The overall rate for males was 2.6 times higher than the rate for females. The rate for Blacks was 3.1 times higher than that of Whites, and 2.3 times higher than that of the other races combined. The authors suggest that children under 2, males, and Blacks are at higher risk for burn injuries than older people, females, or Whites. Products which were frequently associated with burn injuries included those involved in food preparation and consumption, flammable liquids, and clothing.

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152

Rossomando, Christina, & Schaenman, Philip. (December, 1993). The community-based fire safety program: Preliminary report. Washington, DC: Tobacco Institute. This report describes a program to distribute fire safety education literature and smoke detectors to at-risk populations at a community level. The program was originally developed in Oregon, and pilot-tested in Illinois, Maryland, and South Carolina. The program analyzed fire data in each city to identify high-risk groups and locations to determine the target group. Market research and community groups were used to plan and implement the program. Preliminary findings indicate that these pilot programs were useful in reducing fire deaths in target areas. As a result of the pilot programs, the authors developed a model program that can be used in any community to educate the public about fire safety and smoke detectors, with special emphasis on those at greatest risk from fire.

153

Rothstein, Fred C. (June, 1986). Caustic injuries to the esophagus in children. Pediatric Clinics of North America, 33(3), 665-674. The ingestion of caustic chemical agents, usually accidentally by children, produces a wide range of injuries that vary from minor mouth burns to the death of tissue in the esophagus and stomach. Factors that affect the seriousness of the injury include the type of material swallowed, the potency of the material, and the amount of time the material stays in the esophagus. Symptoms include vomiting, dysphagia (difficulty swallowing), drooling, abdominal pain, and refusal to drink liquids, but many cases present no symptoms. Treatment focuses on prevention of strictures, scarring that obstructs the esophagus.

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Schaenman, Philip, Lundquist, Barbara, Stambaugh, HoUis, Camozzo, Elyse, & Granito, Anthony. (1987). Overcoming barriers to public fire education in the United States. Arlington, VA: TriData. The authors suggest that public fire education is a vital but often neglected part of fire prevention in the United States. Four groups are key players in public fire education: mayors and city managers, schools, fire services, and the insurance industry. This report outlines the barriers and problems that hinder each of these groups, and gives recommendations to improve the quality and effectiveness of current fire safety education programs.

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Injury Prevention for Young Children: A Research Guide

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Shingleton, Bradford J. (August 8, 1991). Eye injuries. The New England Journal of Medicine, 325(6), 408-413. The author discusses the evaluation and prevention of eye injuries. He discusses vision threatening injuries such as chemical burns, ruptured globe (corneal laceration), and hyphema (bleeding in the anterior chamber usually resulting from blunt trauma to the globe). The home was the site of injury in 25% of patients. Children had a small proportion of the injuries overall, but a disproportionate burden of the severe injuries. Shingleton recommends wearing eye protection such as goggles or helmets with face masks.

156

Simon, Jeff, Levensohn, Alan, Metzger, Barbara B., Hardman, Susan, & Klein, Susan J. (December, 1993). Burn prevention through Weatherization Assistance Programs. American Journal of Public Health, 83(12), 1787-1788. This article describes the Weatherization Assistance Program in New York State, which may help reduce the potential for burn injuries to children living in fural communities in substandard houses. In New York, burns are the most common cause of death from home injuries to children under 15. To help reduce the incidence of burn injuries, New York instituted preventive measures through the Weatherization Assistance Program. This program reduces energy costs by repairing and replacing windows, furnaces, and boilers and performing energy audits. The program serves low-income families, the elderly, minorities, and the disabled. Once repairs are made, inspectors perform follow-up checks that include fixing potential fire hazards. The authors suggest that this program may have potential for other injury prevention efforts by educating clients about poisoning and other household hazards.

157

Simon, Paul A., & Baron, Roy C. (April, 1994). Age as a risk factor for burn injury requiring hospitalization during early childhood. Archives of Pediatric and Adolescent Medicine, 148(4), 394-397. This study used hospital discharge data and a burn unit admission log to examine the variation by age in the rates and causes of burn injury requiring hospitalization during early childhood. Subjects were 122 children ages 0 to 4 in the Denver, Colorado metropolitan area who sustained burn injuries and were hospitalized during 1989 and 1990. The annual incidence was computed at 40.5 per 100,000 children ages 0 to 4. Children ages 6

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to 24 months accounted for 88% of all cases and were seven times more likely to be hospitalized for a burn injury than other children. Scalding and contact with hot objects accounted for 64% and 20% of cases, respectively, and occurred primarily in children ages 6 to 24 months. The authors suggest that children ages 6 to 24 months are at increased risk of severe burn injury compared with other children, and recommend that this age group should be targeted for prevention efforts. 158

Stanwick, Richard S. (May 15,1985). Clothing burns in Canadian children. Canadian Medical Association Journal, 132(10), 11431149. A Canadian survey of 11 pediatric burn centers showed that an estimated 37 children ages 9 and under are admitted annually to such hospitals because of clothing-related burns. Sleepwear accounts for an estimated 21 such burns per year. Girls suffered the most severe burns and represented eight of the nine children in the study who died. The style of clothing (loose and flowing as opposed to snug) was the most significant predictor of burn severity, length of hospital stay, the need for skin grafting, and survival. The author reviews the success of regulatory actions in other countries and recommends specific preventive strategies for Canada.

159

Thomas, Katherine A., Hassanein, Ruth S., & Christophersen, Edward R. (November, 1984). Evaluation of group well-child care for improving burn prevention practices in the home. Pediatrics, 74(5), 879-882. The authors randomly assigned 58 couples to an experimental group and a control group, all of w h o m were enrolled in a group well-child care class that lasted 90 minutes. The control group was provided with information and discussion on nutrition, dental care, safety in the car and home, child d e v e l o p m e n t , child r e a r i n g , illness m a n a g e m e n t , a n d immunizations. The experimental group received information and discussion on the same topics. This group also received specific information on burn prevention, including hot water heater settings and smoke detectors. On a subsequent home visit, 65% of the couples in the experimental group had their hot water temperatures measured at 54.4°C (130°F) or less, whereas all of the couples in the control group had hot water temperatures more than 54.4°C (130°F). Based on this study, the authors suggest that

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Injury Prevention for Young Children: A Research Guide the pediatrician may now be in a position to include effective safety counseling procedures for well-child care.

160

Thompson, Janet C , & Ashwal, Stephen. (March, 1983). Electrical injuries in children. American Journal of Diseases of Children, 137(3), 231-235. This article discusses electrical injuries among y o u n g children. The severity of electrical injury depends on three primary factors: the resistance of skin and internal body structures, the polarity of the current (AC or DC), and the frequency, intensity, and duration of the stimulus. Skin resistance is very low in newborn infants because of high water content and thin layers of skin. Susceptibility to electrical injury is also related to age. For example, a toddler is more likely to get an oral burn because of chewing on electrical cords, and the severity of the burn is increased because of the wetness of a toddler's mouth. The authors make recommendations for preventing injuries from the major sources of electrical hazards for children: electrical cords, appliances, toys, and power lines.

161

Trunkey, Donald D., & Pascoe, Delmer J. (1988). Burns and smoke inhalation. In Pascoe, Delmer J, & Grossman, Moses, Quick reference to pediatric emergencies (pp. 169-178). Philadelphia, PA: J. B. Lippincott Company. This chapter provides technical information about burn injuries. The authors point out that burns are the leading cause of accidental death in the home environment among children ages 1 to 4, and that at least 50% of childhood burns are preventable. Common burn hazards to young children under 6 include playing underfoot in the kitchen, overturning cups of hot liquids, pulling electric cords of coffee pots and frying pans, hot bath water, chewing on extension cords, playing with matches, and climbing on stoves. Older children obtain burns from fireworks, chemistry sets, gasoline, climbing around high-tension wires, playing with fire, matches, or gasoline. All children are at risk for burns from house fires and gas tank explosions during auto accidents. Other information in this chapter includes a detailed description of the child's skin, how to determine the severity of a burn injury, and how to treat a burn.

162

Walker, Bonnie L. (August, 1995). The effects of a burn prevention program on child care providers. Fire Technology, 31(3), 244-264

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Fire and burns are the second leading cause of injury to young children ages 0 to 4. To be effective, fire and burn prevention education and training must reach the people who care for young children. Increasingly larger percentages of young children are cared for in out-of-home settings including child care centers and family child care facilities. The majority of children, however, are still cared for by their parents or other relatives for all or part of their days. An injury prevention program was needed that was interesting, useful, and effective with child care providers in different settings. A burn prevention curriculum was developed as part of a comprehensive injury prevention project. The content was developed by a group of experts in a variety of related fields including injury prevention, early childhood education, child care administration, instructional design, and evaluation. Operators of child care facilities, parents, and care providers were involved in the planning and implementation of a training workshop. The program was tested with 141 child care providers at 7 sites. Subjects included child care center staff, family child care operators, and parents of young children. Materials included an instructor manual, coursebook, video, and test booklet. Subjects' knowledge, attitudes, and practices intentions were tested before and after the training. Subjects also completed a program evaluation. Results indicated significant improvement in knowledge, attitudes, and practices intentions for the total group and for subjects at each site. Gains made by center staff and family day care providers were significant on all three measures, and for parents on knowledge and practices. Measures of attitudes and injury prevention practices indicated a high level of acceptance of program goals. A large majority of the subjects said the program was useful and interesting. An analysis of the test results by objective indicated that subjects had improved their knowledge scores on each objective. They had the highest achievement on topics related to understanding characteristics of burns, understanding the hazards and prevention techniques related to smoke, matches, lighters, and hot surface burns. An important finding was that child care providers in different environments can be instructed in burn prevention using the same program. 163

Walker, Bonnie L. (1995). Injury prevention for young children: Preventing burns and scalds. Crofton, MD: Bonnie Walker & Associates. This coursebook and videotape is part of a training program for operators and staff of residential care facilities, group homes,

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Injury Prevention for Young Children: A Research Guide and other personal care facilities for special populations. The author illustrates the need for burn prevention and gives practical prevention interventions based on how fires start and spread Hazards discussed are matches, lighters and smoking materials, heaters, hot surfaces, scalding tap water, scalding liquids, hot foods, electrical outlets, and sunburn. Information is also included on applicable codes and standards, installing and testing smoke detectors, fire extinguishers, testing hot water temperature, emergency escape planning, and first aid for burns.

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Warmer weather sparks more burns. (May, 1992). USA Today Magazine, 120(2564), 6. This article discusses the types of burns that are frequently seen during the summer months. Each year, more than 2,000,000 people are victims of burn injuries and between 8,000 and 12,000 die. Common causes of burns during the spring and summer include careless use of fireworks, walking barefoot on hot campfire coals, scalds from home canning, and careless use of gasoline. Approximately 75% of all burns result from the victim's own actions. Children under 5 and older adults are at the greatest risk for burn-related injuries and death. The article offers tips to prevent these types of burn injuries.

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Weaver, Alissa M., Himel, Harvey N., & Edlich, Richard F. (JulyAugust, 1993). Immersion scald burns: Strategies for prevention. Journal of Emergency Medicine, 11(4), 397-402. This case study reports an elderly woman with a physical and neurological handicap who suffered scald burns covering 20% of her total body surface area while bathing. This life-threatening injury could have been prevented with a temperature-controlling water valve.

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Webne, Steve L„ & Kaplan, Bonnie J. (October, 1993). Preventing tap water scalds: Do consumers change their preset thermostats? American Journal of Public Health, 83(10), 1469-1470. This study of 62 families evaluated whether families would raise preset safe water heater temperatures. The authors found that 60% of the sample made no change in their preset thermostats; however, the study did demonstrate that 40% of the families did raise preset safe thermostat settings. Some of those families (27%) who did not move the temperature settings still had hazardous (over 54°C) water temperatures. The authors suggest that future

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efforts encourage manufacturers to produce systems with accurate thermostats that will deliver safe tap water. 167

Yamamoto, Loren G., Wiebe, Robert A., Matthews, Wallace J., Jr. (April, 1991). A one-year prospective ED cohort of pediatric burns: A proposal for standardizing scald burns. Pediatric Emergency Care, 7(2), 80-84. This Hawaiian study collected data on 143 pediatric patients visiting a pediatric emergency department with burns over a 1year period. Sixty-four percent of the patients were males. Common causes of burns included hot water (17%), hot food (23%), hot appliances (18%), and charcoal and grills (9%). Sixty-six percent of the burns took place at home. The hospitalization rate was 8%. The authors suggest that scald burns be defined by a uniform standard, so that data from various studies can be consistent and comparable to future studies.

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Yeoh, Chee, Nixon, James W., Dickson, W., Kemp, Alison, & Sibert, J. R. (August, 1994). Patterns of scald injuries. Archives of Disease in Childhood, 71(2), 156-158. This study analyzed children admitted to a burn unit to describe common patterns of bath water scald injuries in children, to examine differences between accidental and non-accidental bath water scalds in children, and to examine the potential for prevention. Bath scalds in children under 5 caused an estimated 14.7 per 100,000 children to be admitted to the specialist burns unit in a year. The majority of the children were injured by falling in the water, but the tap was turned on by 7 children themselves and by 10 siblings. Six children put hands in the hot water and two children were accidentally put into bath water that was too hot and were quickly withdrawn. Four children suffered nonaccidental immersion scald injuries from hot water. These injuries were characterized by a clear tide mark, a story that did not fit the injuries, associated injuries, and by symmetrical lesions. Accidental scalds were more likely irregular geographical injuries and asymmetrical. The authors suggest that the best way to prevent scald injuries would be to reduce the temperature of hot water heaters.

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his chapter includes articles and studies about child abuse and firearm injuries. Child abuse often includes homicides and injuries from firearms. Child abuse is the leading cause of homicide for infants and young children. Abusive behavior can include physical abuse, psychological abuse, sexual abuse, or neglect. Articles in this chapter deal with prevalence, methods of abuse, risk factors, hazards, and prevention ideas. Individuals performing the abuse are staff of child care facilities, parents, and other caregivers including relatives, baby-sitters and siblings of various ages. Injuries which often result from abuse are burrs, bruises, bites, fractures, internal injuries, head injuries, drowning, asphyxiation, poisoning, and gunshot wounds. Major hazards for child abuse are caregiver stress, untrained caregivers, and poverty. The major prevention interventions suggested in the literature are training and closer supervision of caregivers, better reporting procedures, awareness of the medical profession, and environmental controls. 169

Alexander, Greg R., Massey, Ronnie M., Gibbs, Tyson, & Altekruse, Joan M. (February, 1985). Firearm-related fatalities: An epidemiologic assessment of violent death. American Journal of Public Health, 75(2), 165-168. The authors developed an epidemiologic profile of the problem of firearm fatalities in South Carolina, focusing on trends and levels based on demographic characteristics. The study examined South Carolina firearm fatalities during 1970 to 1978. During the study period, there were 29 firearm fatalities among

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Injury Prevention for Young Children: A Research Guide children ages 0 to 4,11 of which were coded as homicide. Firearm fatalities in South Carolina were the sixth leading cause of death in 1975 and accounted for 2.9% of all deaths to residents. The authors suggest that the subgroups and geographic areas of high risk documented by the study could be used to plan future preventive strategies, and recommend that state and local health professionals become more directly involved in preventing firearm fatalities.

170 Alexander, Randell C, Surrell, James A., & Cohle, Stephen D.

(February, 1987). Microwave oven burns to children: An unusual manifestation of child abuse. Pediatrics, 79(2), 255-260. Because the increased popularity of microwave ovens in homes could present a new source of injury to children as well as adults, the authors reviewed the cases of two children who sustained full-thickness burns as a result of being placed in microwave ovens. In the first case, the hospital staff treating the child used a process of elimination to pinpoint the cause of the burns and were able to elicit an admission from the mother that she had placed the child in the microwave oven. In the second case the injuries of a 14-month-old boy were similarly inconsistent with normal burns, and authorities were eventually able to determine that child abuse by the babysitter was the cause. As of the writing of this article, these were the only two known cases of child abuse by the use of a microwave oven.

171 Alexander, Randell, Sato, Yutaka, Smith, Wilbur, & Bennett,

Thomas. (June, 1990). Incidence of impact trauma with cranial injuries ascribed to shaking. American Journal of Diseases of Children, 144(6), 724-726. The authors examined data from 24 brain-injured child abuse victims who had been diagnosed as being victims of shaking to evaluate a theory that shaking alone was insufficient to produce the injuries and fatalities being reported. By using computer tomography and magnetic resonance imaging, developed since shaken baby syndrome was first described, the authors were able to establish whether external trauma occurred for infants thought to have been shaken. The authors compiled data from the 24 infants initially diagnosed as having shaken baby syndrome, including physical examination, computer and laboratory testing, and autopsy. The authors report that half of the patients showed no evidence of direct impact, and that evidence of external trauma was not always fatal. Using these findings, the authors were able to demonstrate that shaking by itself can cause severe or fatal brain

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injury and that shaking by itself can be the cause of injuries that may or may not include direct trauma. 172

Annest, Joseph L., Mercy, James A., Gibson, Delinda R., & Ryan, George W. (June 14, 1995). National estimates of nonfatal firearm-related injuries: Beyond the tip of the iceberg. Journal of the American Medical Association, 273(22), 1749-1754. This study evaluated the magnitude and characteristics of nonfatal firearm-related injuries treated in hospital emergency rooms in the United States and compared nonfatal injury rates with fatal injury rates. Using the National Electronic Injury Surveillance System (NEISS), the authors were able to estimate that of the 151,373 persons with nonfatal gun-related injuries treated annually in hospital emergency departments in the United States, 99,025 were treated for nonfatal firearm-related injuries. The authors found that nonfatal firearm-related injuries outnumbered firearm-related deaths by a ratio of 2.6 to 1. Recognizing that the NEISS has several limitations for compiling information on the non-fatal firearm-related injuries, the authors recommend a national injury surveillance system that provides uniform data on firearm-related mortality and morbidity to aid in risk factor research and in developing and evaluating firearm- and violence-related intervention programs.

173

Barber-Madden, Rosemary. (1983). Training day care program personnel in handling child abuse cases: Intervention and prevention outcomes. Child Abuse and Neglect, 7(1), 25-32. This article describes a child abuse awareness training program for day care workers and a study which assessed the program's effectiveness when compared to other training provided to day care workers. Having provided the training program to 18 sites in Pennsylvania, the authors conducted a follow-up study to determine the effectiveness of the program by surveying 84 day care programs in southeastern Pennsylvania and comparing the intervention and prevention activities of two groups: those programs whose staff participated in the training and those whose staff did not. While an assessment of intervention activities showed that there was no difference between the groups, an analysis of prevention activities showed that day care workers in the trained group were significantly more involved in prevention and that the trained group used community resources for referral of high risk families more often that the other groups.

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Berthier, M., Oriot, D., Bonneau, D., Chevrel, J., Magnin, G., & Gamier, P. (September-October, 1993). Failure to prevent physical child abuse despite detection of risk factors at birth and social work follow-up. Child Abuse and Neglect, 17(5), 691-692. The authors discuss the case of a 1-month-old girl who died as the result of child abuse by her young, unmarried parents. The authors were particularly interested in this case because the infant had been identified at birth to be at risk for child abuse because she was an unwanted child with young parents on welfare. As a result of this identification, the family was included in a plan for regular home follow-up visits by social workers and office visits to a pediatrician from the Mother and Child Protection Institution. The parents cooperated in this program and were judged responsive. The authors conclude that there are limits to even extensive child abuse prevention programs.

175

Bloch, Harry. (October, 1988). Abandonment, infanticide, and filicide: An overview of inhumanity to children. American Journal of Diseases of Children, 142(10), 1058-1060. The author traces acts of violence committed against children throughout history. The motives for such acts have ranged from economic greed to religious superstition. The author concludes by pleading for the nations of the world to prevent repeating the violence and abuse of the past by preserving the rights and health of children.

176

Cashell, Alan W. (September, 1987). Homicide as a cause of the sudden infant death syndrome. American Journal of Forensic Medicine and Pathology, 8(3), 256-258. This article discusses the case of homicidal asphyxiation of an infant and the attempted asphyxiation of his 4-month-old sibling as evidence that murder may sometimes be mistaken as sudden infant death syndrome (SIDS). The author suggests that any SIDS deaths may, in fact, be homicides and urges pathologists and physicians to be more wary of autopsies of infants when there is no traumatic injury involved. Pathologists are advised order full body x-rays and look at the child's social history (perhaps by making a call to the child's pediatrician) in each case before entering a cause of death on a death certificate. The author also suggests that using an alternate term, such as "undetermined," on the death certificate and autopsy report would alert authorities that further investigation was warranted.

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177

Christoffel, Katherine K., Anzinger, Nora K., & Merrill, David A. (December, 1989). Age-related patterns of violent death, Cook County, Illinois, 1977 through 1982. American Journal of Disease of Children, 143(12), 1403-1409. This retrospective study of violent child deaths in Cook County Illinois during 1977 to 1982 was conducted to clarify which features from other locales and eras should guide prevention efforts in the 1990s and beyond. Violent deaths, in this report, included both cases ruled as a homicide and those ruled as of an undetermined manner. Of the injury circumstances listed in the article, blunt injury and gunshot wounds caused the greatest number of deaths, and parents were the predominant perpetrators among victims ages 5 and under. The authors noted that there are specific differences for younger and older patterns of fatal injury, that there is an overrepresentation of male and black victims, and that children living in urban and areas and in poverty areas have the highest rate of violent deaths. Because the deaths of very young children were often related to neglect or maltreatment by parents or other caregivers, the authors recommend that these caregivers should be given training to learn to care for infants and toddlers and that communities complement the child care provided by families. The authors also suggest strategies to protect the two groups at highest risk for violent death: black children ages 3 and under and ages 11 and older in poor urban areas.

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Christoffel, Katherine K. (June, 1990). Violent death and injury in U. S. children and adolescents. American Journal of Diseases of Children, 144(6), 697-706. The author presents a review of the factors that contribute to the violent death and injury of children and adolescents in the United States. The causes for violent death and injury include child abuse and neglect, assault, and homicide. Child abuse is the leading cause of homicide in the first few years of life. Firearm assault is involved in 25% of firearm injuries for children from the ages of 0 to 4. One percent of deaths of children ages 5 and under are the result of murder. The author identifies a list of options for primary and secondary prevention for each of the three types of violence and cited gun control as a primary prevention against assault and parent aids as a primary prevention against child abuse and neglect. The author suggests that only when it becomes a national priority can violence join measles and pneumonia on the list of problems that are no longer leading causes of childhood injury and death.

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Christoffel, Katherine K., & Liu, Kiang. (1983). Homicide death rates in childhood in 23 developing countries: U. S. rates atypically high. Child Abuse and Neglect, 7,339-345. This article discusses homicide and possible homicide rates for children in the United States as compared to the rates in 23 other developed countries. The authors found that rates in the United States were among the five highest for two childhood age groups: infants under age 1 and ages 1 to 4. For infants in the United States, male death rates are unusually high, while among toddlers and preschoolers, girls appear to be more at risk. Because handgun deaths are comparatively rare in these age groups, the authors suggest that other factors, particularly social isolation of parents, should be examined more thoroughly. The authors recommend several preventive approaches, including guidance for families in need of help, social services to high risk families, home visitors for new parents, and drop-in centers to minimize parental isolation.

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Christoffel, Katherine K., Liu, Kiang, & Stamler, Jeremiah. (1981). Epidemiology of fatal child abuse: International mortality data. Journal of Chronic Diseases, 34,57-64. The authors studied 1974 World Health Organization (WHO) data on age-specific death rates due to definite and possible inflicted injuries among infants and children in 52 countries. Because only a few countries have laws requiring reporting child abuse or neglect, the authors found that comparing statistics between countries was not reliable. There were, however, four findings: 1. Death rates in infancy due to definite inflicted injury were independent of death rates due to definite inflicted injury for the general population, 2. These death rates in infancy were the same in developed and undeveloped countries, 3. Death rates due to inflicted injury for children ages 1 to 4 in developing countries are independent of the rates for the whole population, but in developed countries these rates are almost the same as that for the population as a whole, and 4. Murder rates for children ages 1 to 4 olds differ significantly between developed and developing countries as do those rates for the populations as a whole.

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Christoffel, Katherine K., Zieserl, Edward J., & Chiaramonte, Janet. (September, 1985). Should child abuse and neglect be considered when a child dies unexpectedly? American Journal of Diseases of Children, 139(9), 876-880.

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The authors studied infant deaths during 2 years at a pediatric teaching hospital to develop guidelines for clinicians who must decide when to explore the possibility of child abuse or neglect when a child dies unexpectedly. Of the 43 infant deaths studied, the 27 were due to natural causes. Nine deaths were related to suspected child abuse or neglect: in three of those cases, evidence of injury was found only at autopsy. The authors cited two factors that should determine the necessity for more thorough evaluation: an infant dead on arrival and an infant ages 1 and under. The two factors identify a high-risk group requiring at least hospital-based investigation into the possibility of abuse or neglect. The authors advise that reporting for suspected child abuse or neglect is justified if an initial evaluation does not eliminate concern, if unsuspected trauma is found on autopsy, or if there is physical or social evidence of child abuse or neglect. 182

Christoffel, Katherine Kaufer. (July, 1992). Pediatric firearm injuries: Time to target a growing population. Pediatric Annals, 21(7), 430-436. This article reviews what the magnitude of the firearm injury problem in the United States, risk factors for injury, and available prevention approaches. The author discusses the pathophysiology of firearm injuries, the three different circumstances of injury (assault or homicide, suicide, and unintentional injury), risk factors, and viable prevention methods. Among children ages 1 to 9, homicides are the most frequent source of firearm injury and death, followed by unintentional injuries. The author suggests that pediatricians continue to document the problem and to advocate legislative and primary prevention efforts.

183

Christoffel, Tom, & Christoffel, Katherine. (June, 1987). Nonpowder firearm injuries: Whose job is it to protect children? American Journal of Public Health, 77(6), 735-738. This article reviews various alternative approaches to control the use of nonpowder firearms, especially by children. Hospitalization as a result of injuries caused by BB, pellet, or dart guns is almost 6% for children ages 2 to 5 and almost 17% for children under age 2, compared to a 4% rate for all reported consumer products. The authors suggest that because these nonpowder firearms are often perceived as toys, controlling the hazard will require children, parents, manufacturers, retailers,

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Injury Prevention for Young Children: A Research Guide government, and the courts taking the problem seriously, and taking serious steps to protect children from firearm injury.

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Daniel, Jessica H., Hampton, Robert L., & Newberger, Eli H. (October, 1983). Child abuse and accidents in black families: A controlled comparative study. American Journal of Orthopsychiatry, 53(4), 645-653. The authors evaluated 402 families with children ages 4 and under to identify families of child abuse and accident victims. The authors presented a comparison of risk indicators for accidents and abuse among black families that participated in a larger study of pediatric social illnesses (abuse, neglect, failure to thrive, accidents, and ingestions). In the course of the study, the authors recognized the need for helping participating families obtain essential social services to relieve the life stresses they were experiencing. Black families who abused their children were more likely to suffer from poverty, social isolation, and stressful relationships with and among family members. The authors recommend four steps to prevent child abuse in high-risk families: provide financial support, establish contact with professional who can help family members in times of personal distress, provide diagnostic consultation, and implement therapeutic intervention programs.

185

Danoff, Nancy L., Kemper, Kathi J., & Sherry, Bettylou. (July, 1994). Risk factors for dropping out of a parenting education program. Child Abuse and Neglect, 18(7), 599-606. This study compared parents who completed a clinic-based parenting program to dropouts to identify risk factors for parents not completing the program. The program, aimed at mothers at risk for child maltreatment, was offered at three Seattle, Washington health centers providing comprehensive pediatric care to low-income families. Of the 172 parents enrolled, 124 (72%) completed the program. Those who dropped out of the program were more likely to be attending the program at Site Three, teenaged, African-American, and living in an environment that scored below 32 on the Home Observation for Measurement of Environment assessment. There were no statistically significant differences between those who dropped out and those who completed the program in marital status, education, referral rate to Child Protective Services prior to the start of parenting classes, or Nursing Child Assessment Teaching Scale scores. Based on these data, the authors recommend that program planners develop

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appropriate strategies to keep teenage mothers in parenting programs. 186

Elrod, Jeanne M., & Rubin, Roger H. (July-August, 1993). Parental involvement in sexual abuse prevention education. Child Abuse and Neglect, 17(4), 527-538. This study assessed what parents know and need to know about child sexual abuse. The authors also sought to determine what, when, and how parents want their children educated about sexual abuse, and who they felt should be educating their children. Fifty-one mothers and 50 fathers of preschool and day-care center children were interviewed. The authors found that parents wanted to be the primary educators of their children, but they showed a lack of knowledge about important sexual abuse issues and planned to discuss only the least threatening topics. However, the parents were open to numerous methods and referral sources for prevention education. The authors also found that the men in the study viewed their role as fathers as less involved in educating their children or themselves about sexual abuse. The authors recommend that future research investigate parents' motivations and perceived barriers in the prevention of sexual abuse.

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Fink, Arlene, & McCloskey, Lois. (1990). Moving child abuse and neglect prevention programs forward: Improving program evaluations. Child Abuse and Neglect, 14(2), 187-206. The authors evaluated 13 studies on child abuse and neglect programs from 1978 to 1988 to determine the quality of published research and offer suggestions for improvement to evaluators, program planners, and funders. Analysis of these studies showed careful attention to methodologic detail, but authors found the studies lacked sufficient information to evaluate the effectiveness of the programs. The evaluators did not define abuse or neglect, and used data based on reported abuse. The authors suggest that future research use standard definitions of abuse, neglect, and risk and include data on the costs of abuse and neglect.

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Firearm ownership and storage practices in New Mexico. (1992). Santa Fe, NM: State of New Mexico Department of Health. This study used a telephone survey to assess the ownership and use of firearms in New Mexico. Of those surveyed, 40% owned firearms. Households likely to own guns were in rural areas, and earning more than $25,000 per year. Twenty-one percent of firearm-owning households with young children were

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Injury Prevention for Young Children: A Research Guide found to store their guns unsafely. Recommendations for encouraging safe ownership and storage of firearms safely include public education programs aimed at handgun owners and households with small children, and making handguns less likely to fire accidentally.

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Garbarino, James. (1986). Can we measure success in preventing child abuse? Issues in policy, programming, and research. Child Abuse and Neglect, 10(2), 143-156. This article reviews efforts to set child abuse prevention goals in the United States by the Surgeon General's Report on Health Promotion and Disease Prevention and the National Committee for the Prevention of Child Abuse. The author argues that goals for prevention must be based on solid research, and evaluates the adequacy and validity of current data. For future efforts at program design and evaluation, the author makes several recommendations, including: 1. Be as precise as possible in stating prevention goals and the limitations of those claims, 2. Recognize that prevention efforts may only work in specific conditions, 3. Make the basis of any goal-setting appropriate and clear, 4. Involve both generalized and targeted primary prevention interventions, 5. Use comparable communities as targets for intervention, 6. Use multiple measures for evaluation, and 7. Use measures to both control destructive patterns of behavior and replace those destructive patterns with positive patterns.

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Hampton, Robert L., & Newberger, Eli H. (January, 1985). Child abuse incidence and reporting by hospitals: Significance of severity, class, and race. American Journal of Public Health, 75(1), 56-60. The authors examined the variables associated with the initial diagnosis of child abuse by hospitals and the proportion of cases subsequently reported to child protective service agencies. Estimates from the National Study of the Incidence and Severity of Child Abuse and Neglect showed that hospitals recognized over 77,000 cases of child abuse between May 3, 1979, and April 30, 1980. The authors found that hospitals identified children who were younger, black, lived in urban areas, and had more serious injuries, and that hospitals failed to report to child protection agencies almost half of the cases that met the study's definition of abuse. By further analysis, the authors identified factors that separated reported from unreported cases: income, mother's role in abuse, emotional abuse, race, maternal employment, and sexual

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abuse. A disproportionate number of unreported cases were victims of emotional abuse and came from families with higher incomes. The authors suggest that these data indicate a need to review both the system and process of reporting child abuse to government agencies. 191

Harruff, Richard C. (December, 1992). So-called accidental firearm fatalities in children and teenagers in Tennessee, 19611968. American Journal of Forensic Medicine and Pathology, 13(4), 290-298. The authors studied 255 firearm fatalities reported by Tennessee State medical examiner, especially those classified as accidents involving victims ages 19 and under from 1961 through 1988. Playing with a gun was the most frequent type of incident, and the person responsible for pulling the trigger was equally likely to be a friend, a family member, or the victim. The urban mortality rate was nearly twice the rural rate. More than half of the deaths in urban counties occurred indoors and involved handguns, whereas in rural counties only a third were due to handguns and the location was more often outdoors. The authors recommend that medical examiner reports include more information than is currently recorded if they are to be useful in guiding public policy to reduce firearm injuries.

192

Heifer, Ray E. (1982). A review of the literature on the prevention of child abuse and neglect. Child Abuse and Neglect, 6,251-261. The author reviews the literature on child abuse and neglect and summarizes the programs that have been found effective. Among the 10 areas reviewed and classified, the author discusses several that yielded encouraging results, including work with newborns and their mothers, home care projects, programs on parent education, and studies in family violence. The author suggests that the prevention of many forms of child abuse and neglect is achievable if the approach is both community-oriented and multifaceted.

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Heifer, Ray E. (1991). Child abuse and neglect: Assessment, treatment, and prevention, October 21, 2007. Child Abuse and Neglect, 15(Supplement), 5-15. This article describes a vision for the future of child abuse prevention in the year 2007. The author names ten impediments to the existing prevention, treatment, and protection system and suggests that existing programs for children and their families

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Injury Prevention for Young Children: A Research Guide should be restructured. In outlining the necessary elements for change, the author offered a definition of child maltreatment: "Any interaction or lack of interaction between a child and his or her care parent which results in nonaccidental harm to the child's physical a n d / o r developmental state." One abuse prevention program discussed is a study initiated by the Kempe Center called "Rebuilding Family Foundations." In describing the service models involved in this program, the author discusses assessment services, preventive services, and therapeutic services, as well as staff training and interaction.

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Hutson, H. Range, Anglin, Deirdre, & Pratts, Michael J., Jr. (February 3,1994). Adolescents and children injured or killed by drive-by shootings in Los Angeles. The New England Journal of Medicine, 330(5), 324-327. The authors conducted a study to determine the frequency of drive-by shootings involving children and adolescents in Los Angeles in 1991 and to identify the population at greatest risk for injury and death. Of the 677 adolescents and children who were the targets of shootings, 429 (63%) had gunshot wounds and 36 (5.3%) died from their injuries. In addition, the authors found that 303 of those with gunshot wounds (71%) were gang members, that arms and legs were the areas of the body most commonly injured, and that handguns were the most frequently used type of firearm. Because the study revealed that all the homicide victims were African-American or Hispanic, and 97% were boys, they noted that African-American and Hispanic children and adolescents, especially male gang members, had a significantly higher risk than their Asian and white counterparts of injury and death from driveby shootings in Los Angeles. The authors recommend that future efforts investigate why violent street gangs form and develop programs to prevent violence and to restrict access to firearms.

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Huxley, Peter, & Warner, Richard. (October, 1993). Primary prevention of parenting dysfunction in high-risk cases. American Journal of Orthopsychiatry, 63(4), 582-588. This study evaluated the Community Infant Project (CIP) in Boulder, Colorado, an early intervention program geared to the prevention of parenting dysfunction in high-risk families during the prenatal period and the first three years of life. Twenty cases treated by CIP were selected to match a control group of 20 families referred to CIP but not treated because the program was full. Outcome was measured by the Adult/Adolescent Parenting

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Inventory (a measure of parental attitudes toward child care), the HOME Scale (an interviewer-rated assessment of home environment), the Bayley Scales of Infant Development, and the family's use of health care and other services, plus child abuse and neglect reports. The authors observed that CIP cases were slightly more able to empathize with their children. On the HOME scale, the CIP group showed more favorable scores in emotional and verbal responsiveness of the mother, the provision of play material, and the mother's involvement with the child. On the Bayley Scale, the control and intervention groups did not differ on most items, but on the use of health care and other services, the groups differed in use of the parenting center and well-child care as well as in emergency room use. Pointing to the main aim of the Community Infant Project (prevent parenting dysfunction and resulting child abuse, neglect, failure to thrive, developmental delay, and failure to bond), the authors conclude that the CIP program's approach of integrated, intensive, home-based services aimed at preventing parenting dysfunction can change parental attitudes and practices, reduce the use of community health and social services, and decrease infant morbidity. 196

Jason, Janine, & Andereck, Nathan D. (1983). Fatal child abuse in Georgia: The epidemiology of severe physical child abuse. Child Abuse and Neglect, 7(1), 1-9. This study compared 51 fatal child abuse cases occurring in Georgia between July, 1975 and December, 1979 to non-fatal cases and to the Georgia population. The authors found that overall rates of fatal child abuse were higher for male perpetrators and black perpetrators. The highest child abuse fatality rates were found in poor, rural, white families (3.3 per 100,000 children) and in poor, urban, black families (2.4 per 100,000 children). Risk factors for fatal abuse included early childhood, teenage childbearing, and low socioeconomic status. These characteristics were similar to those of the severe child abuse cases noted in the early child abuse literature. Non-fatal cases did not clearly share these risk factors. Characteristics associated with the fatal cases were not necessarily attributable to all child abuse cases. The authors recommend that child abuse research should use restricted, stated case definitions, and that intervention and prevention programs should not generalize research findings to all forms of child abuse.

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Jason, Janine, Andereck, Nathan D., Marks, James, & Tyler, Carl W. (1982). Child abuse in Georgia: A method to evaluate risk factors and reporting bias. American Journal of Public Health, 72(12), 1353-1358. The authors examined data collected from July, 1975 through December, 1979 from the Georgia Department of Protective Services Central Registry on confirmed, nonconfirmable, and ruled-out child abuse reports to reveal reporting biases based on demographic characteristics. The authors discuss several examples of factors or categories for which an association was suggested in other studies, but which were not supported by the authors' analysis, including urban residence, teenage motherhood, infancy, and mothers and other female perpetrators. Certain households do appear to be at increased risk for child abuse: large families, families without a biological mother or biological father, and families needing Aid to Families with Dependent Children (AFDC). Because this increased risk appeared to be slight, the authors recommend improving surveillance that requires identification of reporting biases.

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Jason, Janine, Carpenter, Mary M., & Tyler, Carl W„ Jr. (February, 1983). Underrecording of infant homicide in the United States American Journal of Public Health, 73(2), 195-197. The authors investigated a sudden drop in homicide rates for infants that occurred between 1967 and 1969. The investigation suggested that two classification revisions during this time were responsible for the apparent decline: changes in related codes set forth in the Eighth Revision of International Classification of Diseases, Adapted (ICDA) and revision of the standard certificate of death in 1968. The ICDA added a category: "Injuries undetermined whether accidentally or purposely inflicted," and the standard certificate of death was revised when a box (or boxes) marked "Accident, Suicide or Homicide," had an additional category included: "Undetermined." The authors recognized that the "Undetermined" category gave examiners an easy means of avoiding a definite diagnosis of homicide, particularly for infants. Because both vital statistics and law enforcement data have usually indicated that the first year of life is a peak age for child homicide, the authors cautioned that the effects of the revisions discussed should be recognized when assessing homicide as a cause of death for infants.

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199

Keck, Nancy J., Istre, Gregory R., Coury, Daniel L., Jordan, Fred, & Eaton, Antoinette P. (June, 1988). Characteristics of fatal gunshot wounds in the home in Oklahoma: 1982-1983. American Journal of Diseases of Children, 142(6), 623-626. The authors reviewed all unintentional firearm deaths among people ages 20 and under in Oklahoma during 1982 and 1983. There were 32 unintentional deaths from firearms during the study period. The death rate in rural counties was four times that of urban counties. Twenty-seven deaths (85%) occurred at home, with an adult present in only two cases. The home death rate for males was 5.2 times that of females, with males ages 15 to 19 at highest risk. The rates among whites and Native Americans were similar, at 1.5 and 1.2 per 100,000, respectively, with no deaths among the black population. The authors conclude that firearms are a significant cause of mortality in the pediatric age group, and suggest that counseling parents about the hazards of firearms may prevent deaths through better supervision and more responsible gun care and storage.

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Krents, Elisabeth, Schulman, Valerie, & Brenner, Sheila. (1987). Child abuse and the disabled child: Perspectives for parents. Washington, DC: Alexander Graham Bell Association for the Deaf. The authors discuss the problem of child abuse, both physical and sexual, with special emphasis on disabled children's particular vulnerability to exploitation and abuse. Schools and parents have special roles in confronting and dealing with this issue. The authors stress the need to ensure that disabled children are provided both accurate information on sexual abuse and the necessary skills to protect themselves from victimization. The authors list signs of physical abuse, neglect, sexual abuse, and emotional maltreatment and offer specific suggestions for parents and schools to prevent abuse.

201

Leventhal, John M., Egerter, Susan A., & Murphy, Janet M. (November, 1984). Reassessment of the relationship of perinatal risk factors and child abuse. American Journal of Diseases of Children, 138(11), 1034-1039. The authors performed a case-control study of 117 cases and controls to determine potential risk factors for child abuse. They examined four perinatal risk factors: prematurity of the infant, low birth weight of the infant, young maternal age at the birth of the infant, and young maternal age at the birth of the mother's first

80

Injury Prevention for Young Children: A Research Guide child. Cases were chosen from children who were reported to the Yale-New Haven Hospital Child Abuse Registry and were selected for evidence of physical abuse, ages 10 and under, and a non-twin birth. Physical abuse was defined as an act of commission by one of the caretakers that resulted in physical injury to the child. The authors found no relationship between prematurity or low birth weight and abuse, but there was an association between child abuse and young maternal age (both at the birth of the study child and at the birth of the first child). The authors suggest that identifying children at risk of abuse involves more than attempting to determine specific demographic risk factors, but rather evaluating the wide-ranging variables involved in parent-child relationships.

202

Liang, Belle, Bogat, G. Anne, & McGrath, Marianne P. (September-October, 1993). Differential understanding of sexual abuse prevention concepts among preschoolers. Child Abuse and Neglect, 17(5), 641-650. The authors analyzed preschoolers' understanding of sexual abuse prevention concepts and whether children comprehended these skills in the order taught by prevention programs. Using the "What If Situations Test" (WIST) as a basis for the study, the components of WIST were analyzed: recognizing good and bad touches, refusing the perpetrator, leaving the situation, finding an adult, and accurately disclosing the abuse. Subjects were 117 preschoolers who were individually administered the WIST. Based on the children's test scores, the authors conclude that although many children understand the sequence of preventive skills as they are taught in prevention programs, for the youngest children, skills for refusing the abuser were better developed than skills for recognizing the abuse. The authors recommend that more items assessing children's responses to appropriate touch should be included in the testing.

203

Lindsey, Duncan, & Regehr, Cheryl. (October, 1993). Protecting severely abused children: Clarifying the roles of criminal justice and child welfare. American Journal of Orthopsychiatry, 63(4), 509-517. This article reviews the roles of justice and child welfare agencies in the prevention and intervention of child abuse and neglect. Suggesting that abuse reporting laws enacted in the late 1960s and early 1970s resulted in overburdening child welfare agencies and shifting their focus from a benevolent helping

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intervention to one of investigation and accusation, the authors recommend that the criminal justice system shoulder a greater responsibility, that abuse should be handled by the criminal justice system, while neglect should be the focus of the child welfare system. The authors conclude by offering a model framework for intervention in allegations of child abuse that include specific responsibilities for each agency. 204

Margolin, Leslie, & Craft, John L. (1990). Child abuse by adolescent caregivers. Child Abuse and Neglect, 14(3), 365-373. This study estimated the frequency and severity of child abuse committed by adolescents who were in non-parental caregiving roles. Using cases in which either physical or sexual abuse was substantiated through child welfare investigation, the authors m a d e comparisons between adolescent and adult caregivers. Caregiver age did not appear to have a significant difference on the occurrence of physical abuse, but adolescents committed substantially more sexual abuse than older caregivers. Sexual abuse committed by adolescents was also more likely to involve intercourse and physical assault. The authors suggest that future research address ways to develop programs aimed at training teenage caregivers in junior and senior high schools, training that could reduce child abuse by adolescent caregivers and train them to be better parents as well.

205

Margolin, Leslie. (March, 1994). Child sexual abuse by uncles: A risk assessment. Child Abuse and Neglect, 18(3), 215-224. The author used the cases of 982 mothers who reported on child care and living arrangements involving uncles, and case records documenting the sexual abuse of 171 children by 148 uncles. The purpose of this study was to examine the ways uncles ordinarily became involved with children, the conditions under which that involvement became associated with sexual abuse, and the role gender played in this dysfunction. Among the findings, the author noted that although aunts were responsible for 28 times more child care than uncles, uncles were responsible for 48 times more child sexual abuse. Further, although female children did not have more exposure to uncles than did males, they appeared four times more likely to be victimized. About 19% of the abusive uncles lived with the children they abused, and most of the remainder came into contact with them as child care providers or during overnight visits. The author recommends three type of intervention: educating children to be aware of sexual abuse,

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Injury Prevention for Young Children: A Research Guide teaching parents to take the threat seriously, and identifying and treating the perpetrator.

206

Martin, John R., Sklar, David P., & McFeeley, Patricia. (January, 1991). Accidental firearm fatalities among New Mexico children. Annals of Emergency Medicine, 20(1), 58-61. The authors studied all unintentional firearm fatalities occurring in New Mexico to children ages 0 to 14 between 1984 and 1988. Loaded firearms were readily available in 93% of all unintentional firearm fatalities happening among children ages 0 to 12. Because the majority of these deaths were considered preventable, the authors recommend that manufacturers design safer weapons and trigger mechanisms and modify ammunition to reduce the risk of fatal injury.

207

McCIung, H. Juling, Murray, Robert, Braden, Nancy Jo, Fyda, John, Myers, Robert P., & Gutches, Lynn. (June, 1988). Intentional ipecac poisoning in children. American Journal of Diseases of Children, 142(6), 637-639. This article describes the abuse of ipecac, which is a safe emetic (substance which induces vomiting) for emergency home use, but which also provides the potential for child abuse. The chronic administration of ipecac can result in unusual symptoms, such as chronic diarrhea and vomiting, muscle weakness, colitis, cardiomyopathy, fever, edema, or electrolyte disturbances. The authors suggest that toxicology laboratories may not look for or report the presence of this drug in their routine screens, delaying the recognition of chronic ipecac poisoning in patients.

208

Morrow, Paul L., & Hudson, Page. (September, 1986). Accidental firearm fatalities in North Carolina, 1976-1980. American Journal of Public Health, 76(9), 1120-1123. The authors reviewed accidental gunshot fatalities in North Carolina during 1976 to 1980. There were 210 cases, of which 94 were self-inflicted and 116 were inflicted by others. Young white males predominated as victims, 31% of whom were ages 15 and under. Sixty-five percent of the accidents occurred in the home and 18% occurred in rural, hunting locations. Forty-one percent of the cases involved shotguns, 39% involved handguns, and 16% rifles. Sixteen percent of the accidents involved children playing with guns and 14% involved dropped or mishandled weapons. During the same period, there were 2,553 suicides and 2,509 homicides by firearm.

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209

Newberger, Eli H., Hampton, Robert L., Marx, Thomas J., & White, Kathleen M. (1986). Child abuse and pediatric social illness: An epidemiological analysis and ecological reformulation. American Journal of Orthopsychiatry, 56(4), 589601. This study matched children ages 4 and under hospitalized for child abuse, domestic accidents, failure to thrive, and ingestions with children hospitalized for comparably severe medical conditions. Through parental interviews, the authors found that families of the children with social illness appeared to have more stress in their lives than the families of children with medical conditions. When the study families were divided into three clusters (ecologic advantage, ecologic adversity, and ecologic crisis), the authors found that no specific set of variables could identify abusing families from those with other diagnoses. The authors suggest that the three clusters used in this study could be used as a matrix for organizing data from families with a history of pediatric social illness.

210

Ordog, Gary J., Wasserberger, Jonathan, Schatz, Ivan, OwensCollins, Deborah, English, Kerry, Balasubramanian, Subramanian, & Schlater, Theodore. (June, 1988). Gunshot wounds in children under 10 years of age. American Journal of Diseases of Children, 142(6), 618-622. The authors studied 34 children ages 10 and under who were treated for gunshot wounds from 1980 to 1987. These injuries were divided by cause into four groups: unintentional injury, child neglect, child abuse, and intentional attempts at homicide. Ten of the children were unintentionally shot by other children or accidentally shot themselves. One shooting was classified as child abuse, and 20 were deemed to be caused by guardian neglect. Seven of the cases were reported by police as gang-related. The authors conclude that the majority of gunshot injuries in young children are the result of having handguns in the home and child neglect.

211

Patterson, Patti J., & Smith, Leigh R. (February, 1987). Firearms in the home and child safety. American Journal of Diseases of Children, 141(2), 221-223. The authors surveyed 150 families in the pediatric outpatient clinics at a Texas university to evaluate firearm ownership and hazards. Thirty-eight percent of those surveyed kept at least one gun at home. Of those who kept firearms at home, 55% reported

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Injury Prevention for Young Children: A Research Guide that the gun was loaded at all times, and 10% reported that the gun was kept loaded, unlocked, and within the reach of a child. The authors conclude that household firearms pose a significant risk to children and that intervention by physicians could help reduce this public health problem.

212 Paulson, Jacqueline S. (1983). Covert and overt forms of

maltreatment in the preschools. Child Abuse and Neglect, 7(1), 4554. This study was based on data from observations of 60 to 70 preschools in the New York City area during 1976 to 1981. The author identified covert forms of maltreatment in staff (directors, teachers, assistants) attitudes toward young children, including insisting that children learn to be independent while reinforcing dependent behavior; overemphasizing the acquisition of academic skills, irrespective of age; excessively relying on packaged educational materials; not using materials with intrinsic interest for children; having a lack of enthusiasm for working with young children; rigidly adhering to routine for convenience; and disliking particular children. Overt forms of maltreatment to gain compliance or obedience from young children ranged from direct verbal attack (insult, sarcasm, ridicule, threats, name calling, or humiliation), to emotional abuse (withholding of affection or compassion), to clear physical coercion (pulling, pushing, shoving, yanking, expulsion from class, or isolation in class). These patterns were not limited to a particular model but occurred in each preschool category. The author suggests that early childhood educators should receive special training and well-supervised internships to improve the preschool environment and prevent the forms of abuse described in this study.

213 Reece, Robert M., & Grodin, Michael A. (February, 1985).

Recognition of nonaccidental injury. Pediatric Clinics of North America, 32(1), 41-60. This article is a review of the literature addressing the problem of identifying intentional injuries. The authors describe a series of injuries and the accidental and intentional characteristics of each: drowning, poisoning, skin injuries (bruises or bite marks), burns, head injuries, eye injuries, and internal injuries. Discerning the cause of injury as intentional or accidental should include both physical and laboratory examination, as well as gathering information about the child's family, home environment, and medical history. The authors suggest that future research must

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further assess the definition and control of abuse, including measures of outcome or success for prevention programs. 214

Renz, Barry M., & Sherman, Roger. (May, 1993). Abusive scald burns in infants and children: A prospective study. The American Surgeon, 59(5), 329-334. This study evaluated the cases of 30 consecutive deliberately scalded children to characterize the scald-abused child. Mean age was 22.5 months, mean burn size was 18.1% of the total body surface area, and 37% of the children required a surgical procedure for the scald. All 30 children had burns on the buttocks. Four (13.3%) had other injuries. Eighty percent of patients had at least one complication. In 30%, diarrhea complicated nutrition support, wound, or autograft care. Four (13.3%) patients with a mean burn size of 32.3% of the total body surface area, diarrhea, and burns involving the buttocks, perineum, and external genitalia died from burn wound infections. The authors conclude that the average scald-abused child is an undernourished 2-year-old with a 15% to 20% burn involving the buttocks who has a high incidence of complications and a 10% to 15% mortality from burn infection. The majority of these children have one or more pre-burn health problems, and many have diarrhea. Because frequent exposure to fecal material increases the risk of infection, the authors suggest that burns involving the buttocks be examined frequently to prevent infection.

215

Rivara, Frederick P., Kamitsuka, Michael, D., & Quan, Linda. (January, 1988). Injuries to children younger than 1 year of age. Pediatrics, 81(1), 93-97. The authors studied the circumstances and characteristics of emergency room-treated injuries in children under age 1 were studied and compared unintentional injuries to those caused by abuse. Unintentional injuries were seen 15 times more frequently in an emergency room than injuries caused by abuse. The majority of unintentional injuries were minor. Injuries caused by abuse were commonly multiple, severe, and more likely to result in longterm disability. The authors suggest that unintentional injuries are rarely serious and that closed head injury, rib or lower extremity fractures, and abdominal injuries are usually indicative of abuse.

216

Schetky, Diane H. (March, 1985). Children and handguns: A public health concern. American Journal of Diseases of Children, 139(3), 229-231.

86

Injury Prevention for Young Children: A Research Guide This article reviews data on children and handgun injuries and deaths, including firearm homicide, suicide, accidental deaths, and handgun injuries. The author emphasizes four points: 1. There is no safe place to keep handguns around children, 2. A handgun purchased for self-defense is more likely to be used on a family member than an intruder, 3. Children do not distinguish between toys and real guns and do not fully comprehend death, and 4. Victims of violence often identify with the aggressor and become perpetrators of violence. The author discusses the issue of handgun control, and suggests that prevention interventions involve both parents and physicians in protecting children from violence.

217

Senturia, Yvonne D., Christoffel, Katherine Kaufer, & Donovan, Mark. (March, 1994). Children's household exposure to guns: A pediatric practice-based survey. Pediatrics, 93(3), 469-475. This study used survey data to describe the prevalence of firearms in households containing children who go to pediatricians, the types of firearms owned, the purposes of such ownership, the conditions of firearm storage, and the social correlates of ownership. Of the 5,233 families surveyed, 37% owned firearms, including rifles (26%), handguns (17%), and powder firearms (32%). Thirteen percent of 823 handguns and 1% of 1,327 rifles were reported both unlocked and loaded. Recreation was the most common reason for both rifle (75%) and handgun (59%) ownership. Forty-eight percent of handguns were kept for self-protection, compared with 21% of rifles. Households owning guns were more likely located in a rural area, living in a single family dwelling, containing at least one adult male, and having fewer preschool children. The authors suggest that pediatricians routinely see children in families that own firearms, including some that keep loaded and unlocked handguns, and recommend that physicians routinely counsel their patients about firearm safety.

218

Slaby, Ronald G., Roedell, Wendy C, Arezzo, Diana, & Hendrix, Kate. (1995). Early violence prevention: Tools for teachers of young children. Washington, DC: National Association for the Education of Young Children. This book describes strategies to reduce violence and address the effects of exposure to violence in early childhood settings. The techniques include many traditional approaches: positive interactions, a well-organized physical and programmatic

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environment, opportunities for children to make choices, and teaching and modeling of social skills. In addition, the authors suggest that in many instances our instinctive responses can work against stated goals, such giving children attention when they are being aggressive. To address this kind of problem, the authors provide some new approaches: teaching children how to stand up to aggressors in nonviolent ways, controlling the effects of media violence, and teaching social problem-solving skills. Recognizing that some children have violent behavior patterns that are deeply rooted, the authors provide strategies such as developing a behavior change plan, using time-outs, and offering concrete reminders and incentives. 219

Smith, J. A. S., & Adler, R. G. (1991). Children hospitalized with child abuse and neglect: A case-control study. Child Abuse and Neglect, 15(4), 437-445. The authors conducted a case-control s t u d y of 45 hospitalized abused children to assess the risk factors for child abuse among children from similar social classes. Cases were matched for age, gender, family structure, and social class with children admitted to hospital for an acute illness. Abused children were more likely to have younger parents, fewer siblings, and to have been separated from their mothers during the first year of life. The parents of abused children were more likely to have been abused as children and to have a poor relationship with the child's other parent. The families of abused children had also encountered more stressful life events in the preceding 12 months. Other previously recognized risk factors were not shown to have a statistically significant association with child abuse. Because child abuse is more prevalent among families with lower socioeconomic status, the association with many of these factors has been accepted as implying a causal relationship. The authors suggest that matching families of abused children by socioeconomic class and family structure casts doubts on some previously-held beliefs about the risk factors for child abuse.

220

Sorenson, Susan B., Richardson, Barbra A., & Peterson, Julie G. (May, 1993). Rac€/ethnicity patterns in the homicide of children in Los Angeles, 1980 through 1989. American Journal of Public Health, 83(5), 725-727. This study used data from 246 children ages 14 and under who were murdered in Los Angeles, California from 1980 through 1989 to establish age, gender, and ethnicity risk patterns for

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Injury Prevention for Young Children: A Research Guide homicide. Homicide rates were higher for children ages 0 to 4 than for ages 5 to 14. Homicide rates by gender were similar at young ages, but males ages 5 to 14 had higher rates than females. Homicide rates by race were lowest for non-Hispanic White, higher for Hispanic, and highest for black children. The authors suggest that future research develop intervention programs directed toward black infants and toddlers, the group at highest risk in this study.

221

Thomas, Joyce N., Rogers, Carl M., Lloyd, David, & Sihlangu, Ruth. (July, 1985). Child sexual abuse: Implications for public health practice. Rockville, MD: Division of Maternal and Child Health, U. S. Department of Health and Human Services. This pamphlet discusses issues related to child sexual abuse which are more common to public health programs and services which provide care to middle- and low-income segments of the population. Topics discussed include implications for public health practice, defining child abuse, the scope of the problem, maternal and child health issues, vulnerable families, how cases enter the public health system, community health teams, general principles of medical management, interviewing the child and parents, the physical examination, communicable disease control, psychosocial considerations, legal considerations in cases of child sexual victimization, and cultural and ethnic values. The authors conclude by making recommendations for future public health programs and prevention efforts.

222

Tilden, Virginia P., Schmidt, Terri A., Limandri, Barbara J., Chiodo, Gary T., Garland, Michael J., & Loveless, Peggy A. (April, 1994). Factors that influence clinicians' assessment and management of family violence. American Journal of Public Health, 84(4), 628-633. This study used questionnaires about clinicians' experiences with and attitudes toward family violence to determine what factors influence clinicians' decision-making about identifying abuse and intervening with victims. A third of the subjects reported having received no training on child, spouse, or elder abuse in their professional training programs. Subjects with education on the topic more commonly suspected abuse in their patients than those without. Spouse abuse was suspected more often than child abuse, while elder abuse was suspected infrequently. A significant number of subjects did not view themselves as responsible for dealing with problems of family

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violence. Subjects indicated both low confidence in and low compliance with mandatory reporting laws. The authors conclude that there is a need for educators to expand current training of clinicians on family violence and for legislators to reexamine the effectiveness of and compliance with current mandatory reporting laws. 223

Wasik, Barbara Hanna, & Roberts, Richard N. (March, 1994). Survey of home visiting programs for abused and neglected children and their families. Child Abuse and Neglect, 18(3), 271283. This study used a survey to collect data on home visiting programs. Of the 1,904 programs participating in the survey, 224 had services for children who were abused or neglected as a primary focus. The authors found that over 70% of the 224 programs identified social service as their organization affiliation which, in contrast to other providers, offered a broad range of services for the abused or neglected children and their families. The most frequently identified purpose for providing services was the social and emotional development of the child. Parenting skills and parent coping were considered the most important services. Stress m a n a g e m e n t was considered more i m p o r t a n t by respondents of programs for abusing families than by those providing services to other families. Approximately half the respondents reported that they required a bachelor's or master's degree for employment. The authors suggest that these data suggest a need for home visiting programs to refine or improve training, hiring practices, and supervision and to include evaluation of current programs in the development of future policies and programs.

224

Wurtele, Sandy K., Kast, Laura C , & Melzer, Anastasia M. (November-December, 1992). Sexual abuse prevention education for young children: A comparison of teachers and parents as instructors. Child Abuse and Neglect, 16(6), 865-876. This study compared teachers and parents as instructors of a sexual abuse prevention program. One hundred seventy-two Head Start preschoolers were randomly assigned to a personal safety program taught by their teachers, parents, both teachers and parents, or to a general safety control program. Following program participation, children who were taught by their teachers, parents, or both showed improved knowledge about sexual abuse and higher levels of personal safety skills compared with those in the

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Injury Prevention for Young Children: A Research Guide control group. These gains in knowledge and skills were found to be maintained 5 months later at follow-up. Children taught by their parents showed greater improvements in recognizing inappropriate-touch requests and personal safety skills than children taught by their teachers. Children who received the program both at home and school were better able to recognize appropriate-touch requests and to demonstrate higher levels of personal safety skills than children taught only at school. The authors suggest that both home and school personal safety programs can be used effectively as part of a multiple, diverse approach to the complex problem of child sexual abuse.

225

Wyatt, Gail Elizabeth, & Peters, Stefanie Doyle. (1986). Methodological consideration in research on the prevalence of child sexual abuse. Child Abuse and Neglect, 10(2), 241-251. This article focuses on four studies, describing how differences in methodology and sample characteristics may contribute to the variation in prevalence rates. The authors suggest that two aspects of data collection appeared to be the most significant factors accounting for discrepant findings: the use of fact-to-face interviews rather than the use of self-administered questionnaires, and the use multiple questions to ask about specific types of abusive sexual behavior. Variation in the age ranges of subjects is another factor that may also have an effect on prevalence rates. The use of random sampling techniques, the area of the country in which the study was conducted, the educational level of subjects, and the ethnic composition of the sample appeared to have no influence on the prevalence findings. Because previous research has produced varying prevalence rates, the authors suggest that further prevalence research should use the techniques described in this article to confirm the results of earlier studies.

226

Zuravin, Susan J., Benedict, Mary, & Somerfield, Mark (October, 1993). Child maltreatment in family foster care. American Journal ofOrthopsychiatry, 63(4), 589-596. The authors studied 296 Maryland foster homes to determine predictors of maltreatment of children living in family foster care. Sixty-two of the homes had at least one confirmed maltreatment report during the 5-year study period. The authors found four characteristics that indicated increased risk: homes that had younger foster mothers, homes in which children shared bedrooms with other family members, homes about which case-

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workers had reservations, and homes that were restricted for placement of certain children. Kinship-care homes, where other family members served as foster parents, were found to present decreased risk. The authors recommend further research to prevent maltreatment in foster care, especially towards children who have already been victimized by their natural parents.

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4

Choking and Asphyxiation

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or children under age 1 (infants), suffocation is the leading cause of accidental death. For children ages 4 and under, choking is one of the top seven causes of accidental death. The articles and books in this chapter present information on prevalence, types of injuries, risk factors, common hazards, and prevention interventions. For infants, many deaths are characterized as "Sudden Infant Death Syndrome." Infants also are suffocated by plastic bags in their cribs or playpens. For older children, choking deaths are commonly caused by small objects, toys, balloons, and food. Articles discussing strangulation on cords are also included. Prevention recommendations are caregiver recognition of danger and removing hazardous objects from the environment. Also important is knowing first aid for choking such as the Heimlich maneuver and finger sweep. Rescue methods differ for infants and older children. The role of the Consumer Product Safety Commission is emphasized in the literature. 227

American Academy of Pediatrics Committee on Pediatric Emergency Medicine. (September, 1993). First aid for the choking child. Pediatrics, 92(3), 477-479. This article reviews abdominal thrusts, back blows, chest thrusts, and finger sweeps, four common techniques used as first aid for choking children. The authors recommend that rescuers use back blows for infants less than 1 year old, and abdominal thrusts for children ages 1 year and over.

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Baker, Susan P„ & Fisher, Russell S. (September 19, 1980). Childhood asphyxiation by choking or suffocation. Journal of the American Medical Association, 244(12), 1343-1346. The authors reviewed the medical examiner records for 42 children ages 10 and under who died from asphyxiation during 1970 to 1978. Twelve of the children choked on food, and eight choked on other objects. Objects that were small, round, and pliable were responsible for most of the choking incidents. Suffocation caused 22 of the deaths, 4 of which were infants who suffocated on plastic bags in their cribs or playpens. The authors emphasize the role of the Consumer Product Safety Commission in creating regulations to reduce choking hazards for children, and suggest that further changes in product safety and regulations are needed.

229

Choking: To save a life [videotape]. (1989). Chicago, IL: Encyclopaedia Britannica Educational Corporation. This 12-minute video demonstrates choking rescue techniques such as the Heimlich maneuver and the finger sweep.

230

Day, Richard L., Crelin, Edmund S., & DuBois, Arthur B. (July, 1982). Choking: The Heimlich abdominal thrust vs back blows: An approach to measurement of inertial and aerodynamic forces. Pediatrics, 70(1), 113-119. This article discusses the effectiveness of the Heimlich maneuver and back blows for choking infants and young children. The authors suggest that back blows, because they produce less pressure than the Heimlich maneuver, may actually cause foreign material to drive farther down the child's airway.

231

Esclamado, Ramon M., & Richardson, Mark A. (March, 1987). Laryngotracheal foreign bodies in children: A comparison with bronchial foreign bodies. American Journal of Diseases of Children, 141(3), 259-262. The authors studied the records of 20 children with foreign objects in the larynx and trachea to discover whether symptoms of choking in this area were different from those of foreign objects in the bronchial area. Subjects ranged in age from 6 months to 17 years, with 80% ages 3 and under. The most common symptoms among the subjects were stridor (noisy breathing), wheezing, sternal retractions, and coughing. Common symptoms of bronchial foreign bodies are cough, decreased breath sounds, wheezing, and

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dyspnea. The authors describe techniques used to diagnose and treat both conditions, and give recommendations for each. 232

Gilbert-Barness, Enid, Hegstrand, Linda, Chandra, Sunita, Emery, John L., Barness, Lewis A., Franciosi, Ralph & Huntington, Robert. (March, 1991). Hazards of mattresses, beds and bedding in deaths of infants. American Journal of Forensic Medicine and Pathology, 12(1), 27-32. The authors examined 52 infants who had died suddenly over the previous 4 years. In 20 of the cases, the deaths were due to preventable accidents rather than Sudden Infant Death Syndrome (SIDS). These accidental deaths fell into four categories: suffocation on water beds, suffocation on sheepskin rugs, accidents associated with beds, and overlying. Nine of the infants died lying down on an adult free-flowing water bed. Three infants died sleeping on thick, piled sheepskin rugs. The bed-related deaths included several infants whose heads became wedged in the crib or bed frame, and one infant thrown off a water bed, and one infant who strangled on a cord while in his crib. The overlying deaths were caused by adults falling asleep in beds with young infants. The authors describe each case, and give several recommendations to improve the safety of infants and young children in beds and cribs.

233

Goodson, Barbara, & Bronson, Martha. (1993). Which toy for which child: A consumer's guide for selecting suitable toys: Ages birth through five. Washington, DC: U. S. Consumer Product Safety Commission. This booklet describes the various developmental stages of children ages 0 to 5, and explains which toys are suitable for children at each stage. Because young children tend to explore objects by putting them in their mouths, choosing safe toys for young children can significantly reduce the risk of choking.

234

Greensher, Joseph, & Mofenson, Howard C. (October, 1993). Aspiration accidents: Choking and drowning. Pediatric Annals, 12(10), 747-752. In addressing the problem of the choking child, the authors of this article examine some of the methods of treatment for this condition. The two most common maneuvers are abdominal thrusts and chest thrusts. The authors note that if a choking victim can speak or breathe and is coughing, the foreign object had the best chance to dislodge spontaneously. Any intervention is unnecessary and potentially dangerous. However, if there were

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Injury Prevention for Young Children: A Research Guide partial obstruction with poor air exchange or cyanosis, or complete obstruction, then immediate intervention would be required. The article includes a table of recommended treatments for childhood choking and eight steps to prevent foreign body aspiration. Four major factors contribute to childhood drownings: high-risk individuals, inadequate supervision, inadequate barriers, and harmful practices. To prevent childhood drowning, the authors suggest that communities should protect children from access to dangerous bodies of water, that children ages 3 and under should use life jackets when near water, that children should know how to swim, and that safety rules should be taught and enforced.

235

Heimlich, Henry J. (July, 1982). First aid for choking children: Back blows and chest thrusts cause complications and death. Pediatrics, 70(1), 120-125. This article describes two methods of first aid for choking children: back blows and abdominal thrusts (the Heimlich maneuver). The author suggests that back blows, which are often recommended for choking infants, can actually cause airway obstructions to lodge further down the airway. The author concludes that abdominal thrusts, despite the risk for broken ribs or other injury, have proven to be the safest way to clear foreign objects out of the airway, even for very small children and infants.

236

Henderson, John M. (August, 1989). Balloons as a cause of airway obstruction. American Family Physician, 40(2), 171-173. The author discusses balloons as a serious risk of choking mortality among young children. If the balloon bursts while the child is inflating it, pieces of the balloon may be thrust into the child's airway. Because the material is light, flexible, and easily stuck to the inside of the airway, the obstruction is very difficult to clear. The author recommends that children be taught how to blow u p balloons with their teeth clenched to prevent the risk of death or serious injury from inhaling balloon fragments.

237

Hord, Jeffery D., & Anglin, David. (October, 1993). Accidental strangulation of a toddler involving a wall light switch. American Journal of Diseases of Children, 147(10), 1038-1039. This article describes the strangulation death of a 3 year-old boy. The boy was strangled by cords from a hanging light switch that was marketed as a device for young children to become more independent. The company that marketed the switch removed the

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product from the market as soon as they were notified of the boy's death. 238

Kraus, Jess F. (March-April, 1985). Effectiveness of measures to prevent unintentional deaths of infants and children from suffocation and strangulation. Public Health Reports, 100(2), 231240. The author describes several measures developed in the 1950s to prevent childhood suffocation and strangulation, and uses data from California to evaluate their effectiveness. The measures aimed at refrigerator or freezer entrapment, suffocation by plastic bags, and cave-ins at construction sites have been proven effective since their inception in the late 1950s. However, the number of strangulation deaths in cribs has not declined, despite regulations and crib design changes. The author recommends that manufacturers offer incentives for people to remove or remodel older cribs that do not meet the current standards, and that manufacturers evaluate the new strangulation risks posed by newer designs.

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Langlois, Jean A., Wallen, Beth A. R., Teret, Stephen P., Bailey, Linda A., Hershey, J. Henry, & Peeler, Mark O. (June 5,1991). The impact of specific toy warning labels. Journal of the American Medical Association, 265(21), 2848-2850. The authors surveyed 199 toy buyers to evaluate whether toy warning labels would affect which toys they would purchase for 2 and 3 year old children. Many of the buyers (44%) said they would purchase for a child between the ages of 2 and 3 a toy labeled "Recommended for 3 and up" and only 5% said they would buy a toy labeled "Not recommended for below 3 —small parts." The authors suggest that these findings indicate that more specific warning labels on toys with choking hazards would reduce the number of hazardous toys bought for young children.

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Rund, Douglas A. (December, 1989). Airway obstruction: The Heimlich maneuver. The Physician and Sportsmedicine, 17(12), 36-40. This article gives an overview of the history and mechanics of the Heimlich maneuver. Tests on animal and human subjects have shown this technique effective in preventing deaths and serious injuries from choking on food. If performed correctly, the Heimlich maneuver can be used by a minimally trained person to safely dislodge food or other material obstructing the choking

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Injury Prevention for Young Children: A Research Guide victim's airway. The author uses illustrations to demonstrate this technique, and gives instructions for various choking situations.

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Ryan, C. Anthony, Yacoub, Wadieh, Paton, Tom, & Avard, Denise (November, 1990). Childhood deaths from toy balloons. American Journal of Diseases of Children, 144(11), 1221-1224. The authors describe four children who suffocated after swallowing whole or partial rubber balloons. Of all children's products, balloons are the leading cause of product-related choking deaths in the United States. The authors suggest that adults should always blow up balloons for children, that balloons be banned from hospitals, day care centers, and schools, that balloon packages carry warning labels, and that manufacturers should redesign toy balloons to reduce the risk of choking.

5

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rowning is one of the leading causes of accidental death for children ages 0 to 4. These fatalities occur in bathtubs, in five-gallon buckets, swimming pools, and other bodies of water. Risk factors for drowning accidents include seizure disorders, lack of supervision, lack of barriers or fencing near pools, and activities near water. The articles included in this chapter discuss prevalence, risk factors, and environmental hazards. Prevention efforts focus on recognizing danger and eliminating hazards such as u n g u a r d e d pools, increasing supervision of infants and toddlers, providing safety education for young children, and providing adequate rescue and medical care for victims. 242

Brenner, Ruth A., Smith, Gordon S., & Overpeck, Mary D. (May 25, 1994). Divergent trends in childhood drowning rates, 1971 through 1988. Journal of the American Medical Association, 271(20), 1606-1608. The authors examined trends in unintentional drownings among children ages 0 to 19 in the United States from 1971 to 1988. The National Center for Health Statistics and U. S. Bureau of the Census provided data that the authors used to determine age-, race-, and gender-specific drowning rates. During the 18 years studied, there were 45,680 unintentional drowning deaths among children ages 0 to 19. Drowning rates declined 5.8% per year in children ages 10 to 14 and 5.4% per year in children ages 15 to 19. The rate for toddlers (ages 1 to 2) declined 1.6% per year. The rate

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Injury Prevention for Young Children: A Research Guide for infants (children younger than 1 year) increased 1.6% per year. The authors conclude that future prevention efforts should focus on the infant and toddler age groups that showed little or no improvement in drowning prevention during the years studied.

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Budnick, Lawrence D., & Ross, David A. (June, 1985). Bathtubrelated drownings in the United States, 1979-81. American Journal of Public Health, 75(6), 630-633. This study used National Center for Health Statistics and Consumer Product Safety Commission data to evaluate bathtubrelated drownings and injuries in the United States from 1979 to 1981. During 1979 to 1980, 710 people drowned in bathtubs. Rates were lowest in New England and highest in Pacific and Mountain states. Young children and the elderly were at the highest risk. Personal risk factors varied with age and included a history of being left unattended (for children under age 5), frequent history of seizures (ages 5 to 39), history of alcohol or drug use (ages 40 to 59), and a history of falls (ages 60 and over). In addition to eliminating personal risks, modifying bathrooms to counteract slippery surfaces and taking showers instead of baths may decrease the risk of drowning in bathtubs for all age groups.

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Drownings at U. S. Army Corps of Engineers recreation facilities, 1986-1990. (May 15, 1992). Morbidity and Mortality Weekly Report, 41(19), 331-333. This article describes drownings at U. S. Army Corps of Engineers lakes and reservoirs during 1986-1990. The Corps is the largest federal provider of water-based recreation facilities in the United States. During the five years studied, 1,107 people drowned at Corps facilities, of whom 30% were ages 16 to 25,13% were ages 26 to 30, and 6% were children ages 5 and under. Most of the drownings occurred during swimming or wading (44%), boating (23%), and fishing from shore (17%). A majority of the swimmingrelated drownings (62%) occurred outside designated swimming areas. The Corps has developed a water safety program for use at all Corps facilities called "Your Safety—Our Concern," which uses public service announcements and posters to promote safe swimming and other activities.

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Gulaid, Jama A., & Sattin, Richard W. (1988). Drownings in the United States, 1978-1984. Morbidity and Mortality Weekly Report, 37(SS-1), 27-33.

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The authors used National Center for Health Statistics Data to determine the number of deaths by drowning in the United States from 1978 to 1984. During the 7 years studied, an average of 6,503 persons drowned each year, ranging from a high of 7,026 in 1978 to a low of 5,388 in 1984. Children ages 5 and under and young adults between ages 15 to 24 had the highest drowning rates. The circumstances of drowning varied by age group: swimming pools were the greatest hazard for toddlers and bathtub drownings were the most common for children and for adults ages 70 and over. Drowning rates varied according to climate, geographic location, and a variety of personal risk factors. The authors conclude that the drop in fatalities from 1978 to 1984 shows some progress in the prevention of drownings, but suggest that more research and prevention efforts are necessary, especially among the high-risk groups established in this study. 246

Hassall, I. B. (June, 1989). Thirty-six consecutive under 5-year-old domestic swimming pool drownings. Australian Paediatric Journal, 25(3), 143-146. The author examined data collected by nurses on 36 New Zealand children ages 5 and under who drowned in residential swimming pools during 1982 to 1986. The subjects were 22 boys and 14 girls, 78% of whom were ages 1 to 2. At least 80% of the pools had inadequate barriers or fencing according to New Zealand's 1987 Swimming Pools Act. Had the 1987 regulations been in place, the author suggests that at least 80% of the drowning deaths would have been prevented.

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Hedberg, Katrina, Gunderson, Paul D., Vargas, Carol, Osterholm, Michael T., & MacDonald, Kristine L. (September, 1990). Drownings in Minnesota, 1980-85: A population-based study. American Journal of Public Health, 80(9), 1071-1074. This population-based study examined drownings in Minnesota during 1980 to 1985. Death certificates and incident reports showed that 541 people drowned in Minnesota during the years studied. Most of the drownings (62%) occurred during the summer months. These summer drownings primarily involved boating (42%) and swimming (35%). Eleven percent of the drownings occurred during the winter months. These deaths primarily involved snowmobiles and motor vehicles breaking through ice on lakes and waterways (71%). The risk of drowning was highest during March and April, when ice is melting, and during October and November, when lakes and waterways begin

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Injury Prevention for Young Children: A Research Guide to freeze. Drowning rates were highest for men, people ages 15 to 25, and children ages 5 and under. The authors suggest that these data should be used to target drowning prevention programs, especially in colder climates.

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Kemp, Alison M., & Sibert, J. R. (May, 1993). Epilepsy in children and the risk of drowning. Archives of Disease in Childhood, 68(5), 684-685. This British study examined the records of 306 children who drowned or nearly drowned in the United Kingdom during 1988 and 1989. Of these children, 10 had incidents related to epilepsy. Five of the children with epilepsy also had other disabilities. The authors suggest that children with epilepsy should swim at lifeguard-supervised pools, and should be encouraged to take showers rather than baths. Children with less controlled epilepsy or with associated learning difficulties should be closely supervised at all times while swimming and bathing.

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Kemp, Alison, & Sibert, J. R. (May 2,1992). Drowning and near drowning in children in the United Kingdom: Lessons for prevention. British Medical Journal, 304(6835), 1143-1146, This British study examined patterns of drowning and near drowning among British children ages 15 and under during 1988 and 1989. A total of 306 children had reported drowning or near drowning incidents, of whom 149 died. A majority of the children (68%) were ages 5 and under. Mortality was lowest in public pools (6%) and highest in rivers, canals, and lakes (78%). Most of the children (83%) were unsupervised at the time of the accident. The authors conclude that supervision and safety barriers are important and necessary methods of prevention for drowning and near drowning incidents.

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Metropolitan Life Insurance Company. (May, 1977). Accidental drownings by age and activity. Statistical Bulletin, 58,2-5. This study examined 4,962 drowning fatalities to review the various activities in which drowning victims were engaged prior to death. Swimming was the most frequently mentioned activity, with 1,238 deaths (25% of all drowning deaths) attributed to such activity. Playing near bodies of water resulted in 697 deaths (14% of the total), and 343 deaths occurred while fishing from a boat (7%). Recreational boating was reported in 349 drownings. Drownings in nonrecreational situations occurred while driving a motor vehicle (355 cases), attempting a rescue (143 cases), and

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bathing (100 cases). Activities varied by age: children under age 5 were susceptible to drowning while bathing, playing near water, and standing or walking near water. Children ages 5 to 14 accounted for a majority of bathing or wading as well as swimming drownings. Boating, diving, and fishing drownings were more common among ages 15 to 44. The elderly (ages 65 and over) drowned most often after walking or standing near water. 251

Metropolitan Life Insurance Company. (July-August, 1977). Swimming pool drownings. Statistical Bulletin, 58,4-6. This article deals with 644 drownings that occurred in swimming pools in 1966. More than half (359) of those who drowned were children under 10 years of age. A majority of these drownings were among ages 1 to 4, with 242 or nearly 40% of the fatalities at these ages. The most prevalent cause of drowning was exhaustion, followed by stepping or falling into water, a cramp or other attack, hitting an object, and collapse or loss of a flotation device. Inadequate fencing was reported in 282 of these drownings. The National Safety Council recommends that the two most important drowning prevention interventions are security, which includes fencing and gates around pools, and supervision.

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North Carolina drownings, 1980-1984. (October 10, 1986). Morbidity and Mortality Weekly Report, 35(40), 635-638. According to medical examiner records, a total of 1,052 persons drowned in North Carolina from 1980 to 1984. Death rates were higher for nonwhites and for males. Most of the drownings occurred in natural settings such as lakes or rivers. Most victims were swimming (41%) or fishing (15%). Drowning circumstances varied by age, gender, and medical conditions. Males accounted for 98% of fishing deaths, and females accounted for 43% of bathrelated deaths. Out of the 80% tested, alcohol was detected in 48% of the victims, and 34% had blood-alcohol levels equal to or above the legal level of intoxication.

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O'Carroll, Patrick W., Alkon, Ellen, & Weiss, Billie. (July 15, 1988). Drowning mortality in Los Angeles County, 1976-1984. Journal of the American Medical Association, 260(3), 380-382. The authors examined Los Angeles County Coroner's Office data on drownings from 1976 to 1984. There were 1,587 drownings (1,130 males, 457 females) during this 9-year period. The largest proportion of drownings (44.5%) for both sexes and for most age g r o u p s occurred in private s w i m m i n g pools. D r o w n i n g

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Injury Prevention for Young Children: A Research Guide circumstances varied by age and gender. Children ages 2 to 3 had the highest swimming pool drowning rate. The elderly also showed high drowning rates, mostly in swimming pools and bathtubs. The authors suggest that prevention interventions directed toward at-risk age groups in their individual at-risk environments (such as safety regulations governing pool fencing and bathroom safety devices for the elderly) may help reduce the number of deaths due to drowning.

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Orlowski, James P. (February, 1987). Drowning, near-drowning, and ice-water submersions. Pediatric Clinics of North America, 34(1), 75-92. The author reviews drowning, near drowning, and ice water submersions. Drowning is the second most common cause of unintentional-injury deaths in children. Swimming pools and natural bodies of water close to home are the most common sources of risk for children. The single most important step in the treatment of drowning victims is the immediate institution of resuscitation and first aid as soon as possible. Ice-water submersions are different than other near drowning events because of the protective effect of the cold. Victims of ice water submersions can remain in the water much longer than other near drowning victims with less damage to the brain and body systems. Drowning prevention techniques should include pool fencing, supervision of swimmers, knowledge of cardiopulmonary resuscitation (CPR), water safety training, use of life jackets, and teaching children how to swim.

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Pearn, John H. (March, 1992). The urgency of immersions. Archives of Disease in Childhood, 67(3), 257-258. The author reviews the epidemiology, management, and prevention of child drowning and near drowning incidents. Risk of drowning for children varies according to the availability and density of environmental water hazards. In addition to the portion of children who die from drowning, another significant percentage suffer permanent neurological damage as a result of asphyxiation. Water hazards include bathtubs, pools and ponds, larger bodies of water, and spas. Another source of drownings is child abuse. Immediate resuscitation after drowning could eliminate 30% of drowning deaths, so teaching parents how to perform CPR and other rescue techniques is important. The author suggests that further research into the causes and treatment of drowning injuries and deaths is needed.

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256

Pearn, John H., Wong, Richard Y. K., Brown, Joseph, HI, Ching, Yi-Chuan, Bart, Robert, Jr., & Hammar, Sherrel. (May, 1979). Drowning and near-drowning involving children: A five-year total population study from the city and county of Honolulu. American Journal of Public Health, 69(5), 450-454. The authors studied 140 consecutive child drownings or near drownings in Hawaii during 1973 to 1977. Of the children who lost consciousness in the water, 73% survived. The overall annual rate of drowning (3.1 per 100,000) was low for a society with regular access to water. The authors give suggestions for other urban societies to continue safety regulations and programs targeted at proven risk groups.

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Present, Paula. (September, 1987). Child drowning study: A report on the epidemiology of drownings in residential pools to children under age five. Washington, DC: U. S. Consumer Product Safety Commission. This report describes a study of drownings in residential swimming pools during a 5-month period in 1986. The study concluded that males and children ages 1 to 3 were at highest risk. Children with one or more siblings were also at risk due to less parental supervision time per child, as were those who were last seen in an area with the least amount of expected risk of drowning (inside the house or in the yard, porch or patio). Floating objects in the pool also attracted children to the water. Small pools that occupied a majority of the back yard area were most likely involved in these incidents. Pools where drowning incidents happened were less likely to have complete barriers and selfclosing gates or doors than pools where no incidents were reported. Of the victims, more than half were reported to have been in the water more than 5 minutes. Length of time missing, delayed arrival of emergency help, waiting before beginning first aid, and delaying first aid to call for help were all factors increasing the risk of poor health outcome. The report provides the specific data gained from the study, as well as the instruments used to collect data.

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Press, Edward, Walker, James, & Crawford, Isabelle. (December, 1968). An interstate drowning study. American Journal of Public Health, 58(12), 2275-2289. This study examined 1,201 drownings in five states during a 12-month period. Children and young adults ages 10 to 19 accounted for a majority of drownings. The site of drowning

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Injury Prevention for Young Children: A Research Guide (pond, ocean, swimming pool) varied according to geographic location. Males accounted for a majority of deaths (84.9%), but the ratio is less significant in the very young (ages 0 to 4) and elderly (ages 65 and over). Most victims who drowned while swimming were ages 10 to 19. Ability to swim, use of life preservers, preexisting medical conditions, artificial respiration, attempts to save others, use of alcohol, and cold water affected the likelihood of death by drowning.

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Spyker, Daniel A. (February, 1985). Submersion injury: Epidemiology, prevention, and management. Pediatric Clinics of North America, 32(1), 113-125. This article describes the epidemiology, prevention, and management of submersion injuries. Most drowning victims are male, and a majority are ages 10 to 19. Many drownings among young children and infants occur in swimming pools and bathtubs at home. Because a large proportion of drowning victims are nonswimmers, the author suggests that all young children be taught how to swim. Other recommended prevention interventions include reducing drug and alcohol use and using protective gates and barriers around swimming pools. The article also describes in detail pre-hospital and hospital management and treatment of drowning victims.

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Wintemute, Garen J., Drake, Christiana, & Wright, Mona. (October, 1991). Immersion events in residential swimming pools: Evidence for an experience effect. American Journal of Diseases of Children, 145(10), 1200-1203. The authors studied drowning and near-drowning in residential swimming pools to determine whether pool ownership experience affected the incidence of drowning events. Pool owners in Sacramento County, California were surveyed concerning the date each household acquired a pool and any drowning or neardrowning incidents. Results showed that the first 6 months of pool ownership were a high risk period for drowning incidents. Many incidents also occurred after the first 6 months. The authors suggest that new pool owners should be targeted for prevention and water safety programs.

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Wintemute, Garen J. (June, 1990). Childhood drowning and neardrowning in the United States. American Journal of Diseases of Children, 144(6), 663-669.

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This article describes childhood drowning, which in some states is considered the leading cause of death for children ages 5 and under. The two major risk groups for drowning are children ages 5 and under and boys ages 15 to 19. Most of the drownings among those ages 5 and under occur in residential swimming pools. Among those who survive near-drowning incidents, most either survive intact or with severe and permanent disabilities. The author suggests that primary prevention of drowning incidents is important because of the narrow margin of time at the onset of drowning that determines the outcome of the event. Recommended prevention interventions include mandatory pool fencing, CPR training for adults and older children, and alcohol abuse education for older children. 262

Wintemute, Garen J., Kraus, Jess F., Teret, Stephen P., & Wright, Mona. (July, 1987). Drowning in childhood and adolescence: A population-based study. American Journal of Public Health, 77(7), 830-832. The authors studied drownings among Sacramento County, California children and adolescents ages 0 to 19 for the years 1974 to 1984. One-third of these drownings occurred in home swimming pools. Children ages 1 to 3 had the highest drowning rates. Males ages 15 to 19 also had high drowning rates, among whom 38% of drownings were alcohol-related. The authors recommend that future drowning prevention efforts include pool fencing legislation, community first aid and CPR training, reduced underage access to alcohol, and improved barriers at waterside roadways.

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Wintemute, Garen J., & Wright, Mona A. (January, 1990). Swimming pool owners' opinions of strategies for prevention of drowning. Pediatrics, 85(1), 63-69. The authors studied Sacramento, California pool owners' attitudes toward CPR and pool barriers. A majority of those surveyed supported voluntary CPR training (86%), and many (40%) favored mandatory training. When asked about barriers, 61% opposed requiring pool barriers, and 49% objected to barrier requirements for new pools. Homes with small children were more likely to support the use of pool barriers. Evidence of a previous drowning or near-drowning event had little effect on the attitudes of those surveyed. The authors suggest that communities sponsor CPR classes for pool owners and further develop barrier specifications and requirements.

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Yamamoto, Loren G., Yee, Ann Barbara, Matthews, Wallace J., Jr. & Wiebe, Robert A. (June, 1992). A one-year series of pediatric ED water-related injuries: The Hawaii EMS-C project. Pediatric Emergency Care, 8(3), 129-133. The authors studied 133 pediatric patients admitted to a Hawaiian emergency department with water-related injuries over a 12-month period. There were 13 submersions, 7 cases of head trauma, 3 cases of neck trauma, 88 cases of external injury, and 34 other injuries. A majority of the patients (70%) were male. Young children (ages 1 to 5) were more likely to have submersion injuries, and older children were more likely to be victims of trauma. Activities leading to the injuries included swimming, playing and surfing. The authors suggest that prevention efforts be based on the particular risks for each age group. For older children, safety results from knowing how to swim and avoiding risky behavior. For younger children, being closely supervised around water and having pool barriers are important interventions.

6 Falls

F

alls are one of the leading causes of accidental death and injury among young children ages 0 to 4. This chapter includes articles and books providing information about prevalence, risk factors, hazards, prevention interventions, and consequences of falls, such as fractures and head injuries. Several articles deal with falling from balconies and windows, steps and stairs, beds, tables, and chairs. Articles about accidents involving baby walkers are included in this section. Several articles discuss falls on playgrounds and prevention techniques. 265

Baker, M. Douglas, & Bell, Randi E. (December, 1991). The role of footwear in childhood injuries. Pediatric Emergency Care, 7(6), 353-355. The purpose of this retrospective study was to assess the influence of footwear on injury. The subjects were all injured children presenting to the Emergency Department of The Children's Hospital of Philadelphia during February, May, July, and October 1988. Information was collected concerning the type and characteristics of footwear worn and environmental factors. Comparisons were made between those involving and those not involving loss of footing (LOF) during injury. Of the 3,015 children studied, LOF occurred in 1,075 (35.8%). Overall, significantly more injuries involved LOF in children whose feet were covered (n=946, 37.0%) than in those who were barefoot (n=129, 29.1%) at the time of injury (p<.001). However, children wearing low-top sneakers had the lowest rate of LOF (24.0%) of any group. Children wearing

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Injury Prevention for Young Children: A Research Guide rough-sole footwear had LOF significantly less frequently (24.2%) than those wearing smooth-sole footwear (51.8%; p<.001). Rubbersole footwear was less frequently associated with LOF (n=488, 28.6%) than were other sole materials (n=457, 53.8%; p<.001). The authors concluded that rough-sole footwear was a potential injury prevention strategy.

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Bergner, Lawrence, Mayer, Shirley, & Harris, David. (January, 1971). Falls from heights: A childhood epidemic in an urban area. American Journal of Public Health, 61(1), 90-96. The authors studied the incidence of falls of children in New York City. The authors found that fatalities were associated with falls of four or five stories. Results of the study show a profile of a fall victim to be a preschool male in good health with no serious illnesses or accidents in the past. Compared to other children, the fall victim is judged by his mother to be more active, and likes rough types of play. The victim is usually the middle child in a large family (6 or more children), with no father in the home. The authors also found that unguarded windows were the primary source of danger from falls.

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Board of Trustees. (August, 1991). Use of infant walkers. American Journal of Diseases in Children, 145(8), 933-934. The authors discuss the hazards associated with the use of infant walkers. Of the 70% to 80% of infants who will use a walker, 30% to 40% will have an accident. Most of these accidents are minor, and do not require attention by a physician. The most common types of injuries are caused by falling down stairs, tipping over in the walker, and trapping fingers. Nearly all serious walker-related injuries occur from falling down stairs. Following serious injuries, one-third of parents stop using the walker immediately, one-third stop use within 2 months (because infants begin walking on their own), and one-third continue using the walker despite the injury. Most injuries occur with at least one parent present and, in the case of stairwells, with gates in place. Occurrence of walker-related injury is related to amount of time spent in the walker (55% of injuries occur to infants who spend more than 2 hours in a walker). The authors recommend that physicians advise parents of the risks associated with infant walkers and emphasize that walkers do not help infants learn to walk or take the place of parental supervision.

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268

Campbell, Margaret, Ferguson, James, & Beattie, Thomas F. (December 15, 1990). Are falls from supermarket trolleys preventable? British Medical Journal, 301(6765), 1370. This article discusses a series of falls from supermarket carts among young children ages 9 to 50 months. The authors note that supermarkets do not usually provide restraints in their carts and recommend that parents and supermarkets be advised that such restraints should be used because this type of fall is a preventable accident.

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Fazen, Louis E. Ill, & Felizberto, Pamela I. (July, 1982). Baby walker injuries. Pediatrics, 70(1), 106-109. The author studied 49 children ages of 8 and 14 months to determine the patterns of use and injuries related to baby walkers. Data were obtained by surveying parents with a written questionnaire and a follow-up phone interview. Most respondents (86%) placed their children in various types of baby walkers between ages 4 months to 1 year. Half of the 42 infants who used walkers experienced at least one accident involving tipping over, falling down stairs, or trapping fingers. Two of these incidents resulted in injuries serious enough to require medical treatment. Both infants sustained head and neck injuries after falling down stairs in a walker. Whereas most stairway and finger entrapment accidents occurred before the age of 7 months, tipping over was much more likely to occur after the age of 8 months. The injuries reported in this study were more common, but less severe, than previously reported. The authors suggest that pediatricians and other child health advocates inform parents about the health risks of baby walkers, encourage regulatory agencies to improve product labeling, and encourage manufacturers to adjust product design to the age and weight specifications of the growing infant.

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Garrettson, L. K., & Gallagher, Susan S. (February, 1985). Falls in children and youth. Pediatric Clinics of North America, 32(1), 153-162. In a study of fall injuries in Massachusetts, young children fell most often from stairs and steps. Falls from beds, tables, and chairs were also common. Falls from heights such as windows, roofs, balconies, and trees accounted for only 9% of the injuries. Concrete or asphalt surfaces were associated with more injuries than other surfaces. Children who die in falls most often received head and neck trauma. Prevention devices found to be most effective were gates on stairways, window guards, and improved

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Injury Prevention for Young Children: A Research Guide playground surfaces. Behaviors preventing falls were adjusting the mattress level of cribs at age-appropriate times, removing pillows and large toys that extend the infant's height, and changing infants on the floor rather than using changing tables. Using baby walkers was also associated with increased falls for infants. This article also addresses causes and preventative behaviors associated with choking caused by accordion gates and burn injuries caused by infants in baby walkers pulling over hot liquids and touching hot surfaces.

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Kavanagh, Carol A., & Banco, Leonard. (March, 1982). The infant walker: A previously unrecognized health hazard. American Journal of Diseases of Children, 136(3), 205-206. The authors investigated the use of infant walkers within a large prepaid pediatric group practice. Of 195 patients ages 5 to 15 months surveyed during a 3-month period, 150 patients (77%) used infant walkers. Of those, 47 patients (31%) reported an accident resulting in an injury. These included closed head trauma, fractures, lacerations, tooth evulsion, and soft palate perforation. The authors concluded that walkers offer no benefit and that the risk of injury associated with the use of infant walkers should be of concern for those physicians who care for preambulatory children.

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Kraus, Jess F., Rock, Amy, & Hemyari, Parichehr. (June, 1990). Brain injuries among infants, children, adolescents, and young adults. American Journal of Diseases of Children, 144(6), 684-691. The authors summarize epidemiological data on brain injuries to infants, children, adolescents, and young adults. The authors estimate that 29% of all injury deaths among children ages 0 to 19 are caused by brain injuries. The leading cause of brain injury varies by age. In a study conducted by the authors, more than two-thirds of brain injuries among infants were caused by falls. For preschool children, falls and motor vehicles accounted for 51% and 22%, respectively. At older ages, motor vehicles and sports or recreation gradually equal and exceed the rate of brain injury from falls. The authors discuss the use of helmets to prevent some exposures to brain injury.

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Kravitz, Harvey, Driessen, Gerald, Gomberg, Raymond, & Korach, Alvin. (1969). Accidental falls from elevated surfaces in infants from birth to one year of age. Pediatrics, 44(Supplement), 869-876.

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This study assessed the frequency and circumstances of falls from elevated surfaces in 536 infants ages 1 and under, 200 from an urban pediatric clinic, and 336 from a suburban private practice. Nearly half of the infants studied had a reported fall during the first year of life. Among the clinic group, 77% reported a fall, a much higher incidence than the 30% reported by the private practice group. Most of the infants who fell could not yet walk and were dependent on parental protection from accidental falls. The heights of the surfaces from which the infants fell ranged between 20 and 60 inches, roughly 2 to 5 feet. The authors give several explanations for the data obtained in this study, and make recommendations for further research and injury prevention efforts. 274

Kravitz, Harvey, & Grove, Morton. (December, 1973). Prevention of accidental falls in infancy by counseling mothers. Illinois Medical Journal, 144(12), 570-573. The purpose of this study was to analyze the effectiveness of a program to counsel mothers of infants concerning preventing falls. Subjects were suburban mothers of infants. The mothers of one group of 336 infants received no counseling. The parents of a second group of 320 infants received specific oral and written instructions about the dangers of falls in infancy. Signs were placed over every examining table in doctors' offices to serve as a reminder during the infants' monthly visits. The two groups had similar socioeconomic status, home life, age of mother, and birth order of children. The study found that there was a significant decrease in the percentage of falls in the counseled group compared to the uncounseled group. Very few multiple falls were observed in either group, suggesting that suburban mothers learn to control infant injury after an initial fall. Head injury was the most common type of injury in both groups. The authors conclude that counseling mothers on the danger of falls of infants is effective.

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Meller, Janet L. & Shermeta, Dennis W. (December, 1987). Falls in urban children. American Journal of Diseases of Children, 141(12), 1271-1275. The authors conducted a retrospective review of the charts of 48 children and adolescents admitted to an urban emergency room between 1980 and 1985 with a history of a vertical fall from a height. These data were compared to a previous review from the same institution for the years 1965 to 1974. The authors found an

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Injury Prevention for Young Children: A Research Guide increase of 37.5% in the number of injuries during the study period. Most of the falls were from heights of 12 feet or less, although an increasing proportion of children in our series (33%) fell from heights of 36 feet or less. Falls sites included windows, walls, and roofs. The mean age of children with significant injuries was 7.5 years, with 27% of children ages 3 and under suffering a documented injury, as opposed to 67% of children over age 3. Children were more apt to suffer a fracture than any other injury, most likely a broken arm. The authors conclude that falls in urban areas continue to be a significant source of morbidity and mortality in children.

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Partington, Michael D., Swanson, Jill A., & Meyer, Fredric B. (June, 1991). Head injury and the use of baby walkers: A continuing problem. Annals of Emergency Medicine, 20(6), 652654. The purpose of this retrospective clinical review was to determine the frequency of baby walker use as a contributing factor in head injuries in children ages 2 and under. All children at an urban trauma center and multi-specialty clinic ages 2 and under who were evaluated for a head injury during a 3-year period. A total of 129 cases were reviewed. Baby walker-related injuries occurred in 19 of 129 patients (14.7%) which represented the third most common mechanism of injury in this age group. Mean patient age at the time of injury was 8.7 months. Of the 19 accidents involving walkers, 18 (94.7%) involved falling d o w n stairs. Nine children (47.4% of all walker-related injuries) suffered fractures of the cranial vault. No patients required surgical intervention, although one required treatment for post-traumatic meningitis. The authors conclude that baby walkers continue to be a frequent cause of head injury in this age group, and recommend that further efforts be made to deal with these preventable injuries.

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Playground-related injuries in preschool-aged children—United States, 1983-1987. (1988). Morbidity and Mortality Weekly Report, 37(41), 629-632. From 1983 to 1987, nearly 6.72 million emergency room visits in the United States were caused by product-related injuries among preschool children ages 1 to 4. Approximately 305,000 of these injuries involved playground equipment. These playground equipment-related injuries occurred most frequently at home, in sports or recreation settings, or at school. Of the 82,108 injuries in

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preschool-aged children attending day care, 27,232 were related to playground equipment. 278

Reiber, Gregory D. (1993). Fatal falls in childhood. How far must children fall to sustain fatal head injury? Report of cases and review of the literature. American Journal of Forensic Medicine and Pathology, 14(3), 201-207. The authors reviewed the records of the Sacramento County Coroner's Office from 1983 to 1991 for cases of fatal head injury in children ages 5 and under with a history of a fall. During the study period, three cases of witnessed falls from heights of over 10 ten were found, compared with 19 deaths initially alleged to have occurred from shorter falls of under 6 feet. Most of these falls from lesser heights occurred under circumstances where there were no unrelated witnesses to corroborate the initial history. Autopsy findings in these cases also tended to be of unexpected severity for the initially proposed mechanism of injury. Most of the shorter fall cases (75%) were ultimately proved to represent inflicted injuries. A literature review on the subject identifies two major viewpoints: the opinion that short falls have a significant potential for fatality or the more widely espoused view that short falls rarely, if ever, cause serious injury or death. The authors suggest that short fall fatalities are rare, with most major injuries and deaths resulting from major impacts and serious falls.

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Sacks, Jeffrey J., Brantley, Mary D., Holmgreen, Patricia, & Rochat, Roger W. (March, 1992). Evaluation of an intervention to reduce playground hazards in Atlanta child-care centers. American Journal of Public Health, 82(3), 429-431. The authors revisited 58 Atlanta, Georgia child care centers two years after a previous study to determine whether playground hazards identified in the previous study had been corrected. In addition, 71 randomly-selected child care centers were assessed as controls. The authors identified 9.4 hazards per playground at the intervention sites, compared with 8.0 at the control sites. Because the number of hazards at the intervention sites was still higher than control sites, the authors conclude that the intervention used in the previous study was ineffective. The previous study had used investigators to identify and explain the hazards to child care center directors, and to distribute educational materials. The authors suggest that alternative approaches, such as rewriting regulations, providing better training for agency inspectors, enforcing regulations more vigorously, educating child care center

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Injury Prevention for Young Children: A Research Guide directors more extensively, and making parents more aware of hazards and inspections may be more feasible and effective methods of identifying and eliminating hazards in child care settings.

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Sacks, Jeffrey J., Holt, Kenneth W., Holmgreen, Patricia, Colwell, Lewis S., Jr., & Brown, J. Marion, Jr. (August, 1990). Playground hazards in Atlanta child care centers. American Journal of Public Health, 80(8), 986-988. The authors identified 684 playground hazards in 66 Atlanta child care centers despite regulations mandating hazard-free play areas. Of 21 centers with 5 or fewer hazards, 42.9% reported a playground-related injury in the previous year. Of 25 centers with 6 to 11 hazards, 52% reported a playground-related injury. Of 20 centers with 12 or more hazards, 60% reported a playgroundrelated injury. Climbing equipment 6 or more feet tall generally had inadequate impact-absorbing undersurfacing and had over twice the rate of fall injuries as climbing equipment less than 6 feet tall. The authors suggest that regulations governing child care center playgrounds should be more specific and better enforced.

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Sacks, Jeffrey J., Smith, J. David, Kaplan, Karen M., Lambert, Deborah A., Sattin, Richard W., & Sikes, R. Keith. (September 22-29, 1989). The epidemiology of injuries in Atlanta day-care centers. Journal of the American Medical Association, 262(12), 1641-1645. The authors collected injury reports for children attending 71 day care centers in Atlanta, Georgia over a 1-year period. Of the 143 injuries reported, 83 (58.0%) were related to falls, and 24 (82.8%) of the 29 severe injuries were fall-related. A majority of the injuries were head injuries (68.5%). The authors computed the rate of injury at 1.77 per 100,000 child-house in day care. Nearly 47% of injuries occurred on the playground. Because a majority of playground injuries were fall-related, the authors suggest that impact-absorbing playground surfaces may reduce the number of injuries in day care settings.

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Sosin, Daniel M., Keller, Patricia, Sacks, Jeffrey J., Kresnow, Marcie-jo, & van Dyck, Peter C. (May, 1993). Surface-specific fall injury rates on Utah school playgrounds. American Journal of Public Health, 83(5), 733-735. The purpose of this study was to estimate the rates of fall injuries on school playgrounds according to different

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playground,surfaces. Injuries related to falls from climbing equipment and the surfaces involved were identified from injury reports for 1988 to 1990 from 157 Utah elementary schools. The rate of fall injuries per 10,000 student-years were asphalt, 44; grass, 12; mats, 16; gravel, 15; and sand, 7. These data did not show that impact-absorbing surfaces reduced fall injuries on playgrounds better than grass. The authors suggest that improved field studies are needed to guide policy decisions for playground surfacing. 283

Spiegel, Charlotte N., & Lindaman, Francis C. (December, 1977). Children Can't Fly: A program to prevent childhood morbidity and mortality from window falls. American Journal of Public Health, 67(12), 1143-1147. This article discusses "Children Can't Fly," a health education program developed by the New York City Department of Health to prevent child falls from windows. The program had four major components: 1. Reporting falls by hospital emergency rooms and police precincts, followed up by counseling, referral, and data collecting by public health nurses; 2. Informing the public and elevating their awareness of the hazards; 3. Educating the c o m m u n i t y t h r o u g h door-to-door h a z a r d identification, counseling by outreach workers, community organization efforts with schools, tenant groups, clinics, churches, health care providers, and other groups; and 4. Providing free, easily-installed window guards to families with young children living in high-risk areas. During the 3 years of the program, the authors found a 50% decrease in the number of falls, and a 35% decrease in the number of fall-related deaths. Because of the significant results of this study, the authors suggest that the "Children Can't Fly" program be used as a model for other fall-prevention programs.

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Stoffman, John M., Bass, Martin J., & Fox, A. Mervin. (September 15, 1984). Head injuries related to the use of baby walkers. Canadian Medical Association Journal, 131 (20), 573-575. To determine what proportion of head injuries in children ages 24 months and under who presented to an emergency department were related to the use of baby walkers, the authors reviewed the charts of 52 such children. Walkers were involved in 42% of the head injuries among children under 12 months and in none of those among the children ages 12 to 24 months. All walker-related injuries, including skull fractures in three children, involved stairs. The authors also sent questionnaires to families with children ages 3 to 18 months attending a private pediatric

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Injury Prevention for Young Children: A Research Guide practice to determine the prevalence of falls involving baby walkers among these children and the factors associated with such falls. Of the 152 responding families, 82% reported using or having used a walker, 36% reported that their child had a fall while in a walker. Walker-related falls were found to be directly associated with the amount of time spent in the walker and with a previous fall from the walker by an older sibling. The authors suggest that since there is no demonstrated benefit, the use of baby walkers should not be encouraged and parents should be advised of the potential hazards.

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Strahlman, Ellen, Elman, Michael, Daub, Erich, & Baker, Susan. (April, 1990). Causes of pediatric eye injuries: A populationbased study. Archives of Ophthalmology, 108(5), 603-606. The authors conducted a population-based study of eye injuries requiring hospital admission for children ages 16 and under in Maryland during 1982. The authors estimate that the incidence of eye injury in the study group was 15.2 per 100,000 per year. Male patients outnumbered female patients as victims of eye injuries by a ratio of approximately 4 to 1. Eye injuries in children ages 11 to 15 occurred at more than twice the rate of younger children. The most common cause of pediatric ocular trauma was accidental blows and falls (37%). Sports and recreational activities accounted for 27% of all eye injuries, 39% of all nonpenetrating injuries, and 40% of all injuries in children ages 11 to 15. The authors conclude that the majority of pediatric eye injuries are preventable, and that implementing well-established safety precautions would greatly reduce eye injuries in children.

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Use of infant walkers. (August, 1991). American Journal of Diseases of Children, 145(8), 933-934. Many parents use baby walkers because of the convenience they provide in keeping children occupied. Unfortunately, parents may develop a false sense of security that leads to diminished vigilance over the safety of their infant. Although most injuries that result from walkers are minor, serious trauma from head injuries, lacerations, and burns does occur occasionally. The American Medical Association recommends that physicians counsel parents on the risk of injury that can occur from the use of infant walkers and inform parents that these devices do not either promote bipedal ambulation or offer a substitute for careful parental supervision.

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nfectious diseases are a major health problem for young children. Although usually not fatal, colds and diarrhea are common among young children and are a special problem for infants and young children in child care settings. Articles about these viral and bacteria diseases and their effects on young children are included in this chapter. Articles about foodborne illness, also caused by bacteria, are included here. The United States Department of Agriculture estimates that there are between 21 and 80 million cases of foodborne illness (commonly referred to as food poisoning) every year. About 6 million of these cases require medical treatment. Infants and young children comprise one of the most at-risk populations for serious results from foodborne illness. The most common causes are food left at room temperature too long, poor hygiene, and improper food handling. Articles discuss prevalence issues, hazards, and prevention of infectious diseases, foodborne illness in both home and child care settings, air quality and its role in respiratory and infectious diseases in day care settings, and pediatric AIDS. 287

Bartlett, Alfred V., Jarvis, Betty A., Ross, Virginia, Katz, Theodore M., Dalia, Margaret A., Englender, Steven J., & Anderson, Larry J. (1988). Diarrheal illness among infants and toddlers in day care centers: Effects of active surveillance and staff training without subsequent monitoring. American Journal of Epidemiology, 127(4), 808-817.

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Injury Prevention for Young Children: A Research Guide This 3-year longitudinal study examined the staff at Maricopa County, Arizona, day care centers to determine the effects staff training and supervision on the incidence of diarrhea among infants and toddlers. Of the 21 centers studied, 10 received staff training in methods to reduce infectious diseases. The study showed that staff training without follow-up monitoring and supervision made no difference in rate of illness. Significant improvement in illness rates was shown in both the control groups who had supervision and the trained groups who were also supervised. The authors suggest that training in safe procedures, when accompanied by follow-up monitoring of practices, is the best way to reduce the incidence of diarrheal illnesses and infectious diseases in day care settings.

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Bean, Nancy H., Griffin, Patricia M., Goulding, Joy S., & Ivey, Cecile B. (March, 1990). Foodborne disease outbreaks, 5-year summary, 1983-1987. Morbidity and Mortality Weekly Report, 39(SS-1), 15-57. This article is a report of foodborne disease outbreaks, defined here as incidents involving two or more people experiencing similar illness directly related to food. During 1983 to 1987, 2,397 outbreaks were reported, representing a total of 91,678 cases of food poisoning. In situations with confirmed causes (38% of total outbreaks studied), bacterial agents were responsible for 66% of outbreaks, and 92% of cases. Chemical agents caused 26% of outbreaks, and 2% of cases; parasites caused 4% of outbreaks and less than 1% of cases; and viral agents caused 5% of outbreaks, and 5% of cases. The fact that less than half of the outbreaks had confirmed etiologies suggests that methods of investigation should be improved. The authors conclude that the disparity between the number of outbreaks compared to the number of actual cases in each cause category indicates that both figures should be included in any study of food poisoning.

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Bell, David M., Gleiber, Dennis W., Mercer, Alice Atkins, Phifer, Robi, Guinter, Robert H., Cohen, A. Jay, Epstein, Eugene U., & Narayanan, Manoj. (April, 1989). Illness associated with child day care: A study of incidence and cost. American Journal of Public Health, 79(4), 479-484. The authors studied children ages 3 and under to determine the risk and cost of illness associated with day care. Subjects were 843 children enrolled in a prepaid health plan during a 7-month period. Children who attended day care centers were 4.5 times

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more likely to be hospitalized than children in other settings. The primary predictor of illness was the number of children in the room. Mean monthly cost of medical care for children in day care centers was $32.94. Child illness in this group was responsible for 40% of the parents' being absent from work. 290

Black, Robert E., Dykes, Aubert C , Anderson, Kern E., Wells, Joy G., Sinclair, Susanne P., Gary, G. William, Jr., Hatch, Milford H., & Gangarosa, Eugene J. (1981). Handwashing to prevent diarrhea in day-care centers. American Journal of Epidemiology, 113(4), 445-451. The authors studied the effect of a handwashing program on the incidence of diarrheal illness in day care centers. Subjects were four Georgia day care centers, two control centers, and two treatment centers which began a supervised h a n d w a s h i n g program. After the treatment program began, the incidence of diarrhea began to drop, and the treatment centers maintained an illness rate that was approximately half of the rate of the control centers during all 35 weeks of the study. The authors suggest that a similar handwashing program will prevent some diarrheal illnesses in day care settings.

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Cherian, Thomas, Steinhoff, Mark C , Harrison, Lee H., Rohn, Dale, McDougal, Linda K., & Dick, James. (March 2, 1994). A cluster of invasive pneumococcal disease in young children in child care. Journal of the American Medical Association, 271(9), 695-697. The authors studied an outbreak of pneumococcal disease at a small family child care home in Baltimore, Maryland. All six children in the child care home had Streptococcus pneumoniae bacteria, including the two children who showed no signs of illness. Because the caregivers, parents, and health care workers failed to notice the cluster of pneumococcal infection in these children, the authors suggest that parents and caregivers should watch more carefully for the incidence and patterns of infectious diseases among the children in their care. A vaccine may be the most effective means of preventing these infections, but until the vaccine is developed, early detection and isolation can prevent children in day care or child care settings from infecting one another.

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Crawford, Florence G., & Vermund, Sten H. (August, 1987). Parasitic infections in day care centers. Pediatric Infectious Disease Journal, 6(8), 744-749. In this article the authors review the epidemiology and control of parasitic infections in day care centers (DCCs). The findings that they cite focus on the relationship between prevalence of Giardia and age in day care center children that suggest person-to-person transmission. While low prevalence rates among infants ages 1 and under are probably due to their relative immobility, the higher rates in toddlers are caused by mobile, nontoilet-trained children who have poor personal hygiene and frequent hand-to-mouth behavior. The authors also examine the increased incidence of Cryptosporidium and other infections in relation to day care centers. They provide a twelve-step program for prevention and control of the infections and a three-fold program for treatment of the infections.

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Daneault, Serge, Beausoleil, Monique, & Messing, Karen. (March, 1992). Air quality during the winter in Quebec day-care centers. American Journal of Public Health, 82(3), 432-434. The authors studied day care centers in Montreal, Quebec, Canada to determine whether indoor air quality met standards for carbon dioxide content, humidity, and temperature. Only 9 of the 91 centers studied met the study standard for carbon dioxide content. High levels of carbon dioxide were positively associated with densely populated centers and poor ventilation systems. Onesixth of the centers also had humidity levels outside the acceptable range. Because air quality is a factor in the high incidence of respiratory and infectious diseases in day care settings, the authors recommend that air quality in day care centers be mandated by air quality standards that already exist for office and other industrial buildings.

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Deli items may dish up dose of listeria. (July-August, 1992). FDA Consumer, 26(6), 9-13. This article describes Listeria monocytogenes, a group of foodborne bacteria that may cause little or no illness in healthy people, but can present a significant risk to the elderly, those with impaired immune systems, pregnant women, and newborns. Risk for listeriosis can be reduced by handling food properly, avoiding soft deli cheeses, and reheating leftover or ready-to-eat foods (such as hot dogs or deli cold cuts) before eating. The article gives examples of listeriosis outbreaks, practical food-handling tips, and

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other available information, as well as discussing Food and Drug Administration efforts to control listeria in food products. 295

Gessner, Bradford D., & Beller, Michael. (May 1, 1994). Protective effect of conventional cooking versus use of microwave ovens in an outbreak of salmonellosis. American Journal of Epidemiology, 139(9), 903-909. The authors studied cases of salmonella food poisoning following a community picnic to determine the causes and risk factors associated with illness. Food poisoning was associated with one of two roasted pigs prepared and flown in from a Seattle, Washington restaurant. The roast pork had been prepared after being thawed for several hours at room temperature by cooking in a flame broiler. One of the pigs had been left unrefrigerated after cooking for 17 to 20 hours. Of those who took home and reheated leftovers from the picnic, all 10 who reheated the pork in microwaves became ill, compared with none of the 20 who reheated the meat in conventional ovens or skillets. The authors suggest that health officials educate the public about the protective effect of conventional oven cooking compared to microwave oven cooking in cases of food mishandling to prevent food poisoning.

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Harning, Abigail T. (August, 1992). Stirring up trouble: Foodrelated emergencies. Journal of Emergency Medical Services, 17(8), 24-30; 79-83. This article reviews the nature, risks, and management of food-related emergencies. These emergencies are divided into three categories: acute gastroenteritis caused by bacteria or parasite infection, neurological syndromes caused by bacteria infection, and allergic reactions to food. The author describes the effects and symptoms of the agents involved in each category, and gives directions for emergency treatment of each case. Prevention of illness and death from food poisoning may be accomplished by handling food properly to reduce the risk of emergencies, and by promptly reporting and treating emergencies when they occur.

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Harter, Lucy, Frost, Floyd, Grunenfelder, Gregg, Perkins-Jones, Kathy, & Libby, John. (February, 1984). Giardiasis in an infant and toddler swim class. American Journal of Public Health, 74(2), 155-156. Giardia is an intestinal parasite that causes diarrheal illness. The authors investigated the incidence of Giardia among children in an infant and toddler swimming class with a Giardia-infected

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Injury Prevention for Young Children: A Research Guide child. Of 70 children in the class, 61% were Giardia positive. Of 53 mothers tested, 39% were positive, and 28% of 21 fathers tested positive. None of the child's playmates who did not attend the swimming class were Giardia positive. The authors examined the characteristics of the pools used for the class, and the specific characteristics of the class activities which may have contributed to the spread of Giardia.

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Harter, Lucy, Frost, Floyd, & Jakubowski, Walter. (April, 1982). Giardia prevalence among l-to-3 year old children in two Washington State counties. American Journal of Public Health, 72(4), 386-388. The authors studied Giardia infection in two Washington State counties to determine whether the rate of infection differed according to source of drinking water. Of the two counties surveyed, one was served by deep wells or springs, and the other was served by municipal surface water or shallow wells. Prevalence of Giardia among the 518 children studied was 7.1% and was not related to the source of water, attending a day care center, or the parent's occupation. Risk factors for infection included having a history of drinking untreated water and having at least one sibling between ages 3 and 10.

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Hygiene challenges in group child care [videotape]. (1993). Cincinnati, OH: Procter & Gamble. This videotape describes some of the infectious disease hazards in group child care, and gives suggestions and prevention ideas for staff of child care centers. The primary methods of preventing infectious disease are frequent handwashing, disinfecting surfaces, and proper use of disposable diapers. Handwashing should be done repeatedly by staff and children, especially after diaper changes. Toys, play surfaces, chairs, and tables should also be disinfected after each use. Using disposable diapers, changing them regularly, fitting them snugly, and disposing of them properly can also keep contamination and leakage to a minimum.

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Labbe, Ronald G. (July-August, 1991). Clostridium perfringens. Journal of the Association of Official Analytical Chemists, 74(4), 711-714. Clostridium perfringens is a common cause of bacterial food poisoning in humans primarily associated with meat and poultry prepared in restaurants. This bacteria is commonly found in food

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service establishments and institutional settings because it can survive the cooking process and continue to grow at relatively high temperatures, especially when large quantities of food are prepared in advance of serving and left on low heat to keep warm. Infection with this bacteria may cause severe diarrhea and abdominal pain, as well as nausea, fever, and vomiting. Death is not common, except among those who are institutionalized or in poor health, and particularly among children and the elderly. Because this type of food poisoning can be prevented by proper food handling, the author suggests that previously cooked food should be refrigerated promptly, and then properly reheated before serving. 301

Leggiadro, Robert J., Callery, Barbara, & Dowdy, Sue. (January, 1989). An outbreak of tuberculosis in a family day care home. Pediatric Infectious Disease Journal, 8(1), 52-54. The authors examine an outbreak of tuberculosis that affected four unrelated children who attended a family day care home. In this case the source of infection was a 40-year-old daughter who assisted in the day care home. After detailing each case, the authors examine the public health ramifications of the situation and point out that current recommendations for tuberculosis screening of child day care staff need implementation and enforcement and that such screening should be extended to small, informal, day care homes because this is the most common form of child day care in the United States.

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Lemp, George F., Woodward, William E., Pickering, Larry K., Sullivan, Peggy S., & DuPont, Herbert L. (1984). The relationship of staff to the incidence of diarrhea in day-care centers. American Journal of Epidemiology, 120(5), 750-758. The authors studied cases of diarrhea among children at 60 day care centers in Houston, Texas. During the 8 months of the study, 986 cases of diarrhea were reported. Several staff variables were positively associated with the incidence of diarrhea: the average frequency of diapering, working with children ages 2 and under, meal preparation, and serving food, as well as the percentage of staff who both serve or prepare meals and diaper children. The findings suggest that day care staff have a role in the transmission of diarrheal illnesses while diapering, preparing or serving food, or working with children ages 2 and under. A daily combination of diapering and food preparation or service is also a

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Injury Prevention for Young Children: A Research Guide risk factor. The authors suggest that the staff responsible for preparing or serving food be excluded from changing diapers.

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Mohle-Boetani, Janet C, Stapleton, Margaret, Finger, Reginald, Bean, Nancy H., Poundstone, John, Blake, Paul A., & Griffin, Patricia M. (June, 1995). Communitywide shigellosis: Control of an outbreak and risk factors in child day-care centers. American Journal of Public Health, 85(6), 812-816. The authors studied an outbreak of shigellosis in 14 Kentucky child day care centers to assess the prevention of shigellosis by handwashing, the risk factors associated with day care centers, and the cases of shigellosis attributable to attending a day care center. The outbreak abated within 3 weeks of intervention, which included promotion of handwashing, surveillance for symptoms, and early diagnosis and treatment. Day care centers with outbreaks of shigellosis were more likely to have a food handler who also changed diapers than centers with no cases of the infection. The outbreak centers also had a higher child-to-toilet ratio. The most common risk factor in families who developed shigellosis was having a child ages 6 and under who attended day care. The authors conclude that community handwashing led to the control of this outbreak, and recommend that emphasizing prevention interventions such as handwashing in day care centers can prevent further day care and community outbreaks.

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Outbreak of Salmonella enteritidis infection associated with consumption of raw shell eggs. (May 29, 1992). Morbidity and Mortality Weekly Report, 41(21), 369-372. This article describes an outbreak of Salmonella poisoning at a restaurant that was traced to salad dressing made from infected eggs. Fifteen diners became ill within 3 days after eating at the restaurant, and 14 had eaten Caesar salad. The salad dressing and ingredients (including eggs) were not available for analysis, but Salmonella enteritidis was detected in some eggs delivered by the same supplier. Salmonella enteritidis is the most commonly reported cause of salmonella poisoning in the United States. Raw or uncooked eggs are the most likely source of infection. Salmonella poisoning can be fatal to young children, to the elderly, and to people with impaired immune systems.

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Pediatric AIDS Foundation. (1995). HIV/AIDS: A challenge to us all. Santa Monica, CA: Pediatric Aids Foundation.

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This program from the Pediatric Aids Foundation includes a booklet and two videotapes aimed at educating children and parents about HIV and AIDS. The book describes how to plan and direct a parents' meeting to discuss HIV and AIDS. Worksheets that explain factual information about the spread and nature of the virus are included as appendices. The videos show footage from an actual parents' meeting and several scenarios that can help parents and educators talk to children about HIV and AIDS. 306

Pickering, Larry K. (June, 1987). Infections in daycare. Pediatric Infectious Disease Journal, 6(6), 614-617. In this article, the author organizes current information about diseases that have been studied in children in the day care setting. He examines the following categories: day care centers, day care homes, preschool or nursery school, mother's day out, and cooperatives. He includes a brief discussion of several prominent diseases: diarrheal disease, hepatitis A, acute respiratory tract illness, influenza, cytomegalovirus, and vaccinepreventable diseases. The author concludes his discussion by summarizing steps to limit the spread of infections in day care settings.

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Staat, Mary A., Morrow, Ardythe L., Reves, Randall R., Bartlett, Alfred V., & Pickering, Larry K. (April, 1991). Diarrhea in children newly enrolled in day-care centers in Houston. Pediatric Infectious Disease Journal, 10(4), 282-286. The authors studied children ages 2 and under at 13 day care centers to determine whether the incidence of diarrheal illness was higher during the child's initial exposure to the day care setting. The incidence rate for children in the first 4 weeks of day care attendance was 4.4 cases per child year, significantly higher than the 2.7 cases per child year rate for the following weeks. The authors suggest that parents be made aware of the higher risk of diarrheal illness during the first 4 weeks of day care attendance. Interventions such as handwashing and keeping surfaces clean may prevent some of the risk of bacterial illness that is common in many day care centers.

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Steketee, Richard W., Reid, Steven, Cheng, Tina, Stoebig, James S., Harrington, Richard G., & Davis, Jeffrey P. (April, 1989). Recurrent outbreaks of giardiasis in a child day care center, Wisconsin. American Journal of Public Health, 79(4), 485-490.

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Injury Prevention for Young Children: A Research Guide The authors studied three outbreaks of giardiasis at a large child day care facility in Wisconsin. The first outbreak affected 47% of children, 35% of staff, and 18% of households tested. The second outbreak affected 17% of children, 13% of staff, and 9% of households, and the third outbreak affected 37% of children, 9% of staff, and 5% of households. The rate of illness among the children was highest among ambulatory diapered children, children who attended day care for 40 or more hours per week, and children who were infected during the previous outbreak. After the first outbreak, measures to treat and prevent further infections (such as improved hygiene practices and early detection programs) were instituted, but the measures failed to prevent further outbreaks.

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Sullivan, Peggy, Woodward, William E., Pickering, Larry K., & DuPont, Herbert L. (September, 1984). Longitudinal study of occurrence of diarrheal disease in day care centers. American Journal of Public Health, 74(9), 987-991. This longitudinal study measured the rates of diarrheal illness among children in 60 Texas day care centers. In the 2 years of the study, 2,708 diarrhea episodes occurred among the 3,800 children ages 6 and under in the study, and 84 diarrhea episodes were reported by center staff. The incidence of diarrhea was 17 times higher in children ages 3 and under than in the older children. The characteristics of the day care center that were positively associated with higher incidence of diarrhea were care of younger diapered children, staff who both prepared food and changed diapers, for-profit management, and no guidelines apart from state regulations. The authors suggest that the costs of treating diarrheal illness are cause to stress prevention techniques in environments such as day care centers which are prone to such illnesses.

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Takala, Aino K., Jero, Jussi, Kela, Eija, Ronnberg, Pirjo-Ritta, Koskenniemi, Eeva, & Eskola, Juhani. (March 15, 1995). Risk factors for primary invasive pneumococcal disease among children in Finland. Journal of the American Medical Association, 273(11), 859-864. This population-based, case-control study evaluated the incidence of pneumococcal disease among children ages 0 to 15 in Finland. Subjects included 149 cases and 284 controls matched for age, gender, and place of residence. Increased risk of pneumococcal disease among those under age 2 was associated with day care attendance and frequent ear infections. For those

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ages 2 and over, increased risk was associated with having an under school-age sibling. Day care center attendance was the most significant risk factor for pneumococcal illness among the children in the study. The authors suggest that programs to prevent pneumococcal disease should target children under age 2 who attend day care or have frequent ear infections. 311 Tauxe, Robert V., Johnson, Kathleen E., Boase, Janice C , Helgerson, Steven D., & Blake, Paul A. (June, 1986). Control of day care shigellosis: A trial of convalescent day care in isolation. American Journal of Public Health, 76(6), 627-630. The authors studied two shigellosis outbreaks at two Seattle, Washington day care centers. Both centers had high rates of diarrheal illness in children, center staff, and families of center children. The smaller center was temporarily closed, but the larger center remained open. Those children and staff who were receiving treatment and who no longer had diarrhea were permitted to return to the center, but were kept in an isolated area with separate bathroom, sink, and play area. Follow-up at both centers found no further cases in the 2 months following the outbreaks. The need for other child care for those at the smaller center that closed was estimated to be 100 times that of the center who allowed the children to return in isolation. The authors suggest that children who are in treatment for diarrheal illness may not necessarily need to be out of day care if their day care center can keep them in isolation for the duration of the infection. 312 Telzak, Edward E., Budnick, Lawrence D., Greenberg, Michele S. Zweig, Blum, Steve, Shayegani, Mehdi, Benson, Charles E., & Schultz, Stephen. (August 9, 1990). A nosocomial outbreak of Salmonella enteritidis infection due to the consumption of raw eggs. New England Journal of Medicine, 323(6), 394-397. This study examined an outbreak of Salmonella enteritidis infection at a New York City hospital. Illness was seen in 404 (42%) of the patients at the hospital, and nine patients (mean age 77.5 years) died. Investigation revealed that the cause of infection was raw eggs used to make mayonnaise for patients on low-sodium diets. As a result of this outbreak, the New York State Department of Health recommended that health care facilities eliminate the use of raw or undercooked eggs for high-risk patients: the elderly, the institutionalized, and those with impaired immune systems.

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Trumpp, Cynthia E., & Karasic, Raymond. (March, 1983). Management of communicable diseases in day care centers. Pediatric Annals, 12(3), 219-229. In this article, the authors discuss the transmission of communicable diseases in the day care setting, with emphasis on prevention of spread to contacts and the management of epidemics. They limit their examination to facilities that provide care for children less under age 5, such as day care centers, family day care homes, and nursery schools and recognize that these settings pose special problems for four reasons in particular: 1. The group is uniquely susceptible to infections spread by close personal contact, 2. This age group allows silent spread of certain infections, 3. The youngest enrollees are usually unimmunized against certain diseases, and 4. Children in diapers can be victims and vectors of disease transmitted by the fecal-oral route. The authors detail the following infections: respiratory tract infection, infection due to haemophilus influenzae type B, infection due to neisseria meningitidis, diarrheal illness, and hepatitis A. They provide five tables detailing the treatment of the named diseases.

314

Van, Rory, Wun, Chuan-Chuan, Morow, Ardythe L., & Pickering, Larry K. (April 10,1991). The effect of diaper type and overclothing on fecal contamination in day-care centers. Journal of the American Medical Association, 265(14), 1840-1844. The authors studied the relationship between different types of diapers and overclothing on bacterial contamination of surfaces and children in day care centers. A total of 2,946 samples were taken during 9 weeks of study from rooms in 4 day care centers. Fecal coliforms, bacteria normally found in the intestinal tract, were found on 307 inanimate objects (15%), 73 toy balls (46%), and 131 hands (17%). Contamination was more common in rooms where cloth diapers with plastic overpants were used than in those where disposable diapers were used. The authors suggest that using disposable diapers covered by clothing is the most effective way to minimize the fecal contamination associated with many infectious diseases at day care centers.

315

Wenger, Jay D., Harrison, Lee H., Hightower, Allen, Broome, Claire V., & the Haemophilus Influenzae Study Group. (December, 1990). Day care characteristics associated with Haemophilus influenzae disease. American Journal of Public Health, 80(12), 1455-1458.

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This case-control study of day care facilities evaluated characteristics associated with the Haemophilus influenzae disease. It was found that facilities where Haemophilus influenzae disease occurred were more likely than control facilities to have personnel using towels or handkerchiefs to wipe children's noses, to admit children who were not toilet trained or had diarrhea, to have a narrow range of children's ages, to have for-profit management, and less likely to use volunteers. Towel or handkerchief use was the only variable independently associated with case facilities. 316

Wood, David, Pereyra, Margaret, Half on, Neal, Hamlin, Julie, & Grabowsky, Mark. (June, 1995). Vaccination levels in Los Angeles public health centers: The contribution of missed opportunities to vaccinate and other factors. American Journal of Public Health, 85(6), 850-853. The authors examined 752 randomly-selected records of 2year-old children at 5 public health centers in Los Angeles. By 2 years of age, only 27% of these children were up to date on recommended vaccinations. Those who were up to date had a history of more missed vaccination opportunities and more wellchild visits. Missed vaccination opportunities occurred during 52% of all visits examined. The authors suggest that more missed opportunities and fewer well-child visits may result in low levels of vaccination among children who visit public health centers.

317

Zell, Elizabeth R., Dietz, Vance, Stevenon, John, Cochi, Stephen, & Bruce, Richard H. (March 16,1994). Low vaccination levels of U. S. preschool and school-age children: Retrospective assessments of vaccination coverage, 1991-1992. Journal of the American Medical Association, 271(11), 833-839. The purpose of this study was to obtain estimates on the percentage of children who were up-to-date on the recommended childhood vaccination series, the percentage of children who were age-appropriately immunized, and the coverage levels by individual vaccines. Vaccination levels were estimated by conducting retrospective immunization coverage surveys of the school health records of children entering kindergarten or first grade in the 1990 to 1991 or 1991 to 1992 school year. Survey sites were selected from among the 60 largest urban areas in the United States. One small city and one rural area were selected for comparison. By their second birthday, 11% to 58% (median 44%) of the children were fully vaccinated. Stricter measurement criteria

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Injury Prevention for Young Children: A Research Guide lowered coverage levels further. Completed series levels at school entry were 71% to 96% (median 87%). The authors conclude that vaccination levels at the second birthday were far below the goal for the year 2000, and suggest that all health providers should administer vaccines according to the recommended schedule.

8 Motor Vehicle, Pedestrian, and Riding Toys Accidents

M

otor vehicle crashes are the leading cause of accidental death for young children, causing nearly twice as many deaths as any other accident class. This chapter includes journal articles and other publications which provide information about the prevalence, risk factors, hazards, and prevention of these injuries. Several articles discuss successes and failures of child passenger safety laws and mandatory seatbelt use to substantially reduce mortality rates. Injuries from pedestrian accidents, sledding, bicycles, and other riding toys are also included in this chapter. 318

Agran, Phyllis, Castillo, Dawn, & Winn, Diane. (June, 1990). Childhood motor vehicle occupant injuries. American Journal of Diseases of Children, 144(6), 653-662. This article examines motor vehicle occupant trauma as the major cause of mortality among the pediatric population. The authors point out that despite enactment of child passenger safety laws in all states and mandatory seatbelt use laws in two-thirds of the states, mortality rates have not decreased to the extent expected. Improving occupant protection for all children will be required to further decrease occupant trauma. The authors recommend that future prevention efforts include developing more user-friendly car seats for young children, requiring all passengers in motor vehicles to wear seatbelts, and improving

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Injury Prevention for Young Children: A Research Guide safety features in all motor vehicles (sturdier framework and air bags).

319

Agran, Phyllis F., Dunkle, Debora E., & Winn, Diane G. (September, 1987). Effects of legislation on motor vehicle injuries to children. American Journal of Diseases of Children, 141(9), 959-964. The authors studied the effects of a child passenger safety law on pediatric motor vehicle trauma data on motor vehicle crash victims were obtained from nine hospital emergency rooms in California. For children ages 4 and under, the authors found that restraint use increased from 26% in the pre-law period to 50% in the post-law period The total number of injured decreased significantly, and the number of head injuries decreased by 17%. Hospital emergency room utilization did not decrease. The authors conclude that mandated restraint use has a positive effect in reducing childhood trauma, but that a large number of children continue to be unrestrained despite the enactment of a child passenger safety law.

320

Atkins, R. M., Turner, W. H., Duthie, R. B., & Wilde, B. R. (December 3, 1988). Injuries to pedestrians in road traffic accidents. British Medical Journal, 297(6661), 1431-1434. This British 2-year prospective study examined injuries to pedestrians in road traffic accidents. Subjects were 500 men and women at the accident department of an Oxford, England hospital during 1983 and 1984. Death rates for pedestrians were significantly higher than those inside the cars or riding motorcycles. The most important factors influencing the seriousness of injuries and deaths were the weight of the vehicle involved in the accident and the age of the victim. Head injuries were the most common, usually involving a brief concussion. The most common serious injuries were leg injuries. Young children and the elderly made up the majority of accident victims in the study. The authors conclude that pedestrians are at higher risk for admission to the hospital, serious injury, or death than those riding motorcycles or riding in cars, and recommend that further studies investigate ways to reduce this trend.

321

Baker, Susan P., Fowler, Carolyn, Li, Guohua, Warner, Margaret, & Dannenberg, Andrew L. (April, 1994). Head injuries incurred by children and young adults during informal recreation. American Journal of Public Health, 84(4), 649-652.

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The authors studied the number of hospital-treated head injuries in children and young adults that were associated with recreational activities such as playground equipment, children's vehicles, skateboards, and roller skates. They examined information from Consumer Product Safety Commission charts that demonstrated sources of head injuries by age group. There were 16,775 head injuries to children ages 0 to 4. Seventy-five percent of these injuries were from playground equipment, 22% from children's vehicles, and 3% from roller skates. In addition to improvements in playground safety, the authors recommended developing a multi-purpose helmet that would be attractive for children to wear w h e n engaging in any activity with a demonstrably high incidence of head injury. 322

Baker, Susan P., Robertson, Leon S., & O'Neill, Brian. (April, 1974). Fatal pedestrian collisions: Driver negligence. American Journal of Public Health, 64(4), 318-325. The authors studied 180 fatal collisions with Baltimore pedestrians. Referees who reviewed the cases judged 46% of the drivers to be probably negligent, 37% probably not negligent, and 17% negligence unknown. Driver negligence was associated with a history of poor driving. Study drivers also had more points for traffic convictions than the average Maryland driver. The study also found that the pedestrians most likely to be killed are often those whose behavior puts them at risk. It was found that threefourths of all pedestrians were either under the influence of alcohol, ages 10 and under, or ages 65 and over. The authors suggest that modifying roads, vehicles, and traffic patterns, as well as increasing the legal ramifications of negligent driving may reduce the number of pedestrian deaths and injuries.

323 Blue ribbon panel on child restraint & vehicle compatibility: Recommendations. (May 30,1995). Arlington, VA: The American Coalition for Traffic Safety, Inc. This report provides recommendations of a panel that was commissioned to review the compatibility between child restraint systems (CRS) and vehicle seating positions and belt systems, and to make recommendations to government, industry, and consumer groups about the proper and secure installation of child restraint systems in vehicles. Because panelists were aware that parents and caregivers of children were unaware of special hardware needed in certain vehicles and often failed to secure children properly in car seats (either improperly using the provided harness, failing to

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Injury Prevention for Young Children: A Research Guide fasten the car seat properly, or using a car seat inappropriate for the child), members focused on compatibility issues at three levels: future products, current products in the market and products under development, and currently-owned and past model products. They recommended that the National Highway Traffic Safety Administration examine the development of a separate anchorage system for child restraint systems in all vehicles. They also recommended that vehicle manufacturers develop extensive educational materials to alert vehicle owners about the proper use of their child restraint systems. They also recommended an intensive campaign to alert the public on correct use and installation of child restraint systems should be undertaken through a broad range of groups including automotive dealers, health care providers and day-care providers.

324

Brison, Robert J., Wicklund, Kristine, & Mueller, Beth A. Quly, 1988). Fatal pedestrian injuries to young children: A different pattern of injury. American Journal of Public Health, 78(7), 793795. The authors studied Washington State death certificates, coroners' reports, and police records to determine patterns of injury for fatal pedestrian-motor vehicle collisions involving children ages 5 and under. There were 71 fatal motor vehiclepedestrian injuries during the 5-year study period. In contrast to the "dart-outs" responsible for a majority of pedestrian injuries among older children, the fatalities in this study were most often caused by the family van or light truck backing over the child in the home driveway. The authors suggest that future prevention efforts include strategies targeted at driveway safety and a review of vans and light trucks as family vehicles.

325

Guerin, Diana & MacKinnon, David P. (February, 1985). An assessment of the California child passenger restraint requirement. American Journal of Public Health, 75(2), 142-144. The authors studied the impact of legislation in California that required children ages 4 and under or weighing less than 40 pounds be transported in a properly-used, federally-approved child passenger seat restraint system. Although an analysis of data showed no significant change in the number of fatalities per month after legislation was in place and enforced, there was a significant reduction in injuries for children ages 0 to 3. A control group of similar children in Texas (a state without child restraint legislation at the time) showed no decrease in injuries for that age group. The

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child restraint legislation did not include children ages 4 to 7 and that the injury rates in this group remained high. The authors suggest that legislation may also be required to encourage parents to buckle up older children. 326

Guyer, Bernard, Talbot, Alice M., & Pless, I. Barry. (February, 1985). Pedestrian injuries to children and youth. Pediatric Clinics of North America, 32(1), 163-174. The authors review the epidemiology of pedestrian injuries and the literature on pedestrian traffic safety and child behavior. They begin their review by focusing on three elements of the epidemiology of pedestrian injuries: the injured pedestrian, the environment in which the injury occurs, and the vehicle and its driver. In focusing their attention on preventing pedestrian injuries to children, they consider several possible intervention strategies: teaching young children to be safer pedestrians, modifying driver behavior, and separating children from cars (developing separate traffic patterns for vehicles and pedestrians). The authors also describe the role of health professionals as advocates for pedestrian safety.

327

Hletko, Paul J., Hletko, Jana D., Shelness, Annemarie M., & Robin, Stanley S. (November, 1983). Demographic predictors of infant car seat use. American Journal of Diseases of Children, 137(11), 1061-1063. The authors conducted a study to identify parents most likely to respond to a postpartum education program by correctly restraining their infants in child restraint devices (CRDs). The program used one-on-one instruction with discussion materials, audiovisual aids, and printed information about CRDs. The authors formulated demographic characteristics for correct and incorrect child restraint device use and found that the most important predictors for correct use were the level of the mother's education, the family having a dentist, the mother not smoking, and the mother reporting she used a seatbelt. The study showed that parents with a higher socioeconomic status were more readily convinced to use CRDs correctly through traditional education methods. They concluded that two strategies should be devised to convince all parents to use CRDs and that a determination about which strategy to use could be made at admission of the expectant mother to the hospital using the four named predictors.

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Kendrick, Denise. (May, 1993). Prevention of pedestrian accidents. Archives of Disease in Childhood, 68(5), 669-672. The author analyzed pedestrian accidents a m o n g 573 children ages 0 to 11 by a locally-derived deprivation score for the years 1988 to 1990. The analysis showed a significantly higher accident rate in deprived areas. The author suggests that area-wide engineering and educational schemes be targeted at areas with high accident rates and calls for further research to determine whether there is adequate provision of safe play areas in deprived areas and to address the issue of safe routes to play areas in these locations.

329

Krassner, Leonard S. (October, 1983). Child restraint devices. Pediatric Annals, 12(10), 733-736. The author examined the efficacy of pediatricians' guidance to the parents of their patients, particularly with regard to safety devices in automobiles. Child restraint devices (CRDs) have been available for years, but the study showed that pediatricians achieved positive results in the use of CRDs w h e n they incorporated advice about safety devices in their routine appointments with patients. Krassner urges doctors to educate themselves about proper child restraints for automobiles and to promote restraint use. The author outlines a set of rules for parents of adolescents to encourage safe, responsible driving.

330

Malek, Marvin, Guyer, Bernard, & Lescohier, liana. (1990). The epidemiology and prevention of child pedestrian injury. Accident Analysis and Prevention, 22(4), 301-313. The authors describe pedestrian injuries to children ages 15 and under. They define child populations at risk of pedestrian injury and review the causes and approaches to prevention of the injuries. They note that children ages 5 to 9, boys, and children in lower socioeconomic classes are at higher risk of pedestrian injury than other children. These injuries take place close to home and frequently occur while the child is at play. The authors discuss the behavior of the child pedestrian and describe m e t h o d s of preventing childhood pedestrian accidents through education of the child pedestrian, education of the driver, financial support of federal agencies and municipal officials, and studies of the influence of the social environment and the implementation of traffic engineering to protect pedestrians. The authors conclude that making the urban residential environment safer for children is

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an important long-term objective and offer suggestions for attaining that goal. 331

Manary, Mark J., & HoUifield, William C. (June, 1993). Childhood sledding injuries in 1990-91. Pediatric Emergency Care, 9(3), 155-158. To categorize sledding accident injuries, the authors conducted a chart review of all injured sledders at St. Louis Children's Hospital during the winter of 1990 to 1991, a review of Consumer Product Safety Commission (CPSC) injury data for 1990, and measurements of sledding speeds. The purpose of their analysis was to characterize the injuries incurred and to suggest methods of prevention. The authors suggest that sledding injuries may be prevented by selecting a safe sledding site, by wearing protective clothing, and by avoiding sledding at times of highest risk.

332

Margolis, Lewis H., Wagenaar, Alexander C , & Liu, Wanda. (October, 1988). The effects of a mandatory child restraint law on injuries requiring hospitalization. American Journal of Diseases of Children, 142(10), 1099-1103. Using data on all inpatients in 16 Michigan hospitals from 1980 through 1985, the authors examined the clinical effects of a mandatory child restraint law. There was a 36% decline in hospitalization for all injuries, with a 25% decline for head injuries, and a 20% decline in extremity injuries for children ages 4 and under among those complying with the law. The authors examined reports describing the effects of mandatory laws for the use of child restraint devices (CRDs) and showed that the implementation of the law increased restraint use and decreased injury frequency and severity, especially in head injuries.

333

Margolis, Lewis H., Wagenaar, Alexander C , & Molnar, Lisa J. (May, 1988). Recognizing the common problem of child automobile restraint misuse. Pediatrics, 81(5), 717-720. The authors discuss the ways child automobile restraints are misused and the major consequences of those misuses. Typical misuses include infant seats facing forward rather than backward, child seats in the front seat rather than the rear, restraint devices not fastened by seatbelts, restraint devices fastened but not snug, seatbelts routed incorrectly, and harnesses not snug. The authors cite the major consequences of misuse, including increased risk of injury when children are improperly restrained and reduced

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Injur Prevention for Young Children: A Research Guide credibility of health experts in the view of legislators and the public because the purported benefits of child restraints are not fully realized.

334

Olson, Lenora M., Sklar, David P., Cobb, Loren, Sapien, Robert, & Zumwalt, Ross. (March, 1993). Analysis of childhood pedestrian deaths in New Mexico, 1986-1990. Annals of Emergency Medicine, 22(3), 512-516. The authors discuss the location and pattern of fatal childhood pedestrian injuries, as well as the effect of age and ethnic differences on fatality rates. Data were obtained from a review of state medical investigator reports and autopsies from 1986 to 1990. Subjects were children ages 0 to 14 in New Mexico who were fatally injured by moving vehicles. The study revealed that Native American children and children ages 5 and under experienced the highest fatality rates. Children ages 5 and under were more likely to be crushed under the wheels of a slow-moving vehicle in both a non-traffic, and a traffic location, whereas older children died from being injured by a high-speed impact event in a traffic location. The authors concluded that young children are at risk for a crush injury in both traffic and non-traffic environments.

335

Pedestrian f a t a l i t i e s - N e w Mexico, 1958-1987. (May 17, 1991). Morbidity and Mortality Weekly Report, 40(19), 312-314. A study of New Mexico pedestrian fatalities during a 30year period showed that rates of fatalities were significantly different between genders and ethnic groups. Rates of pedestrian fatalities were higher for males than for females, and higher for American Indians (in all age groups) than for other groups. Because minorities, especially those in lower socioeconomic groups, are disproportionately represented in injuries, the article suggests that systems used to track the prevalence and causes of injury include ethnic data.

336

Pless, I. Barry, Verreault, Rene, Arsenault, Louise, Frappier, JeanYves, & Stulginskas, Joan. (March, 1987). The epidemiology of road accidents in childhood. American Journal of Public Health, 77(3), 358-360. The authors studied the incidence and severity of medicallyattended motor vehicle accidents among children ages 14 and under in Montreal, Canada. Pedestrians had the highest rate of severe injuries. The rates of pedestrian and bicycle (but not passenger) injuries in low income areas were four to nine times

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greater than those in more affluent areas. The authors compared data from this study to similar studies performed in Massachusetts and Memphis, Tennessee. While there were many similarities, the authors found that two factors were associated with higher rates of injury in the Massachusetts and Memphis studies: younger drivers and the lack of child restraint device laws. 337

Pless, I. Barry, Verreault, Rene, & Tenina, Sonia. (August, 1989). A case-control study of pedestrian and bicyclist injuries in childhood. American Journal of Public Health, 79(8), 995-998. The authors identified children ages 0 to 14 injured in traffic as pedestrians or bicyclists in Montreal, Canada. Two hundred children with injuries who received a score of 2 or more on the Maximum Abbreviated Injury Severity Scale were considered as cases and compared with 400 uninjured children seen in the same hospitals for non-traumatic reasons. The authors conducted interviews and tests with parents to determine the role of a series of social, familial, personal, and behavioral characteristics. After adjustment for age, gender and socioeconomic area of residence, the authors determined that higher risks of injury were related to fewer years of parents' education, a history of accident to a family member, an environment judged as unsafe, and poor parental supervision. Physical health problems, fewer family preventive behaviors, and reported lack of cautiousness were also related to a higher risk. The authors suggest that the child's personality and behavior are weaker risk factors for pedestrian and bicyclist injuries than are family and neighborhood characteristics. In communities where urban planning separates traffic from bicyclists and pedestrians, the authors note that there are significantly fewer injuries.

338

Rivara, Frederick P. (June, 1990). Child pedestrian injuries in the United States: Current status of the problem, potential interventions, and future research needs. American Journal of Diseases of Children, 144(6), 692-696. This article is a review of the literature on pedestrian injuries to children. More than 50,000 children are injured as pedestrians in the United States each year, of whom approximately 1,800 die, 18,000 are admitted to the hospital, and 5,000 have significant long-term damage. The author focuses on three risk factors for child pedestrian injuries: age and sex, poverty, and pedestrian action. Boys have a rate of pedestrian injury that is two times greater than girls, with those ages 5 to 9 being at highest risk.

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Injury Prevention for Young Children: A Research Guide Children who live in poverty are at risk because the areas they live in have high traffic volumes, fewer pedestrian control devices, and fewer alternatives to the street for play. Pedestrian action includes "dart-out" injuries, dashing across intersections, and children being run over by a vehicle backing up. Prevention techniques should rest on a multifaceted approach at local, state, and national levels and should include pedestrian skills training programs, parent education, legislation, environmental modifications, and vehicle design changes.

339

Rivara, Frederick P., & Barber, Melvin. (September, 1985). Demographic analysis of childhood pedestrian injuries. Pediatrics, 76(3), 375-381. The authors examined the factors in a child's living environment and socioeconomic background that contribute to the risk of pedestrian injury. They studied all pedestrian injuries to children ages 0 to 14 occurring in Memphis, Tennessee during 1982 as reported to the police. Among children ages 0 to 14, there were 210 pedestrian injuries, a rate of 139 per 100,000 children. The injured child was most often male, with mean age of 7.3 years. The child was usually struck while crossing the street between intersections, and the injury happened most commonly from 2 to 7 p.m. The authors also found that children ages 5 to 9 and children living in poverty were at much higher risk of pedestrian injuries. The authors recommend that low-income areas should be modified to separate pedestrians from vehicle traffic, to regulate the speed of motor vehicles, and to provide adequate space for playgrounds.

340

Robertson, Leon S. (February, 1985). Motor vehicles. Pediatric Clinics of North America, 32(1), 87-93. The author suggests that the prevention of motor vehicle trauma merits high priority by pediatricians and by society primarily because trauma to child passengers of crashing motor vehicles is the leading cause of death to children after the first few months of life. Despite ample research and advocacy by physicians and others, new cars and trucks continue to be designed with interiors that are lethal to their human occupants when engaged in an accident. While the use of restraints for children and adults is known to reduce injury and save lives, the author notes that proper use of restraints continues to be problematic. The author recommends explaining the relative risk of certain automobiles, noting that the risk of fatal injury approximately doubles on

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average, for each reduction of 20 inches of wheel base (the distance from front to rear axle). He also notes that physicians could recommend alternative transportation for their patients, because using buses, trains or commercially-scheduled airplanes is statistically safer than automobile travel. In conclusion, the author calls for advocacy by physicians and responsible citizens for safe vehicles, improved roadside construction, and a reexamination of the wisdom of including driver education classes in public schools. This last program, the author notes, has had the unintended effect of increasing the number of drivers licensed at age 16 or 17 (drivers who have fatality rates eight to ten times that of 30-yearold drivers). 341

Ruch-Ross, Holly S., & O'Connor, Karen G. (May, 1993). Bicycle helmet counseling by pediatricians: A random national survey. American Journal of Public Health, 83(5), 728-730. The authors examined the results of a survey of pediatricians regarding the frequency of providing counseling to patients about the use of bicycle helmets to prevent injury. Although the questionnaire examined three variables of the participating physicians (personal characteristics, personal bicycling habits, and professional experiences) with childhood injury, professional experience proved to be the most significant with regard to counseling. Physicians who had recent experience with patients injured or killed in cycling accidents reported the highest frequency of counseling about the use of helmets. Eighty percent of those surveyed reported that they discuss bicycle helmet use with their patients at least once before the patient reaches age 12, but very few reported discussing these safety measures with patients younger than 5 years of age.

342

Sargent, James D., Peck, Magda G., & Weitzman, Michael. (July, 1988). Bicycle-mounted child seats: Injury risk and prevention. American Journal of Diseases of Children, 142(7), 765-767. The authors analyzed two existing data sets to examine the frequency, trend, and characteristics of bicycle-mounted child seat injuries to children ages 5 and under. Using reported bicyclerelated injuries to children in this age group in California from 1977 to 1986, the authors found an increased frequency of these injuries, with the rate of passenger injuries rising from 17% to 28% of all reported bicycle-related injuries. In a detailed sample of 52 injuries related to the use of bicycle-mounted child seats, 42% occurred when the bicycle crashed or tipped over and 25%

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Injury Prevention for Young Children: A Research Guide occurred when the child fell out of the seat. Sixty-five percent of the injuries involved the head and face, and 27% of the head injuries were serious. The authors suggest that children riding in these child seats wear appropriate bicycle helmets.

343

Scherz, Robert G. (October, 1981). Fatal motor vehicle accidents of child passengers from birth through 4 years of age in Washington State. Pediatrics, 68(4), 572-575. The author analyzed 39,500 motor vehicle accidents involving children ages 0 to 4 in Washington State. Of the children involved in these accidents, 148 were killed immediately or subsequently died. Of the 6,300 who were wearing some kind of safety restraint, only two (1 in 3,150) were killed. Of the 33,200 not wearing any restraints, 146 (1 in 227) were killed. The author suggests that if all the children had been wearing restraints, there would have been 93% fewer deaths. Fatal accidents involving young children usually occurred under ordinary circumstances on dry roads at low speeds during daylight hours and were unrelated to alcohol usage. The author suggests that pediatricians should continue to educate parents to use approved child passenger restraints.

344

Swoboda, Frank. (February 19,1994). U. S. calls air bags risk to tots: Safety seats won't protect children riding up front. The Washington Post, Al, A15. The National Highway Traffic Safety Administration (NHTSA) warns that putting infants in car seats in a passenger seat with an air bag is dangerous. When the child is facing backwards, as is recommended, the air bag cannot inflate without hitting the safety seat. The force with which the air bag inflates is enough to snap an infant's neck or cause brain damage. The safest place to put an infant in a child restraint seat in the car is facing backward in the center of the rear seat.

345

Tanz, Robert R., & Christoffel, Katherine K. (December, 1985). Pedestrian injury: The next motor vehicle injury challenge. American Journal of Diseases of Children, 139(12), 1187-1190. Because fatal pedestrian injuries are more common than fatal occupant injuries in preschool and school-aged children, the authors of this article examine the importance of pedestrian injury as a cause of early childhood injury and death. Since existing patterns and trends in pedestrian injury statistics are poorly understood, the authors call for the development of effective

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strategies for injury prevention by studying how and why pedestrian injuries occur. While the authors note that children from ages 5 to 9 are the key ages for injury and that death rates are greatest for those ages 10 and under, they name environmental, psychosocial, medical, and behavioral factors in child pedestrian injury as factors that should be included in further study. The authors suggest that future prevention efforts include education (particularly school programs), environmental approaches (separating cars from pedestrians), and evaluating injuries to determine further measures for prevention. 346

Tanz, Robert R., & Christoffel, Katherine K. (October, 1991). Tykes on bikes: Injuries associated with bicycle-mounted child seats. Pediatric Emergency Care, 7(5), 297-301. The authors evaluated the U. S. Consumer Product Safety Commission data concerning injuries related to seats used for carrying children on adult bicycles. There were an estimated 4,960 injuries to children during the 11-year period that the authors examined. The peak age of injury was age 2, and 55% of victims were male. Falls accounted for 80% of the estimated injuries, and head (51%) and face (21%) injuries predominated. Twenty-one percent of the injuries were mild, 60% were moderate, and 19% were severe. Because riding in a bicycle-mounted child seat exposes the child to adult-level forces, the authors suggest that children are at risk because of the bicycle's size, speed, and instability, as well as the child's size and development. The authors recommend using bicycle helmets, improving seat design, and using educational efforts by physicians a n d their organizations to reduce the injuries.

347

Teret, Stephen P., Jones, Alison S., Williams, Allan F. & Wells, Joann K. (January, 1986). Child restraint laws: An analysis of gaps in coverage. American Journal of Public Health, 76(1), 31-34. The authors examined Fatal Accident Reporting System (FARS) data on children ages 0 to 5 killed in motor vehicles for the years 1976 to 1980. The child restraint laws for the 50 states in effect on January 1, 1984 were used to determine whether the children in the study would have been covered by the subsequent laws of the state in which the fatality occurred or if the various exemptions to those laws would still have left these children unprotected. After analysis of the FARS data, the authors were able to compile a state-specific breakdown by scope of coverage of the deaths examined. The authors found that 35% of the 4,020

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Injury Prevention for Young Children: A Research Guide deaths of child motor vehicle occupants ages 0 to 5 that occurred in 1976 to 1980 would not have been covered by the subsequent laws because of the legislative exemptions. The authors recommend that uniform restraint regulations among the states should require restraint use of all vehicle occupants, regardless of age.

348

Wagenaar, Alexander C , & Webster, Daniel W. (October, 1986). Preventing injuries to children through compulsory automobile safety seat use. Pediatrics, 78(4), 662-672. The authors studied the effects of Michigan's law requiring all young children to be restrained when traveling in automobiles. Restraint use among injured children ages 0 to 4 increased from 12% to 51% after the law was implemented. A 28% decrease in the number of children ages 0 to 4 injured in crashes was also attributed to the law. Because changes in the rate of injury did not occur among any of the comparison age groups studied, the substantial increase in use of child restraint devices and decrease in number of children injured during the period after the implementation of the law could be attributed to the passage and enforcement of that law. The authors suggest that pediatricians should instruct the parents of their patients in the proper use of child restraint devices appropriate to the age of their children and should be advocates for expansion of the restraint laws to cover all ages.

349

Walter, Robert S., & Kuo, Anna R. (May, 1993). Taxicabs and child restraint. American Journal of Diseases of Children, 147(5), 561-564. The authors examined the use of taxicabs to transport young children to and from an inner-city clinic. They also examined pediatric taxicab occupant morbidity and mortality data and the exemptions that exist for taxicabs from restraint laws. They found that 35 of 50 states (70%) plus Washington, D. C, exempt taxicabs from child restraint laws. Only 11 (27%) of 41 states with safety belt laws exempt taxicabs. Among the 106 reported taxicab occupant fatalities from 1986 to 1990 in the United States, there were 11 children and adolescents. Taxicab use involving young children was common in the inner-city population surveyed. The authors recommend further efforts to educate taxicab companies about child restraint laws and to implement local legislation linking child restraint device availability to the licensing of taxicabs.

9 Poisoning, Chemical Burns, Bites, and Allergic Reactions

P

)oisoning is a leading cause of accidental death for young children. Accidental death and injury from chemical burns, bites, and allergic reactions also cause a substantial number of deaths and injuries each year and are the subjects of investigations and discussions in the articles which are included in this chapter. Several articles present the success of Poison Control Centers in reducing poisoning deaths in the United States, discuss the prevalence of lead poisoning, and suggest prevention techniques. Medications are a major cause of childhood poisoning and are the subject of several research studies and Consumer Product Safety Commission studies which are reported here. Articles regarding animal bites including flea outbreaks, and allergic reactions are also included in this chapter. 350

Aronow, Regine. (October, 1983). Some ABCs of poisoning in children. Pediatric Annals, 12(10), 739-746. The author reviews the progress in the prevention of poisoning of children. She enumerates the significant developments to achieve this: Poison Control Centers established across the country, the work of the American Association of Poison Control Centers to improve information dispersal, treatment of poisoning and poison prevention education, and federal efforts to distribute information on products, maintain experience data and develop programs to prevent accidental poisoning. Major legislation that has helped the effort includes the 1966 Child

148

Injury Prevention for Young Children: A Research Guide Protection Act, the 1970 Poison Prevention Packaging Act, and the 1972 Consumer Product Safety Act. Maintaining that prevention is the best antidote for accidental poisoning in childhood, the author summarizes by calling for improved treatments for old problems, and therapeutic approaches for new products.

351

Binder, Sue, & Falk, Henry. (February, 1991). Strategic plan for the elimination of childhood lead poisoning. Washington, DC: U. S. Department of Health and Human Services, Public Health Service, Centers for Disease Control. This book is a summary of the U. S. Department of Health and Human Services plan to prevent childhood lead poisoning. The committee responsible for the plan and report suggests that a society-wide effort, such as the one described in the plan, could eliminate lead poisoning as a public health problem in 20 years. The committee makes four major recommendations: 1. Increase childhood lead poisoning prevention programs and activities, 2. Eliminate leaded paint and paint-contaminated dust in high-risk housing, 3. Continue to reduce incidents of exposure to lead from water, food, air, soil, and the workplace, and 4. Establish a national surveillance system to track and record cases of children with high blood lead levels.

352

Blatt, Steven D., & Weinberger, Howard L. (July, 1993). Prevalence of lead exposure in a clinic using 1991 Centers for Disease Control and Prevention recommendations. American Journal of Diseases of Children, 147(7), 761-763. The authors studied 233 children between ages 9 and 24 months who visited an outpatient pediatric department for wellchild visits during 1991. When blood lead levels where tested, the authors found that 25.5% of children ages 9 to 12 months, and 36.1% of children ages 12 to 24 months, had elevated blood levels. The authors also tested for erythrocyte protoporphyrin levels, a common indicator of lead poisoning. The authors found that erythrocyte protoporphyrin was not sensitive at the lower acceptable blood levels recommended by the Centers for Disease Control in 1991, and was no longer an adequate screening test for lead poisoning. The authors suggest that the high prevalence of lead poisoning found in these subjects indicates a need for greater prevention efforts and screening.

353

Chachere, Vickie. (July, 1994). Child-packaging laws: Will officials loosen the cap? Safety & Health, 150(1), 70-72.

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The Consumer Product Safety Commission has asked manufacturers to design new packages that will be easier for adults to open but that will still keep children out. Iron supplements, anti-depressants, heart medications, pesticides, and hydrocarbons are responsible for the majority of child-poisoning deaths. According to poison control center staff, poisonings usually occur when parents unintentionally leave medicines where children can get them, grab the wrong bottle to treat a sick child, or give children too large a dose. Parents must teach their children the dangers of poisons early and stress the difference between medicine and candy. 354

Clarke, Alisone, & Walton, William W. (May, 1979). Effect of safety packaging on aspirin ingestion by children. Pediatrics, 63(5), 687-693. The authors studied Poison Control Center and National Center for Health Statistics data to determine whether the Poison Prevention Packaging Act of 1970 had an effect on the rate of aspirin ingestion incidents for children ages 5 and under. In the 2 to 3 years since the regulation required child-proof packaging, the incidence of baby aspirin ingestion dropped 45% to 55%, and the incidence of other aspirin product ingestion dropped 40% to 45%. The authors suggest that a similar program of safety packaging for other products hazardous to children may be similarly effective in the prevention of child ingestion incidents.

355

Cooper, Jessica M., Widness, John A., & O'Shea, John S. (June, 1988). Pilot evaluation of instructing parents of newborns about poison prevention strategies. American Journal of Diseases of Children, 142(6), 627-629. This study examined the effectiveness of a poison prevention and syrup of ipecac distribution program on parents of newborns. The authors compared the time between poisoning exposure and parent calls to local poisoning centers. During the 3 months of evaluation, the parents who had received information and ipecac called the poison center significantly sooner than parents who had not. Both treatment and control groups had a similar incidence of potentially dangerous exposures. Parents in the treatment group were also more likely to have more child-safe homes.

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356

Corpus, Larry D., & Corpus, Kathleen M. (April, 1991). Mass flea outbreak at a child care facility: Case report. American Journal of Public Health, 81(4), 497-498. This article describes an outbreak of cat fleas at a child care facility in Mississippi. The outbreak was discovered after reports of adult fleas biting children and facility staff. Of the two buildings, one was the source of 99% of fleas collected. The source of the outbreak was determined to be cats from surrounding areas occupying the building's crawl space. The outbreak was contained by blocking the entrance of cats into the crawl space and using insecticides throughout the facility. The authors suggest that openings into crawl spaces be closed off, that insecticides be used promptly, and that animals should be kept indoors or on leashes to reduce the risk of similar outbreaks.

357

Fergusson, D. M., Horwood, L. J., Beautrais, A. L., & Shannon, F. T. (May, 1982). A controlled field trial of a poisoning prevention method. Pediatrics, 69(5), 515-520. This New Zealand study evaluated the effectiveness of Mr. Yuk stickers, labels used to indicate products that should not be tasted, ingested, or inhaled, on children ages 2 and 3. The authors compared poisoning rates and household hazards for 583 families with Mr. Yuk labels and 543 families without the labels and found no significant differences. The three main factors associated with the failure of the program were that parents did not label all poisonous substances in the home, that other poisoning hazards (such as garden plants) could not be labeled, and that children ignored the Mr. Yuk label. The authors suggest that the use of Mr. Yuk stickers alone is not an effective means of prevention, but that the stickers may be useful for older children in conjunction with a broader poisoning prevention program.

358

Gaudreault, Pierre, McCormick, Mary A., Lacouture, Peter G., & Lovejoy, Frederick H., Jr. (July, 1986). Poisoning exposures and use of ipecac in children less than 1 year old. Annals of Emergency Medicine, 15(7), 808-810. This prospective study examined poison exposures in children ages 1 and under and the effectiveness of syrup of ipecac in children ages 9 to 12 months. Out of 38,080 calls at the Massachusetts Poison Control Center during the eight months of the study, 9% involved children ages 1 and under. Mobile children were at the highest risk for poisoning. None of the children were hospitalized or died, and most (94%) had no symptoms.

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Household plants (38%) and products (30%) were responsible for a majority of the incidents. Twenty-one children ages 9 to 12 months were given syrup of ipecac under medical supervision and vomited. None of these children showed any side effects, and all stopped vomiting within 30 minutes. The authors conclude that children ages 1 and under are frequently exposed to toxic materials, and that use of syrup of ipecac in children ages 9 to 12 months is safe and effective. 359

Hinds, Michael deCourcy. (May 20,1989). Mother fights to ruin the taste of poison. New York Times, 54L. This article discusses the efforts of an Oregon woman to get United States manufacturers to add Bitrex to products such as detergents, nail polish removers, rodenticides, and antifreeze. Bitrex is a bittering agent that has been proven effective for preventing ingestion of toxic quantities of some household products by young children. Other products that are extremely toxic or corrosive, such as drain and oven cleaners, cause injuries too quickly for the bittering agent to be effective. Bitrex is already in common use in Great Britain and countries in products such as windshield washes-, antifreeze, and herbicides. Some United States companies are also adding Bitrex to laundry detergents that have scents attractive to children.

360

Murray, Lorraine L. (1992). Poison prevention: A guide for teaching poison awareness to preschool children. Albuquerque, NM: New Mexico Poison and Drug Information Center. This book provides guidance for people w h o teach poisoning prevention to young children. The author describes the developmental stages of children that make them likely to be poisoned. The program lessons describe the different kinds of poisons, how children get poisoned, and how children, parents, and caregivers can prevent poisoning. Learning pages, handouts, and suggested activities also reinforce the information in the program.

361

Polakoff, Jo-Ann M., Lacouture, Peter G., & Lovejoy, Frederick H., Jr. (November, 1984). The environment away from home as a source of potential poisoning. American Journal of Diseases of Children, 138(11), 1014-1017. The authors investigated epidemiologic features of poison exposures away from home (including the rate, place of exposure, and products involved), the potential severity of these exposures

152

Injury Prevention for Young Children: A Research Guide (including the need for ipecac syrup and potential toxicity rating), and the preparedness of these environments to handle poison exposures (including the availability of ipecac syrup). The authors collected data on all calls to the Massachusetts Poison Control System (MPCS), Boston involving a poison exposure in a child 5 years old or younger. Comparisons were made using X2 analyses between the study group (exposures occurring away from home) and the control group (exposures occurring at home). During the 2-month study period, there were 4,231 exposures (mean 72 calls per day). Of these, 541 (13%) involved exposures in children away from home. Males were involved in 53% of the exposures in both study and control groups. Drugs were the largest source of exposures and insect and garden preparations were the smallest source in both study and control groups. The authors suggest that parents and professionals instruct children more carefully about the danger of poisons away from home and that grandparents are instructed in poison prevention and have ipecac syrup in their homes.

362

Richards, Warren. (September, 1992). Asthma, allergies, and school. Pediatric Annals, 21(9), 575-583. The author describes the special challenges for schools and children with asthma or allergies. Children with asthma or allergies should be able to control their symptoms at school, have the opportunity to learn without excessive absences or medication side effects, to participate as normally as possible in physical education, have minimal exposure to allergens or irritants at school, and to be accepted by their classmates. The author suggests that these goals can be met by effort from physicians, parents, schools, and children. Appendices to the article contain forms useful for schools to monitor and track the health of children with allergies and asthma.

363

Schnell, Laurie Rennie, & Tanz, Robert R. (February, 1993). The effect of providing ipecac to families seeking poison-related services. Pediatric Emergency Care, 9(1), 36-39. The authors studied the effectiveness of providing syrup of ipecac to 100 families who had experienced a poisoning incident. Before the program, 71% had heard of ipecac, 51% knew what it did, and 47% said they had it. The families were given general safety and poison information, the local emergency department number, and a coded package of ipecac. A follow-up survey after 3 months showed that 92% knew what ipecac did, 76% knew the

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153

poison control or emergency department phone number, and 94% read the ipecac code number. The authors suggest that interventions such as education and ipecac distribution may be more readily received by families who have already experienced a poisoning incident. 364

Steele, Pegeen, & Spyker, Daniel A. (February, 1985). Poisonings. Pediatric Clinics of North America, 32(1), 77-86. This article reviews three child poisoning projects that sought to determine the incidence, at-risk populations, and causes of injury. The three projects used survey, poison center, and emergency department data, and similarly concluded that age, type of product ingested, knowledge and use of poison center, access to information, and appropriateness of emergency department visits were all related to poisoning. The authors suggest applying Haddon's countermeasures to the problem of childhood poisoning, and give a specific example for the prevention of medication poisonings. The three poisoning projects used one-to-one education for parents of young children, community programs, and professional and public education as interventions. Despite the lack of significant demonstrated impact on the incidence of poisonings in any of the three sites, the authors suggest that the projects provide insight for future prevention efforts.

365

Trinkoff, Alison M., & Baker, Susan P. (June, 1986). Poisoning hospitalizations and deaths from solids and liquids among children and teenagers. American Journal of Public Health, 76(6), 657-660. The authors examined 24 deaths and 4,271 hospital admissions among children ages 0 to 19 due to poisoning in Maryland during 1979-1982. Most of the deaths (83%) occurred among teenagers, and two-thirds of the admissions involved teenagers. Four out of five teenage admissions and/or deaths were suicidal or of undetermined cause. The poisons most often ingested by children ages 0 to 4 included aspirin, solvents, petroleum products, tranquilizers, and iron compounds. Among teenagers, the most common causes of poisoning were aspirin, tranquilizers, sedatives, and antidepressants. The authors suggest that reducing the availability of the most hazardous drugs to teenagers and children is an important prevention intervention in this age group.

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366

U. S. Consumer Product Safety Commission. (1993). Poison prevention packaging: A text for pharmacists and physicians. Washington, DC: U. S. Consumer Product Safety Commission. This booklet is designed to help pharmacists and physicians comply with the Poison Prevention Packaging Act. The substances covered by the regulations include aspirin and acetaminophen, methyl salicylate, controlled drugs, iron-containing drugs and dietary supplements, and human oral prescription drugs. There are also several exemptions to the regulations described in the booklet. The booklet ends with a question and answer section detailing the responsibilities of the pharmacist and physician concerning regulated packaging and poisoning incidents.

367

Vernberg, Katherine, Culver-Dickinson, Paula, & Spyker, Daniel A. (November, 1984). The deterrent effect of poison-warning stickers. American Journal of Diseases of Children, 138(11), 10181020. The authors evaluated the effectiveness of poison warning stickers with twenty children ages 12 to 30 months. All 20 children were observed during two 5-minute sessions in a room with ten pairs of containers, half of which were labeled with Mr. Yuk warning stickers. During the first session, none of the children showed a significant preference for labeled or unlabeled containers. The control group did not show any preference for containers during the second session. Children in the treatment group, however, after having a 5-minute education about not touching labeled containers, preferred to touch the labeled containers during the second session. Based on these findings, the authors conclude that poison warning stickers do not deter children ages 12 to 30 months from touching or mouthing labeled containers. The authors suggest that prevention interventions for this age group should include more reinforcement for children, and more education for parents about keeping hazardous products out of reach.

368

Walton, William W. (March, 1982). An evaluation of the Poison Prevention Packaging Act. Pediatrics, 69(3), 363-370. The author used National Electronic Injury Surveillance System and National Center for Health Statistics data to evaluate the effectiveness of the Poison Prevention Packaging Act (PPPA) on accidental ingestions among children ages 5 and under. Substances studied included aspirin, acetaminophen, prescription drugs, and household chemicals. It is estimated that child-proof

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packaging required by the PPPA prevented 200,000 ingestions by children from 1973 to 1978. The rate of ingestion by children for all substances dropped from 5.7 per 1,000 in 1973 to 3.4 per 1,000 in 1978. Over the past 20 years, the rate of death from poisoning among children has dropped from 2.0 per 100,000 to 0.5 per 1,000. Despite the decline in incidents and deaths related to improved packaging regulation, ingestion incidents still occur. The author suggests that further prevention efforts should focus on unregulated products and the education of parents. 369

Woolf, Alan, Le wander, William, Filippone, Gay, & Lovejoy, Fred. (September, 1987). Prevention of childhood poisoning: Efficacy of an educational program carried out in an emergency clinic. Pediatrics, 80(3), 359-363. The study sought to determine whether a brief intervention could change the practices of parents in the keeping and usage of ipecac. A total of 403 families were recruited from the emergency clinic and divided into two groups. Both groups completed a pretest questionnaire about ipecac. Group 1 was given a 5-minute intervention about ipecac. A second control group was contacted by telephone to prevent the bias of the pretest. The results suggested that a brief intervention, even in an emergency clinic, could introduce the topic of poisoning prevention to families and could encourage the storage of syrup of ipecac in the home.

370

Wright, Brett. (February, 1992). High lead levels may permanently lower IQ. New Scientist, 29,13. This article discusses the effects of lead exposure on the IQ of children. A long-term study of almost 500 children living near a lead smelter at Port Pirie, South Australia found that exposure to lead had a lasting effect on a child's intelligence. The findings challenge the belief that lead merely delays intellectual development. Compared with the effect of genetic or social factors such as parental IQ and education, the impact of lead on the child is small, but still significant.

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Author Index Entries are keyed to page numbers.

A Addiss, David G., 36 Adler, R. G., 87 Agran, Phyllis, 133 Agran, Phyllis F., 134 Alexander, Greg R., 65 Alexander, Randell, 66 Alexander, Randell C, 66 Alkon, Ellen, 103 Allshouse, Michael J., 1 Alperstein, Garth, 2 Altekruse, Joan M., 65 Alwash, R., 2 American Academy of Pediatrics, 2 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, 93 American Public Health Association, 2 American Red Cross, 3 Andereck, Nathan D., 77, 78

Anderson, Kern E., 121 Anderson, Larry J., 119 Anglin, David, 96 Anglin, Deirdre, 76 Annest, Joseph L., 67 Anzinger, Nora K., 69 Aprahamian, Charles, 40 Arezzo, Diana, 86 Aronow, Regine, 147 Aronson, R. A., 40 Aronson, Susan S., 4 Arsenault, Louise, 140 Ashwal, Stephen, 60 Atkins, R. M., 134 Avard, Denise, 98 Azzara, Carey V., 18

B Bailey, Linda A., 97 Baker, M. Douglas, 109 Baker, Susan P., 4,5, 38,41,94, 118,134,135,153

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Injury Prevention for Young Children: A Research Guide

Balasubramanian, Subramanian, 83 Banco, Leonard, 43,112 Baptiste, Mark S., 44 Barber, Melvin, 142 Barber-Madden, Rosemary, 67 Barlow, Barbara, 11 Barness, Lewis A., 95 Baron, Roy C , 58 Bart, Robert, Jr., 105 Bartlett, Alfred V., 119,127 Bass, Joel, 14 Bass, Martin J., 117 Bassoff, Betty Z., 5 Bean, Nancy H., 120,126 Beattie, Thomas F., I l l Beausoleil, Monique, 122 Beautrais, A. L., 150 Bell, David M., 120 Bell, Randi E., 109 Beller, Michael, 123 Benedict, Mary, 90 Bennett, Thomas, 66 Benson, Charles E., 129 Bergman, Abraham B., 31 Bergner, Lawrence, 110 Berthier, M., 68 Bever, David L., 6 Bijur, Polly E., 6 Binder, Sue, 148 Black, Robert E., 121 Blake, Paul A., 126,129 Blatt, Steven D„ 148 Blatter, Mark M., 54 Blevins, Ronald, 47 Bloch, Harry, 68 Blum, Steve, 129 Board of Trustees, 110 Boase, Janice C , 129 Bogat, G. Anne, 80 Bonneau, D., 68 Bowman, Leon M., 12 Boyle, Catherine M., 56

Boyle, William E., Jr., 28 Braddock, Mary, 43 Braden, Nancy Jo, 82 Brantley, Mary D., 115 Brenner, Ruth A., 99 Brenner, Sheila, 79 Brigham, Peter A., 53 Brink, Susan, 6 Brison, Robert J., 136 Bronson, Martha, 95 Broome, Claire V., 130 Brown, B. M., 35 Brown, J. Marion, Jr., 116 Brown, Joseph, III, 105 Brozicevic, M. M., 40 Bruce, Richard H., 131 Budnick, Lawrence D., 100,129 Buescher, Paul A., 34 Burke, John F., 56 Butler, N. R., 35 Butler, Neville, 6

c Callery, Barbara, 125 Calonge, Ned, 31, 32 Camozzo, Elyse, 57 Campbell, Douglas T., 13 Campbell, Margaret, 111 Caniano, Donna, 47 Canter, David, 44 Carpenter, Mary M., 78 Cashell, Alan W., 68 Castillo, Dawn, 133 Centers for Disease Control, ii, 7 Chachere, Vickie, 149 Chandra, Sunita, 95 Chang, Albert, 7 Chang, Bei-hung, 18 Cheng, Tina, 127 Cherian, Thomas, 121 Chevrel, J., 68 Chiaramonte, Janet, 70

Author Index Children's Defense Fund, 8 Children's Safety Network, 8 Ching, Yi-Chuan, 105 Chiodo, Gary T., 88 Christoffel, Katherine K., 69, 70, 144,145 Christoffel, Katherine Kaufer, 71,86 Christoffel, Tom, 8, 71 Christophersen, Edward R., 59 Clarke, Alisone, 149 Clarke, Nicola, 53 Cobb, Loren, 140 Cochi, Stephen, 131 Cohen, A. Jay, 120 Cohle, Stephen D., 66 Colton, Theodore, 18 Colver, A. F., 9 Colwell, Lewis S., Jr., 116 Committee on Trauma Research, 9 Conley, Christopher J., 44 Conroy, Carol, 24 Cooper, Jessica M., 149 Corpus, Kathleen M., 150 Corpus, Larry D., 150 Coury, Daniel L., 79 Cox, Pamela, 24 Craft, John L., 81 Crawford, Florence G., 122 Crawford, Isabelle, 105 Crawford, John D., 52, 53 Crelin, Edmund S., 94 Culver-Dickinson, Paula, 154 Cupples, L. Adrienne, 18

D Dalia, Margaret A., 119 Dameron, D. O., 40 Daneault, Serge, 122 Daniel, Jessica H., 72 Dannenberg, Andrew L., 134

159

Danoff, Nancy L., 72 Daub, Erich, 118 Davidson, Leslie L., 11 Davis, Jeffrey P., 127 Davis, W. S., 10 Day, Richard L., 94 Delventhal, Stephen J, 49 DeMaio, Alison, 13 Demling, Robert H., 45 Department of Health and Human Services, 10 Dershewitz, Robert A., 10,11 Dick, James, 121 Dickinson, Paula, 154 Dickson, W., 63 Dietz, Vance, 131 DiGuiseppi, Carolyn, 32 Donovan, Mark, 86 Dowdy, Sue, 125 Drake, Christiana, 106 Driessen, Gerald, 112 DuBois, Arthur B., 94 Duby, John C , 42 Dunkle, Debora E., 134 DuPont, Herbert L., 125,128 Duran, Victoria, 45 Durkin, Maureen S., 11 Duthie, R. B., 134 Dykes, Aubert C , 121

E Eaton, Antoinette P., 79 Edlich, Richard F., 62 Egerter, Susan A., 79 Eggert, Russell W., 12 Eichelberger, Martin R., 1,12 Ekpenyong, L., 56 Elardo, Richard, 12 Ellers, Beth, 17 Elman, Michael, 118 Elrod, Jeanne M., 73 Emerick, Sara J., 13

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Injury Prevention for Young Children: A Research Guide

Emery, John L., 95 Englender, Steven J., 119 English, Kerry, 83 Epstein, Eugene U., 120 Ericson, A. Kyle, 47 Esclamado, Ramon M., 94 Eskola, Juhani, 128

F Fahy, Rita F., 44 Falk, Henry, 148 Fazen, Louis E. Ill, 111 Feck, Gerald, 44 Feely, Herta B., 12 Feldman, Jane A., 46 Feldman, Kenneth W., 46 Felizberto, Pamela I., I l l Ferguson, James, 111 Fergusson, D. M., 150 Fife, Daniel, 24 Filippone, Gay, 155 Finger, Reginald, 126 Finison, Karl, 14 Fink, Arlene, 73 Finn-Stevenson, Matia, 13 Fisher, Leslie, 13 Fisher, Russell S., 94 Flanigan, Joan M., 2 Foster, Laurence R., 13 Fowler, Carolyn, 134 Fox, A. Mervin, 117 Franciosi, Ralph, 95 Frappier, Jean-Yves, 140 Frost, Floyd, 123,124 Fyda, John, 82

G Gallagher, Susan S., 14,15,18, 25, 111 Gangarosa, Eugene J., 121 Garbarino, James, 15,41, 74

Garland, Michael J., 88 Garnier, P., 68 Garrard, Judith, 25 Garrettson, L. K., I l l Gary, G.William, Jr., 121 Gaudreault, Pierre, 150 Gessner, Bradford D., 123 Gibbs, Tyson, 65 Gibson, Delinda R., 67 Gilbert-Barness, Enid, 95 Ginsburg, Marvin J., 5 Gleiber, Dennis W., 120 Glotzer, Deborah, 16 Gomberg, Raymond, 112 Goodenough, Sandra, 14 Goodman, Richard A., 36 Goodson, Barbara, 95 Gotschall, Catherine S., 12 Gottlieb, Lawrence J., 45 Goulding, Joy S., 120 Grabowsky, Mark, 131 Granito, Anthony, 57 Gray, Diana E., 34 Greenberg, Michele S. Zweig, 129 Greensher, Joseph, 16,95 Griffin, Patricia M., 120,126 Grodin, Michael A., 84 Grossman, David C , 16 Grossman, Moses, 29 Grove, Morton, 113 Grunenfelder, Gregg, 123 Guerin, Diana, 136 Guinter, Robert H., 120 Gulaid, Jama A., 100 Gunderson, Paul D., 101 Gunn, Walter J., 17 Gutches, Lynn, 82 Guyer, Bernard, 14,15,17,18, 25,137,138

Author Index

H Haemophilus Influenzae Study Group, 130 Halfon, Neal, 131 Hall, John R., 18 Hall, John R., Jr., 46,47 Hallgren, Kathryn, 19 Halpern, Judith, 52 Hamlin, Julie, 131 Hammar, Sherrel, 105 Hammond, Maria V., 6 Hampton, Robert L., 72, 74,83 Handal, Kathleen A., 3 Hardman, Susan, 58 Hargarten, Stephen W., 40 Harning, Abigail T., 123 Harrington, Richard G., 127 Harris, David, 110 Harris, Virginia Goddard, 13 Harrison, Lee H., 121,130 Harruff, Richard C , 75 Harstad, Paul, 12 Harter, Lucy, 123,124 Hassall, I. B., 101 Hassanein, Ruth S., 59 Hatch, Milford H„ 121 Hauswald, Mark, 55 Hedberg, Katrina, 101 Hegstrand, Linda, 95 Heimlich, Henry J., 96 Heifer, Ray E., 75 Helgerson, Steven D., 129 Hemyari, Parichehr, 112 Henderson, John M., 96 Hendrix, Kate, 86 Hershey, J. Henry, 97 Hibbard, Roberta A., 47 Hightower, Allen, 130 Himel, Harvey N., 62 Hinds, Michael deCourcy, 151 Hletko, Jana D., 137 Hletko, Paul J., 137

161

Holden, Janet A., 19 HoUestelle, Kay, 20 HoUifield, WiUiam C , 139 HoUoway, Barbara R., 36 Holmgreen, Patricia, 115,116 Holroyd, H. James, 20 Holt, Kenneth W., 116 Hopkins, Richard S., 21 Hord, Jeffery D., 96 Horwood, L. J., 150 Hsu, James S. J., 21 Hu, Xiaohan, 22 Hudson, Page, 82 Hunter, Paul, 15 Huntington, Robert, 95 Hutchinson, P. J., 9 Hutson, H. Range, 76 Huxley, Peter, 76 I Indian, Robert W., 21 Istre, Gregory R., 79 Ivey, Cecile B., 120 ; Jacobs, Michael, 36 Jakubowski, Walter, 124 Jarvis, Betty A., 119 Jason, Janine, 77,78 Jero, Jussi, 128 Johnson, Charles F., 47 Johnson, Kathleen E., 129 Jones, Alison S., 145 Jordan, Fred, 79 Judson, E. C , 9

K Kamitsuka, Michael, D., 85 Kaplan, Bonnie J., 62 Kaplan, Karen M., 116

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Injury Prevention for Young Children: A Research Guide

Karasic, Raymond, 130 Karter, Michael J., Jr., 48 Kast, Laura C , 89 Katcher, Murray L, 48,49, 50 Katz, Theodore M., 119 Kaufmann, Roxane, 23 Kavanagh, Carol A., 112 Keck, Nancy J., 79 Kela, Eija, 128 KeUer, Patricia, 116 Kelly, Barbara, 23 Kemp, Alison, 63,102 Kemp, AUson M., 102 Kemper, Kathi J., 72 Kendrick, Abby Shapiro, 23 Kendrick, Denise, 138 Kenney, Brian, 22 King, Amy Suzanne, 23 Klein, Susan J., 58 Korach, Alvin, 112 Koskenniemi, Eeva, 128 Kotch, Jonathan B., 34 Kotelchuck, MUton, 14 Krassner, Leonard S., 138 Kraus, Jess F., 24, 97,107,112 Kravitz, Harvey, 112,113 Krents, Elisabeth, 79 Kresnow, Marcie-jo, 116 Kreuter, Matthew W., 34 Kuhn, Louise, 11 Kuo, Anna R., 146

Learn Not to Burn Foundation, 51 Leggiadro, Robert J., 125 Leland, Nancy Lee, 25 Lemp, George F., 125 Lescohier, liana, 138 LeteUier, Robert, 28 Levensohn, Alan, 58 Leventhal, John M., 79 Levin, Bernard M., 51 Le wander, WUliam, 155 Lewis, Jan, 51 Li, Guohua, 5,134 Liang, Belle, 80 Libby, John, 123 Limandri, Barbara J., 88 Lindaman, Francis C, 117 Lindsey, Duncan, 80 Liu, Kiang, 70 Liu, Wanda, 139 Lloyd, David, 88 Locke, John, 52 Locke, John A., 56 LoGerfo, James P., 31 Lovejoy, Fred, 155 Lovejoy, Frederick H., 14 Lovejoy, Frederick H., Jr., 52, 150,151 Loveless, Peggy A., 88 Lugg, Marlene M., 7 Lundquist, Barbara, 57

L

M

Labbe, Ronald G., 124 Lacouture, Peter G., 150,151 Lambert, Deborah A., 116 Landman, Gary B., 24 Landman, Petra Froehlich, 24 Landry, Gregory L., 50 Langlois, Jean A., 97 Lapidus, Garry, 43

MacArthur, John D., 52 MacDonald, Kristine L., 101 MacKay, Annette, 52 MacKenzie, EUen J., 31 MacKinnon, David P., 136 Maddocks, G. B., 35 Magnin, G., 68 Malek, Marvin, 25,138

Author Index Manary, Mark J., 139 Margolin, Leslie, 81 MargoUs, Lewis H., 26,34,139 Marks, James, 78 Martin, John R., 82 Marx, Thomas J., 83 Massachusetts Department of PubUc Health, 26 Massey, Ronnie M., 65 Matthews, Wallace J., Jr., 42, 63, 108 Mayer, Shirley, 110 McCarthy, M., 2 McCarthy, P. L., 10 McCarthy, Paul L., 23 McCloskey, Lois, 73 McCIung, H. Juling, 82 McCormick, Marie C , 26 McCormick, Mary A., 150 McDougal, Linda K., 121 McFeeley, Patricia, 82 McGrath, Marianne P., 80 McGuire, Andrew, 54 McLoughlin, Elizabeth, 14,52, 53,54 McMiUon, Mollie, 46 Mehta, Kishor, 14 Meller, Janet L., 18,113 Melzer, Anastasia M., 89 Mercer, Alice Atkins, 120 Mercy, James A., 67 MerriU, David A., 69 Messenger, Katherine P., 23 Messing, Karen, 122 Metropolitan Life Insurance Company, 102,103 Metzger, Barbara B., 58 Meyer, Fredric B., 114 Micik, Sylvia, 19 Micik, Sylvia H., 27 Miclette, Michelle, 27 MUler, AUson L., 54 Miller, Robert E., 54

163

Mofenson, Howard C , 16, 95 Mohle-Boetani, Janet C , 126 Molnar, Lisa J., 139 Moore, Francis D., 52 Morow, Ardythe L., 127,130 Morrow, Paul L., 82 Mortensen, B. Kim, 21 Mueller, Beth A., 136 Murphy, Janet M., 79 Murray, Lorraine L., 151 Murray, Robert, 82 Myers, Robert P., 82

N Narayanan, Manoj, 120 National Commission on Fire Prevention and Control, 55 National Committee for Injury Prevention and Control, 27 National Safety Council, 27,28 Nebedum, Archibald, 7 Nelson, David R., 40 Nelson, Harold E., 51 Nelson, Richard P., 38 Newberger, EU H., 72, 74,83 Nixon, James W., 63

o O'Carroll, Patrick W., 103 O'Connor, Gerald T., 28 O'Connor, Karen G., 143 O'Connor, Mary Ann, 28 O'Connor, Patricia, 11 O'Hara, Nancy, 6 O'Neill, Brian, 5,135 O'Shea, JohnS., 149 Ohio Department of Health, 29 Ohio Department of Human Services, 29 Olson, Lenora M., 140 Ordog, Gary J., 83

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Injury Prevention for Young Children: A Research Guide

Oriot, D., 68 Orlowski, James P., 104 Osterholm, Michael T., 101 Othersen, H. Biemann, 55 Overpeck, Mary D., 99 Owens-Collins, Deborah, 83

p

Parker, Douglas J., 55 Parkinson, Michael D., 12 Partington, Michael D., 114 Pascoe, Delmer J., 29, 60 Paton, Tom, 98 Patterson, Patti J., 83 Paulson, Jacqueline S., 84 Pearn, J. H., 29 Pearn, John H., 104,105 Peck, Magda G., 143 Pediatric AIDS Foundation, 126 Peeler, Mark O., 97 Pereyra, Margaret, 131 Perkins-Jones, Kathy, 123 Peters, Stefanie Doyle, 90 Peterson, JuUe G., 87 Phifer, Robi, 120 Pickering, Larry K., 125,127, 128,130 Pinsky, Paul F., 17 Pless, I. Barry, 30,137,140,141 Polakoff, Jo-Ann M., 151 Poundstone, John, 126 Pratts, Michael J., Jr., 76 Present, Paula, 105 Presperin, Celeste, 19 Press, Edward, 105 PubUc Health Division, 30

Q.

Quan, Linda, 85 Quinn, John, 13

R Ramanathan, C, 56 Ramstein, Karen, 24 Rappaport, Claire, 2 Reece, Robert M., 84 Regehr, Cheryl, 80 Reiber, Gregory D., 115 Reid, Steven, 127 Reisinger, Keith S., 54 Renz, Barry M., 85 Reves, Randall R., 127 Reyes, Hernan M., 18 Rice, Dorothy P., 31 Richards, Warren, 152 Richardson, Barbra A., 87 Richardson, Mark A., 94 Rivara, Frederick P., 16,31,32, 85,141,142 Roberts, Richard N., 89 Robertson, Leon S., 33,135,142 Robin, Stanley S., 137 Rochat, Roger W., 115 Rock, Amy, 112 Rodriguez, Juan G., 29 Roedell, Wendy C , 86 Rogers, Carl M., 88 Rohn, Dale, 121 Ronnberg, Pirjo-Ritta, 128 Ross, David A., 100 Ross, Virginia, 119 Rossignol, Annette MacKay, 56 Rossomando, Christina, 57 Rothstein, Fred C, 57 Rouse, Thomas, 1 Roybal, Charlotte, 33 Rubin, Roger H., 73 Ruch-Ross, Holly S., 143 Rund, Douglas A., 97 Runyan, Carol W., 26,34 Ryan, C. Anthony, 98 Ryan, George W., 67

Author Index 165

s Sacks, Jeffrey J., 17,115,116 Sapien, Robert, 140 Sargent, James D., 143 Sato, Yutaka, 66 Sattin, Richard W., 100,116 Schaenman, PhiUp, 57 SchaUer, Robert T„ 46 Schatz, Ivan, 83 Scherz, Robert G, 144 Schetky, Diane H., 85 Schlater, Theodore, 83 Schmidt, Terri A., 88 SchneU, Laurie Rennie, 152 Schonberger, Lawrence B., 17 Schulman, Valerie, 79 Schultz, Stephen, 129 Seattle-King County Department of Public Health, 34 Sein, Carmen, 23 Senturia, Yvonne D., 86 Shannon, F. T., 150 Shapiro, Mary Melvin, 50 Shapiro, Sam, 26 Shayegani, Mehdi, 129 Shelness, Annemarie M., 137 Sherman, Roger, 85 Shermeta, Dennis W., 113 Sherry, Bettylou, 72 Shingleton, Bradford J., 58 Shock, Susan, 41 Sibert, J. R., 35,63,102 Sihlangu, Ruth, 88 Sikes, R. Keith, 116 Simon, Jeff, 58 Simon, Paul A., 58 Sinclair, Susanne P., 121 Sklar, David P., 55,82,140 Slaby, Ronald G., 86 Smith, Diane Klein, 25 Smith, Gordon S., 99

Smith, Herberta, 4 Smith, J. A. S., 87 Smith, J.David, 116 Smith, Leigh R., 83 Smith, Wilbur, 66 Snider, BUI C, 12 Solomons, Hope C, 12 Somerfield, Mark, 90 Sorenson, Susan B., 87 Sosin, Daniel M., 116 Spencer, Harrison C, 36 Spiegel, Charlotte N., 117 Spyker, Daniel A., 106,153,154 Staat, Mary A., 127 Stahl, Kent, 53 Stambaugh, HoUis, 57 Stamler, Jeremiah, 70 Stanwick, Richard S., 59 Stapleton, Margaret, 126 Starfield, Barbara H., 26 Steele, Pegeen, 153 Stein, Robert J., 18 Steinhoff, Mark C, 121 Steketee, Richard W., 127 Stevenon, John, 131 Stevenson, J. H., 56 Stevenson, J. John, 13 Stewart-Brown, Sarah, 6 Stoebig, James S., 127 Stoffman, John M., 117 Strahlman, Ellen, 118 Strange, Gary R., 42 Stulginskas, Joan, 30,140 SulUvan, Peggy, 128 SulUvan, Peggy S., 125 SurreU, James A., 66 Swanson, JiU A., 114 Sweeney, Patrick J., 38 Swoboda, Frank, 144 Szocka, Andrew, 38

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Injury Prevention for Young Children: A Research Guide

T

V

Takala, Aino K„ 128 Talbot, Alice M., 137 Tandberg, Dan, 55 Tanz, Robert R., 144,145,152 Tatum, Pam S., 35 Tauxe, Robert V., 129 Taylor, B., 35 Telzak, Edward E., 129 Tenina, Sonia, 141 Teplica, David, 45 Teret, Stephen P., 36,41,97,107, 145 Teutsch, Steven M., 36 Thacker, Stephen B., 36 The San Diego County Consortium for The California Child Care Health Project, 5 Thomas, Joyce N., 88 Thomas, Katherine A., 59 Thompson, Janet C , 60 Thompson, Robert S., 31,32 Tilden, Virginia P., 88 Tortolero, Susan, 6 Trinkoff, AUson M., 153 Trumpp, Cynthia E., 130 Trunkey, Donald D., 60 Turner, W. H., 134 Tyler, Carl W., 78 Tyler, Carl W., Jr., 78

van Dyck, Peter C , 116 Van, Rory, 130 VanBuren, John, 13 Vargas, Carol, 101 Vermund, Sten H., 122 Vernberg, Katherine, 154 Verreault, Rene, 140,141 Viano, David C , 38

u U. S. Consumer Product Safety Commission, 37,154 U. S. Fire Administration, 46 U. S. Preventive Services Task Force, 37

W Wadsworth, J., 35 Wagenaar, Alexander C , 139, 146 Walker, Bonnie L., 60, 61 Walker, James, 105 Wallace, Helen M., 38 Wallen, Beth A. R., 97 Waller, Anna E., 5,38 Waller, Julian A., 39 Walter, Roberts., 146 Walton, WiUiam W., 149,154 Warner, Margaret, 134 Warner, Richard, 76 Wasik, Barbara Hanna, 89 Wasserberger, Jonathan, 83 Wasserman, R. C , 40 Weaver, AUssa M., 62 Webne, Steve L., 62 Webster, Daniel W., 146 Weesner, Carol L., 40 Weinberger, Howard L., 148 Weiss, BUUe, 103 Weiss, Noel S., 31 Weitzman, Michael, 16,143 Wells, JoannK., 145 Wells, Joy G., 121 Wenger, Jay D., 130

Author Index Wesson, David, 22 Wesson, David E., 22 White, Kathleen M., 83 Wicklund, Kristine, 136 Widness, John A., 149 Widome, Mark D., 41 Wiebe, Robert A., 42, 62,108 Wilde, B. R., 134 WilUams, AUan F., 145 WUliams, Scott D., 21 WiUiamson, John W., 11 Wilson, Modena Hoover, 41 Winn, Diane, 133 Winn, Diane G., 134 Wintemute, Garen J., 106,107 Wisconsin Comprehensive Child Injury Prevention Project, 41 Wols, Matthew, 42 Wong, Richard Y. K., 105 Wood, David, 131 Woodward, William E., 125,128 Woolf, Alan, 155 Wright, Brett, 155

167

Wright, Mona, 106,107 Wright, Mona A., 107 Writer, James V., 21 Wucher, Frederick, 54 Wun, Chuan-Chuan, 130 Wurtele, Sandy K., 89 Wyatt, Gail EUzabeth, 90

Y Yacoub, Wadieh, 98 Yamamoto, Loren G., 42, 63,108 Yee, Ann Barbara, 108 Yeoh, Chee, 63

z

Zavoski, Robert, 43 Zell, Elizabeth R., 131 Zieserl, Edward J., 70 Zuckerman, Barry S., 42 Zumwalt, Ross, 140 Zumwalt, Ross E., 55 Zuravin, Susan J., 90

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Subject Index Entries are keyed to page numbers.

A Abdominal injuries, 85 Absences, excessive, 152 Accidents (see Unintentional injuries) Acetaminophen, 154 Acute care treatment, 10 Acute respiratory tract illness, 127 Adolescents (see also Young adolescents), 8,14,16,25,41, 69,76,81,107,112,113,138, 146 African Americans, 2, 69, 72, 74, 77,79,88 Aid to FamUies with Dependent ChUdren, 78 AIDS (see also HIV), 119,127 Air bags, 134,144 Air transport, 5 Airplanes, 143 Airway obstructions (see also Choking), 94,96,98

Alcohol abuse, 107 Alcohol use, 34,106 AUergic reactions (see also AUergies), 123,147 AUergies, 152 American Academy of Family Physicians, 44 American Academy of Pediatrics, 3,4, 55 American Association of Poison Control Centers, 147 American Indians, 140 American PubUc Health Association, 3,4 American Red Cross, 3 Ammonia (see also Chemical burns), 49 Antidepressants, 153 Anti-scald devices, 52 Appliances, 40,43,60,63 Arizona, 120 Arson, 48 Art suppUes, 7

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Injury Prevention for Young Children: A Research Guide

Asphyxiation (see also Choking), 5, 65, 68, 93, 94 Aspiration, 5,16, 96 Aspirin, 149,153,154 Assault, 7, 27, 34, 69, 71,81 Asthma, 23 Australia, 101,155 Automobile, 12,18,42,138,139, 143,146 AutomobUe restraints, 12,13, 18,35,134,135,136,137,138, 139,140,143,144,145

B

Baby walkers, 16,47,109,110, 111, 112,114,117,118 Bacterial iUness, 127 BaUoons (see also Choking, Hazards), 93,96, 98 Bathtubs, 49,100,101 Bayley Scales of Infant Development, 77 Bicycle helmet, 143 Bicycles (see also Motor vehicle accidents), 1, 29,38,40,42, 133,143,145 Bite marks, 84 Bites, 84 Bites, fleas, 150 Bitrex, 151 Blacks (see also African Americans), 2, 56,69, 72, 74, 77, 79, 88 Boating, 100,101 Book of Accidents: Designed for Young Children, 55 Brain injuries, 24,112 Bruises, 84 Burn centers, 49, 56, 59 Burns (see also Fire), 2, 5,12,14, 15,16,18,29,30,31,36,38, 40,42,43-63, 66,84,85,118, 147

Abusive, 45,47, 55, 63, 66, 84, 85 Chemical, 53, 57,58,147 Flame burns, 49 Hazards Appliances, 11,40,43, 60, 63 Bathtubs, 49 Chemistry sets, 60 Clothing, 53, 56, 59 Exhaust pipe, 49 Fireworks, 41, 60, 62 Flammable liquids, 56 Gasoline, 49, 60, 62 Heating pad, 46,49 High-tension wires, 60 Hot iron casting, 49 Hot Uquids, 45,49, 60,112 Hot water, 43,44, 50, 59, 62,63 Sleepwear, 53, 59 Space heater, 49 Sunburn, 62 Tap water, 40,44,46,48, 49, 50, 51, 53, 62 Water heater, 1,44,49,50, 59,62 Wood stove, 49 Injuries, 43,45, 53, 54, 58, 60, 62,112 Prevention, 18,44, 50,53, 58, 59,60,61 Treatment, 43,44,45, 52, 54, 57, 59, 60 Bus, 143

C California, 7, 24,97,106,107, 134,136,143 Canada, 22,59,122,141 Car restraints (see Automobile restraints)

Subject Index Car seats (see AutomobUe restraints) Cardiomyopathy, 82 Cardiopulmonary resuscitation (CPR), 104,107 Caucasians (see Whites) Caustic chemical agents, 57 Cement, 49 Centers for Disease Control, 38, 148 Chairs, 37,109, 111, 124 Chemical agents, 57 Chemical burns, 53, 57, 58,147 Ammonia, 49 Cement, 49 Chemistry sets, 60 Child abuse, 2,3, 4, 23,27,42, 65-91 Assessment, 72, 76, 77 Burns, 45,47, 55, 63, 66,84,85 Caregiver stress, 65 Family history, 87 Head injuries, 85 Homicide, 5, 7,17,21,29,30, 34,39, 65, 66, 69,70,71, 76, 78,83, 86, 87,88 Neglect, 2,23,34, 65, 69, 70, 71, 72, 73, 75, 77, 79, 80, 83, 87,89 Prevention, 68, 73, 74, 75, 80, 89 Reporting, 3, 65, 70, 71, 74, 75, 78, 80, 89,117,123,137 Reporting laws, 89 Sexual abuse, 65, 73, 74, 79, 80,81,88, 89,90 Treatment, 75 Verbal abuse, 84 Violence, 8,10, 27, 30, 67, 68, 69, 75, 76,86,88 ChUd care, 3,4, 5,7, 8,13,17,19, 23, 28,34, 35,41, 61, 65, 69,

171

81,115,116,119,121,124, 129,150 Child Care and Development Block Grant, 20 Child care centers (see also Day care centers), 4, 29,41, 61, 115,116,124,150 Child care licensing, 3 Child care professionals, 4 Child care providers, 5, 7,13,35, 61,81 Child care workers, 3 Child day care, 20, 36,37,120, 125,126,128 Child development, 3 ChUd passenger safety law, 133, 134 ChUd Protection Act of 1966, 148 Child Protective Services, 72 Child restraint devices, (see Automobile restraints) ChUd restraint laws, 136,139, 140,145,146 Child seats (see Automobile restraints) ChUdhood injury, 1, 5,11,12, 13,15,16,17,19, 22, 26, 27, 29,32,33,35,40,41,143 Childhood Injury Prevention Program Surveillance System, 14 Children Can't Fly, 117 ChUd-resistant lighters, 54 Choking, 15, 32,34, 93, 94,95, 96,97,98,112 Hazards Balloons, 96, 98 Food, 93,94 Pins, 11 Small objects, 94 Toys, 95,97

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Injury Prevention for Young Children: A Research Guide

Cigarette Ughters, child resistant, 54 Cigarettes, fire-safe, 54 CIPPS, (see ChUdhood Injury Prevention Program SurveUlance System) Cleaning agents, 11 Clostridium perfringens (see also Foodborne illness), 124 Coins, 11 Colitis, 82 Colorado, 58,76 Communicable disease control (see also Infectious diseases), 88 Community Infant Project, 76 Connecticut, 23 Consumer Product Safety Act, 148 Consumer Product Safety Commission, 93, 94,100,135, 139,145,147,149 Corneal laceration (see also Eye injuries), 58 Costs, 1, 9,17, 25, 31, 33, 34, 45, 53, 54, 73,120,121,128 CPR (see Cardiopulmonary resuscitation) Cribs, 7,13, 29, 37, 93, 94, 95, 97, 112 Curriculum guides, 5,10, 26, 30, 61 Cyanosis, 96 Cytomegalovirus, 127

D "Dart-outs" (see also Pedestrian accidents), 136,142 Day care centers, 7,10, 20, 24, 25, 98,116,120,121,122,124, 125,126,127,128,129,130

Day care homes, 13,20,40,125, 127,130 Death rates, 28,39, 70,145 Dental health, 35 Dentition (see also Choking, Risk factors), 35, 59 Department of Health and Human Services, 148 Developmental stages, 7,31,53, 95,151 Diapering, 23,125 Diapers, 124,125,126,128,130 Diarrhea (see also Foodborne illness and Infectious Diseases), 82, 85,119,120, 121,125,127,128,129,130, 131 Diarrheal disease, 127,128 Disabilities, 37,49, 50, 51, 58, 79 Drowning, 5, 7,12,14,17,19, 21, 22,24,30,31,32,34,38,39, 40, 65,84,95,96,99-108 Fishing-related, 100,103 Hazards Bathtubs, 99,100,101,104, 106 Boating, 100,101 Epilepsy, 102 Lakes, 100,102,103 Reservoirs, 100 Swimming, 99,100,101, 102,103,104,105,106, 107,108 Swimming pools, 99,101, 103,104,105,106,107 Wading, 100,103 Prevention, 100,102,103,107 Drug side effects, 152 Dysphagia, 52, 57 Dyspnea, 95

Subject Index

E Ear infections, 129 Early chUdhood education, 4, 61 Ecology, 83 Edema, 82 Education programs (see also Training), 136,144 Electric blankets, 46 Electric current, 5 Electric garage door openers, 41 Electrical outlet covers, 10 Electrical shock, 16 Electrocution, 29 Emergency care Finger sweep, 93,94 Heimlich maneuver, 93,94, 96,97 Emergency department (see Emergency room care) Emergency planning, 3 Emergency room care, 25,42, 108 Emergency rooms, 14,15, 22,30, 32,56,67,77,85,113,114, 117,134 Emotional abuse (see also Child abuse), 75, 84 England (see Great Britain) Epidemiology, 9,18, 33, 38,45, 77,104,105,106,116,122, 137,138,140 Epilepsy, 102 Exercise, 35 Eye injuries, 58, 84,118

F Falls, 1, 5,6,13,14,15,16,17,18, 19,22,24, 29,30,31,32,34, 35,38,40,48,100,109,110, 111, 112,113,115,116,117, 118,145

173

Hazards Baby walkers, 47,110, 111, 112,114,118 Playground equipment, 4, 14,16,30, 34,40,42,112, 114,115,116,117,135 Roller skates, 135 Skateboards, 16,42,135 Unguarded windows, 110 FamiUes in crisis, 8 Family issues, 8,16, 35, 68, 72, 75,77,87,88,90,110,137,141 Family violence, 75, 88 Farm machinery, 5,39 FARS (see Fatal Accident Reporting System) Fatal Accident Reporting System, 145 FDA (see Food and Drug Administration) Fecal contamination, (see also Diarrhea), 130 Fecal material, 85 Females, 8,14,31,38,39, 56, 78, 79,81,88,103,118,122,134, 140 Fertilizers (see also Chemical burns), 49 Finger sweep, (see also Heimlich maneuver), 93, 94 Finland, 128 Fire, 7,19, 21, 32,40,43,44,46, 47,48,49, 51, 54, 55, 57, 58, 60, 62, 74 Deaths, 21,44,48, 54, 55, 56, 57 Electrical, 46 Flames, 32 Hazards Cigarettes, 43, 53, 54 Cooking, 48,123,125 Electric blankets, 46 Electrical cords, 29, 53, 60

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Injury Prevention for Young Children: A Research Guide

Gasoline, 49, 60, 62 Heaters, 7,46, 62 Heating pads, 46, 49 Irons, 46 Matches, 11,18,47,51, 53, 60, 61, 76, 83,87 Smoking materials, 48, 54 Smoking, 48,54, 55,137 Residential fires, 24, 47 Safety devices ChUd-resistant lighters, 54 Fire-safe cigarettes, 54 Smoke detectors, 40,45, 47, 51, 54, 57, 59, 62 Sprinklers, 45, 54 Safety programs, 46, 51, 57 Fire departments, 46,54 Firearms (see also Guns) 1, 5,12, 27, 28, 29,31,32, 34, 38,39, 40, 65, 67, 69, 71, 74, 75, 76, 79, 82,83,86 Accidents, 1, 5,12, 27, 28,29, 31,32,34,38,39,40, 65,67, 69, 71, 74, 75, 76, 79, 82, 83, 86 Assault, 69 BB guns, 71 Control, 86 Dart guns, 71 Handguns, 74, 75, 76, 82, 83, 86 Pellet guns, 71 Rifles, 41, 82, 86 Fireworks, 41, 60, 62 First aid, 3, 20, 29, 62, 93, 96,104, 105,107 Fishing, 100,103 Flame burns, 49 Flammable liquids, 56 Fleas, 150 Food and Drug Administration, 123

Food poisoning (see Foodborne illness) Food services, 3 Foodborne bacteria (see Foodborne illness) Foodborne illness, 119,120,122, 123,125,126,129 Clostridium perfringens, 124 Listeria monocytogenes, 122 Salmonella, 126,129 Foreign body injuries, 2,14 Foster homes, 90 Foster parents, 90 Fractures, 2, 32, 65,109,112,114 Freezers, 97

G Gang-related homicides, 76, 83 Garage doors, 41 Garden plants, 150 Gasoline, 49, 60, 62 Gastroenteritis, 123 Gender, 5, 7, 9,14, 21, 28, 31, 48, 56,81,87,88,99,103,104,141 Georgia, 77, 78,115,116,121 Georgia Department of Protective Services Central Registry, 78 Giardia, 122,124 Giardiasis, 128 Great Britain, 2, 6,9, 35,45,46, 102, 111, 134,151 Gun control, 69 Guns (see Firearms) Gunshot wounds, 41, 65, 69, 76, 79,82,83

H Haddon's countermeasures, 153 HaemophUus influenzae, 131

Subject Index Haemophilus influenzae type B, 130 Handguns (see Firearms) Handouts, 6, 29,151 Handwashing, 121,124,126,127 Harnesses, 139 Hawaii, 63,105,108 Head injuries, 2, 7,13, 65, 84, 108,109,112,114,116,117, 118,134,135,139,144 Head Start, 19, 89 Health assessment, 4 Health care, 2, 23,38,41, 77,117, 121,136 Health promotion, 37 Health records, 23,131 Heart medications, 149 Heating pads, 46,49 Heimlich maneuver, 93, 94, 96, 97 Hepatitis A, 127,130 Herbicides, 151 High-tension wires, 60 Hiring practices, 89 Hispanics, 2, 76, 88 HIV (see also AIDS), 127 Home Environment, 60, 77 Fires, 5,43, 49, 53, 54, 60 Injuries, 1, 2,9,10,11,12,15, 18, 22,24, 28, 30,32,40,41, 42,48,49, 53, 54, 58, 60, 63, 65, 66, 68,71, 75, 82, 83, 84, 100,106,110, 111, 113,114, Safety, 6, 9,10,11,23,29,40 Home Injury Prevention Project, 15 Home Observation for Measurement of Environment (HOME) Scale, 72,77 Home visitation programs, 89 Homeless, 2,45

175

Homeless children, 2 Homicidal asphyxiation, 68 Homicides (see also Child abuse), 5, 7,17, 21, 29,30,34, 39, 65, 66, 69, 70, 71, 76, 78, 83, 86,87,88 Gang-related, 76,83 Hospital admissions, 2, 56,153 Hospitalization, 6,11,14,15,17, 24,25,32,34,36,45,46,47, 50, 52, 54, 58, 63, 71,83,87, 121,139,150,153 Hospitals, 2, 22, 24, 25, 35,40, 44,47,49, 52, 56, 58, 59, 66, 67,71, 74,80,87,98,106,109, 117,118,121,129,134,135, 137,139,141,153 Hot food, 43, 62, 63 Hot iron casting, 49 Hot tubs, 41 House fires, 5, 43, 47, 49, 53, 54, 60 Household plants, 151 Hydrocarbons, 149 Hyphema, 58 ][ Ice water submersions (see also Drowning), 104 Illicit drugs, 12 Immunization, 2,131 Inappropriate-touch requests (see also Sexual abuse), 90 Infant formula, 47 Infant seats (see AutomobUe restraints) Infant walkers (see Baby walkers) Infanticide, 68 Infants, 3,13,14,16, 26, 29, 30, 31,41,47, 60, 65, 66, 68, 69, 70,71,76,78,85,88,93,94,

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Injury Prevention for Young Children: A Research Guide

95, 96, 97,99,100,106,110, 111, 112,113,118,119,120, 122,137,139,144 Infections, 45, 85,121,122,123, 124,125,126,127,128,129, Burns, 85 Fecal material, 85 Infectious diseases, 3,4,36, 37, 119,120,122,131 AIDS, 119,127 Cytomegalovirus, 127 Giardiasis, 128 Haemophilus influenzae type B,130 Hepatitis, 127,130 Hepatitis A, 127,130 HIV, 127 Influenza, 127 Pneumococcal disease, 121, 128 Shigellosis, 126,129 Influenza, 127 Injury control, 33,36,38,49 Injury, cost of, 9,17, 25, 27, 31, 33, 34, 37,39,45, 53, 54,120, 121,128 Injury prevention, 1, 2, 3, 5, 6, 7, 8, 9,10,12,13,14,15,16,17, 18,19,21, 22, 26, 27, 28,30, 31,32,33,34,36,37,39,41, 42,43,51,58,61,65,74,86, 93,103,104,106,107,109, 110,113,126,145,154 Injury surveUlance systems, 14 Insect stings, 23 International Classification of Diseases, Adapted, 78 Ipecac, 40,82,149,150,152,155 IQ, 155

i

Jewelry, 11

K Kempe Center, 76 Kentucky, 126 Keys, 11 Kidnapping, 12 Kindergards, 10 Knives, 11

L Lacerations, 2,16,36,112,118 Lakes, 100,102,103 Law, 8,36 Lead, 2,23,35,147,148,155 Exposure, 148,155 Poisoning, 23,35,148 Life jackets, 96,104 Life preservers (see also Life jackets), 106 Lightning, 29 Listeria monocytogenes (see also Foodborne illness), 122 Loss of footing, 109 Low-income households, 11, 58, 72,88

M Males, 8,14,31,39,42,48, 56,69, 70, 73, 76, 77, 79,81,82,86, 88,102,103,105,106,108, 110,134,140,142,145 Malnutrition, 8,85 Maltreatment (see also ChUd abuse), 69, 72, 76, 79,84,90 Mandatory reporting laws, 89 Maryland, 24, 57,90,118,121, 135,153 Massachusetts, 14,15,18,25,26, 30,52,56, 111, 141,150,152 Massachusetts Department of Public Health, 18

Subject Index Massachusetts Statewide ChUdhood Injury Prevention Program, 14,18,25,26 Massachusetts Poison Control Center, 150 Matches, 11,47,51,53,60, 61 Maximum Abbreviated Injury Severity Scale, 141 Measles, 69 Medical malpractice, 36 Medications (see also Poisoning), 11,12,45,149,152,153,154 Acetaminophen, 154 Antidepressants, 153 Aspirin, 149,153,154 Drug abuse, 12 Sedatives, 153 Tranquilizers, 153 Michigan, 139,146 Microwave ovens, 66,123 Minnesota, 101 Mississippi, 150 Missouri, 6 MobUe homes, 56 Mortality, 5,8,15,17, 21, 22, 30, 39,42,56,67,70,75,79,85, 96,103,114,117,133,146 Mother and Child Protection Institution, 68 Motor vehicles, 5,6, 7,10,12,17, 18,19,21,22,24,26,28,29, 30,31,32,34,39,40,42,45, 49,112,133,134,136,140, 142,144,145 Accidents, 6,24,28,29,34,39, 40,42,45,133,134,135, 136,137,140,142,144,146 Injuries, 5, 7,10,17,18,19,21, 22,26,28,29,30,31,32,39, 40,42,112,133,134,136, 140,142,144,145 Mr. Yuk (see Poison warning stickers)

177

N National Academy of Sciences, 38 National Center for Health Statistics, 38,99,100,101,149 National Commission on Fire Prevention and Control, 55 National Committee for the Prevention of ChUd Abuse, 74 National Electronic Injury SurveUlance System, 46, 67 National Highway Traffic Safety Administration, 144 National Safety Council, 103 National Study of the Incidence and Severity of ChUd Abuse and Neglect, 74 Native Americans, 21, 56, 79, 140 Needles, 11 Neglect (see also ChUd abuse), 2, 23,34,65,69, 70, 71, 72, 73, 75, 77, 79, 80,83,87, 89 Negligence (see also Neglect), 56 New Mexico, 30,34, 55, 73, 82, 140 New York, 2,11,14,44, 58, 84, 110,117,129 New York City Department of Health, 117 New Zealand, 101,150 New Zealand's 1987 Swimming Pools Act, 101 Newborns, 75,149 Non-high school graduates, 11 North Carolina, 34, 82,103 Nurses, 101,117 Nursing Child Assessment Teaching Scale, 72 Nutrition (see also Malnutrition), 3,4,8,23,29,35,37,59,85

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Injury Prevention for Young Children: A Research Guide

o Occupational injuries, 5, 27 Ohio, 21, 29 Oklahoma, 79 Oregon, 13, 57,151 Outlet covers, 10

p Parasite infection, 123 Parental errors, 56 Parents, 3,12,13,15,16,18,19, 22,23,24,26,27,30,42,47, 48, 54, 55, 56, 61, 68, 69, 70, 71, 72, 73, 75, 76, 77, 79, 80, 81, 83, 86,87,88,89,91,104, 105,110, 111, 113,116,118, 121,124,127,135,137,138, 141,142,144,146,149,150, 151,152,153,154,155 Pedestrians, 4, 6, 7,12, 21,29,32, 40,42,133,134,135,136,137, 138,140,141,142,145 Accidents, 4, 6, 7,12,17, 21, 29,32,40,42,133,135,136, 137,138,140,141,142,144, 145 FataUties, 4,140 Injuries, 138,142,145 Safety, 137 Pediatric AIDS Foundation, 127 Pennsylvania, 67,109 Pesticides, 149 Physician counseling, 38 Plastic bags, 93,94,97 Playgrounds, 4,14,16,30,34, 40,42,109,112,114,115,116, 117,135,142 Playground equipment, 4,14, 16,30,34,40,42,112,114, 115,116,117,135 Playpens, 7, 37, 93, 94

Pneumococcal disease, 121,128 Pneumonia, 69 Poison Control Centers, 147, 149,150 Poison Prevention Packaging Act, 148,149,154,155 Poison warning stickers, 150, 154 Poisoning, 2, 5, 6,14,15,16,, 17, 18, 23,24,28,30,31,32,34, 35,36,38,40,52,58,65,82, 84,119,147,148,149,150, 151,152,153,154,155 Hazards Antifreeze, 151 Herbicides, 151 Hydrocarbons, 149 Medications, 149 Pesticides, 149 Polishes, 11 Poor air exchange (see also Cyanosis), 96 Post-traumatic meningitis, 114 Potty training (see ToUet learning) Poverty, 45, 65, 69, 72,141,142 Preschool, 6, 7,10,19, 25, 26,29, 30,41,46,48, 51, 73, 84,86, 110,112,114,127,131,151 Preschool teachers, 19 Preschoolers, 41,70,80,89 Prescription drugs (see also Medications) 11,154 Prevention, 1,3,5, 6, 7,8,9,10, 12,13,14,15,16,17,18,19, 21,22,25,26,27,28,29,30, 31,32,33,34,36,37,38,39, 41,42,43,44,46,47,49,50, 51,53,54,55,56,57,58,59, 60, 61, 62,63,65, 67,68,69, 71,73,74,75,76,80,85,86, 88,89,93,100,101,102,103, 104,106,107,108,109,110,

Subject Index 113,117,119,122,124,126, 128,130,133,136,138,139, 142,143,145,147,148,149, 150,151,152,153,154,155 Interventions, 2, 6, 8,16, 29, 33,39,42,65,74,86,93, 103,104,106,107,109,126, 154 Legislative initiatives, 16,30, 37,38,42,54,71,146 Program evaluation, 89 Project PEACH, 6 Protective clothing, 139 Psychiatric disorders, 52 Public schools, 143

R Rebuilding FamUy Foundations, 76 Refrigerators, 97 Reservoirs, 100 Residential fires (see also House fires), 5,43,47,49,53,54,60 Residential sprinklers, 54 Restraints, 134,135,136,137, 138,139,141,144,145,146 Automobile, 12,13,18, 35, 134,135,136,137,138,139, 140,143,144,145 Harnesses, 139 Supermarket, 111 Use of, 146 Rifles, 41, 82, 86 Roller skates, 135

s Sacramento County Coroner's Office, 115 Safe Care/Safe Play, 13 Safe Kids, 52 Safe toys (see also Toys), 16,95

179

Safety belts (see Seatbelts) Safety devices Child-resistant lighters, 54 Electrical outlet covers, 10 Fire-safe cigarettes, 54 Kindergards, 10 Smoke detectors, 40,45,47, 51,54,55,57, 59,62 Sprinklers, 45,54 Salmonella (see also Foodborne illness), 123,126,129 Salmonella enteritidis, 126,129 Salmonellosis, 123 Scalds (see also Burns), 2,40,43, 45,48,49,50,53,56,61,62,63 Hazards Bath water, 63 Home canning, 62 Hot food, 43, 62, 63 Seatbelts, 12,133,137 Sedative/hypnotics, 153 Seizure disorders, 99 Seizures, 100 Sexual abuse, 65, 73, 79, 80,81, 88,89,90 Sexual victimization (see also Sexual abuse), 88 Sheepskin rugs, 95 ShigeUosis, 126,129 Showers (see also Bathtubs), 40, 100,102 Siblings, 63, 65, 87,105 SIDS (see Sudden Infant Death Syndrome) Single parent famUies, 11 Skateboards, 16,42,135 Skin grafting, 45, 59, 85 Skin injuries (see also Bruises), 84 Sleds, 133,139 Sleepwear, 53, 59 Smoke (see also Fire), 40,45,47, 49,51,52,54, 57, 59,61, 62

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Injury Prevention for Young Children: A Research Guide

Smoke detectors, 40,45,47, 51, 54,57,59,62 Smoking, 48,54,137 Social workers, 68 Socioeconomic class, 2,11,36, 38, 77, 87,113,137,138,140, 141,142 Soft palate perforation, 112 South Carolina, 57, 65 Space heater, 49 Spas, 41 Sports, 5,14,17, 30, 32,42,112 Sports and recreational injuries, 3, 5, 7,14,17,22,24,27,32, 34,40,41,42,100,102,103, 108,112,114,116,118,134, 135,138 Sprinklers, 45,54 St. Louis ChUdren's Hospital, 139 Staff, child care, 15, 23, 35, 61, 65, 66, 67, 76,84,120,124, 125,128,129,149,150 Strangulation, 16, 93,95,96,97 Hazards Cribs, 7,13, 29, 37, 93, 94, 95,97,112 Hanging Ught switch, 96 Stress, 89 Stress factors, 65, 79,83,128,149 Stridor (noisy breathing), 94 Submersion (see also Drowning), 106,108 Sudden Infant Death Syndrome, 68,93,95 Suffocation (see also Asphyxiation), 5,18,29,32, 93,94,95,97,98 Hazards Freezers, 97 Refrigerators, 97 Sheepskin rugs, 95 Water beds, 95

Suicide, 5, 7,17, 27, 30, 34, 39, 71,86 Sunburn, 62 Surgeon General, 74 Surgery, 5,35 Supermarket restraints, 111 SwaUowing, 52,57,98 Difficulty, 52,57,98 Hazards BaUoons, 96, 98 Food, 94 Pins, 11 Small objects, 94 Toys, 95,97 Swimming, 99,100,101,102, 103,104,105,106,107,108, 124 Swimming pools, 99,101,102, 103,104,105,106,107 Syrup of ipecac (see Ipecac)

T Tables, 8, 28,109, 111, 124,130 Taxicabs, 146 Teenage mothers, 36, 73 Tennessee, 75,141,142 Texas, 6,83,125,128 The Injury Prevention Program (TIPP), 55 Thermometer, use of, 50 Tobacco, 12 Toddlers, 14, 29,41,46,47, 60, 69, 70,88,96,99,100,101, 120,122 ToUet learning, 23 Tooth evulsion, 112 Toy chests, 7,37,41 Toy guns, 86 Toys, 7,16,37,41, 60, 86,93, 95, 97,98,112,130,133 Traffic, 1, 24, 27,134,135,136, 137,140,141,142,144

Subject Index Traffic accidents (see Motor vehicle accidents) Training, 1,3,12,13,14,29,37, 44, 55, 61,65, 67, 69, 76,81, 84,88,89,104,107,120,142 Tranquilizers, 153 Trauma, 9,10,13,19,22,37,42, 58, 66, 71,108, 111, 112,114, 118,133,134,142 Tuberculosis, 125

o U. S. Army Corps of Engineers, 100 U. S. Bureau of the Census, 99 U. S. Fire Administration, 46, 55 Ultraviolet radiation, 54 Unemployment, 11 Unguarded windows, 110 Unintentional injuries, 2, 6,8, 12,13,15,17, 20, 23,24, 26, 27,28,29,30,35,36,39,41, 42,44,45,47,56,57,60,63, 71,72,74,75,78,82,83,84, 85,86,95,96,102,110, 111, 112,113,114,118,134,138, 139,140,141,142,143,144, 145,147,148,154 United Kingdom (see Great Britain) United States Department of Agriculture, 119 University of Wisconsin Hospital Burn Center, 49 Urban, 19,21,40,43,69, 74,75, 77,78,79,105,110,113,114, 141 Urban planning, 141

v Vaccination coverage, 37,131

181

Vaccinations, 131 Verbal abuse (see also ChUd abuse), 77,84 Victimization, 79,88 Videotapes, 6,61,94,124,127 Violence (see also Child abuse), 8,10,27,30, 67, 68, 69, 75, 76, 86,88 Virginia, 88,119

W Walkers (see Baby walkers) Warning labels, 97,98 Washington, D. C , 146 Washington, State of, 35, 72, 123,124,129,136,144 Watches, 11 Water beds, 95 Water heaters, 1,44,49, 50, 59, 62 Water heater temperature, 1,44, 49,62 Water safety training, 104 Weatherization Assistance Program, 58 What If Situations Test, 80 Whites, 2, 21,39, 56, 76, 77, 79, 82 Wisconsin, 37,41,49, 50,128 World Health Organization, 70 Wound management, 45

Y Yale-New Haven Hospital Abuse Registry, 80 Young adolescents, 41 Young children, 1, 6, 9,18,23, 24,43,45,48, 52, 56, 60, 61, 65,69,83,84,86,89,94,95, 96,97,99,106,109,111,117,

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Injury Prevention for Young Children: A Research Guide

119,121,126,133,136,137, 140,144,146,147,151,153 Your Safety—Our Concern, 100

z Zipper injuries, 29

About the Author BONNIE L. WALKER is president of Bonnie Walker and Associates. She has also compiled Injury Prevention for the Elderly (Greenwood, 1995).