Home accidents childhood - Injury Prevention · accidents in childhood, and yet cause only about...

Injury Prevention 1996; 2: 290-298

INJURY CLASSIC

Home accidents in childhood

Robert J Haggerty

This is the eighth paper ina series of Injury Classic.Our goal is to reprint onesuch paper in each issue toinitiate newcomers to thefield of these old, oftenquoted, and importantcontributions. As many aredifficult tofind, it shouldhelp all of us to have a copyat hand. Your suggestionsaboutfuture articles arewelcome. Write to theeditor with details ofyourfavourite, most quotedpaper.

Department ofPediatrics, HarvardMedical School, theChildren's MedicalCenter and the BostonPoison InformationCenter

Supported by grants fromthe Commonwealth Fundand the Charles H HoodDairy Foundation.

Associate in Pediatrics,Harvard Medical School;associate physician and chief,Child Health Division,Children's Medical Center;director Boston PoisonInformation Center, Boston,Massachusetts.

This paper first appeared inthe New Englandjournal ofMedicine (1959; 260:1322-31) and is reprinted bypermission. Copyright (1959)Massachusetts MedicalSociety.

The following and many similar headines star-tle parent and physicians daily: 'Girl dead, boyblinded by antifreeze'; 'Three small childrenperish in home fire'; and 'Boy, two, dies intwo-story fall'. To the physician, who todaycan usually successfully treat his child patientsfor such serious illnesses as meningitis,erythroblastosis fetalis and dehydration, it isparticularly frustrating to be faced with thedeath or serious injury of one of these childrenfrom an accident; yet except for the first year oflife accidents are the single greatest cause ofdeath during childhood' (table 1).

In 1956 accidents caused over 10 000 deathsin children from 1 to 14 years of age in theUnited States - more than the combined totalof the next four causes' (fig 1), and the impor-tance of accidents as a cause of death risesthroughout childhood until during adolescenceover 50% of all deaths are due to accidents2 (fig2). Even these striking statistics fail toemphasize the full importance of accidents inchildhood, however, for it is estimated that 150to 200 children are non-fatally injured for eachaccidental death, and of these, one in 40 is leftpermanently crippled.

Lest one be led to believe that this impor-tance of accidents in childhood mortality andmorbidity is due to a recent increase in accidentrates, it is pertinent to point out that the deathrates from accidents actually declined 42%from 1928 to 1957.' This decline is primarilydue to improvement in the care of the victimand not the result of a decrease in the rate ofaccidental injury. During the same period,however, mortality from most other causes inchildhood declined even more dramatically,leaving accidents as the most common serioushealth problem of childhood today.

Home accidentsHome accidents account for 380% ofall acciden-tal deaths in children under 15 years ofage, andin the age group under five, 58% of accidentaldeaths occur in or about the home.2 If non-fatalaccidents are added, the rate of all accidentsoccurring in the home varies from 51-6% at 10to 14 years ofage to 91 3% for children under 1year of age3 (fig 3).

In the course of a year, nearly one in everyfive children under 15 years ofage suffers somehome accident serious enough to cause'restricted activity for at least one day4 (fig 4).

ETIOLOGYDetailed information about the etiology ofhome accidents is not now available. It seems

reasonable that there are many causes, perhapsquite different for different types of accidents.For example the etiology and pathogenesis ofpoisonings may differ as much from those ofdrownings as the causes of typhoid fever dofrom those of influenza. The facts now knownabout etiology of home accidents can be bestdescribed under the same divisions that haveproved useful in describing the causes of infec-tions: the agent; the host; and the environ-ment.5

Agents causing home accidentsMost accident statistics combine the nature ofthe injury (bums, falls, and so forth) with thespecific agents (fire, stairs, and so forth)involved, and this leads to some confusionwhen one is trying to make comparisonsbetween different geographic areas. Table 21lists the agent or nature of injury of all fatalhome accidents in the United States for 1956,and table 367 lists the same data collected fromone community for all accidents (fatal andnonfatal, home and outside) for 1954. Fromthese data it is apparent that burns are arelatively uncommon cause of all homeaccidents (about 3%) but tend to threaten lifewhen they do occur and account for about 20%of all home accident fatalities. Falls on the otherhand, are responsible for nearly 40% of allaccidents in childhood, and yet cause onlyabout 5% of the accidental deaths.These statistics are relatively unsatisfactory

for a full understanding of the pathogenesis ofhome accidents, since they add little toknowledge of why a particular child suffers aparticular accident on a particular day. Inaddition, they fail to point out local geographicvariations that affect the type ofaccident risk-such as kerosene in rural areas and drowningsnear seashores. They are frequently imprecise,for mechanical suffocation is still listed as themost frequent cause of accidental death ininfancy, and yet careful studies89 show thatthese babies usually die from other causes,particularly overwhelming infection, and chil-dren who actually die as a result of accidents(bums, fractures, and so forth) may be listedunder one of the complications, such aspneumonia or shock, rather than the primarycause, accidents.By and large the national statistics are of

most value in educating physicians and parentsconcerning the general hazards for different agegroups. Detailed analysis of local statistics(hospital, private physician, or community)may indicate specific hazards peculiar to anarea. Excellent examples of how detailedstudies of one type of accident- burns -can

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Table 1 Death ratesfrom leading causes in the United States, 1956*

Children Cause of Children Cause of ChildrenCause of death <1 year death 1-4 years death 5-14 years

Immaturity 622 Accidents 31 Accidents 20Postnatal asphyxia 495 Pneumonia 15 Cancer 7Congenital 429 Congenital 13 Congenital 3malformations malformations malformations

Pneumonia 322 Cancer 11 Pneumonia 2Birth injuries 315 Enteritis 4 Nephritis 1Accidents 96 Meningitis 2 Rheumatic fever 1

Total deaths 2963 110 47

*Based on Accident Facts.1

Accidents

Cancer

PneumoniaCongenital

malformationsGastritis,enteritis

Meningitis,non-meningococcal

Nephritis

Heart disease

0

-939162 2899

_2 2864

10 991

I672I 502

i5011 437

5000 10 000

100

90

80

70

60

. 50

40

30

20

10

0 l pl<1 1-4 5-9 10-14

Age (years)El Other E Street, highway, sidewalk| Place for recreation * Home

Figure 3 Accidental injuries according to age andplace ofaccident (reproduced with permission from United StatesPublic Health Service Accident Prevention Program3).

No of deaths

Figure I Leading causes of death among children 1-14years of age, 1956 (based on Accident Facts').

<1 I13.11-4 288 7

5-9 38-9

10-14 44-!

15-19

[I0 25

, 18C a 16On' 14cno&-012

0) 8CL-I- 1 0o ao 8o, 6Z 4

20

<15 15-24 25-64

Age (years)

| HomeED Other Eli Motor vehicle 0 Work]5

52-2 Figure 4 Types of accidents and number of injuries/100persons/year (based on Health Statistics from the United

i States National Health Survey).

50

Figure 2 Accidents expressed as a percentage ofall deaths(based on Vital Statistics of the United States2).

lead to a better understanding of the causes andpoint the way toward control are the report byBleck'0 of the agents involved in some 457patients with severe burns hospitalized inNorth Carolina, and the review of 1000 cases ofburns in England by Colebrook."

The environmentIn an effort to learn more about the causes ofhome accidents, the environment has also beenextensively studied and, for analysis, can

usefully be divided into physical and socialenvironment.

Physical environment Death rates from

accidents vary considerably from country to

country; for instance, the death rate from

accidental poisoning per 100 000 male popula-tion 1 to 19 years of age varies from 0 3 in

Sweden to 1 5 in Australia,'2 but the reasons for

this fivefold difference between two countriesof somewhat similar ethnic and economic level

are not clear. Home accidents are more com-

mon in urban areas; the rate per 100 persons peryear varies from 11 3 in cities to 9 7 in ruralfarm areas.4

Seasonal variations are relatively minor andare generally well explained by the differencesin types of accidents at different times of theyear.

In a study of home accidents in Cambridge,Massachusetts, Curry and Sternfeld" foundthe accident rate in certain federal and state

housing projects to be twice that for the rest ofthe city, and others'4-'9 have reported a similarassociation of accidents with 'poor' housing;however there is usually a higher proportion ofpreschool children in housing projects and'poor' housing, and this age group is known to

have a higher accident rate. In one study"3 only20% of all home accidents could be directlyattributed to defects of the physical environ-ment, and it seems, in most cases, that theinceased accident rate in this type of housing isrelated to the nature of the host living there.The area in the home where accidents occur

has been extensively documented (fig 5)13 and isuseful in alerting parents and physicians to

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Haggerty

Table 2 Fatal home accidents according toStates, 1956*

Cause ofaccident All ages of c,

No ofaccidents

Fires, burns 1800Mechanical suffocation 1250Obstruction from food or objects 1150Drowning 1435Falls 490Poisons, including gases 520Firearms 400Other 1690

Totals 8735

*Based on Accident Facts.'tIncludes drownings outside home.

Kitchen

Bedroom

Yard

Living roon

Inside stairs

HallwayOutside stairs

Bathroom

Porch

Cellar

the nature of the injury, by age, United some 50 home accidents in Cambridge. Theyfound that the absence of a supervisory person

Children Children (or, if such a supervisory person was present, he0-4 years 5-14 years was not paying attention to the child at the time

hildhood of age of age of the accident) that is, the child's socialPercentage No of No ofof total accidents accidents environment was the most common

dominant factor in the cause of these accidents.206 1250 550 study poisonings

1342 1150 ralia,'8 270o of the mothers were unaware that16 4 250 1185t the substance taken was actually poisonous. If59 420 100 these figures are found to be similar in the4-6 80 320

19 4 1450 240 United States, they indicate the relative impor-100 0 6250 2485 tance of education in the control ofthis one type

of accident.Backett and Johnston'9 studied social pat-

terns in pedestrian road accidents of children in% England. In a comparison with children who

0 10 20 30 had not suffered such accidents, they foundII several interesting correlations: a higher

29 5 prevalence of family and maternal illness;

222 5 greater crowding; less protected play; greater

14 5 previous accident rate in family members; and

10. 6'poor cooperation' with school health services.

s58 There was no correlation with intelligence or

.7 ~~~~~~~family size.

399The role of the child's peers and other

s2

Waspects of his social environment is also

325 suspected of being important, particularly in

l2.5 the school age group, but has been littler 2-5 studied.

Figure 5 Place of occurrence of 9871 home accidents(based on Curry and Sternfeld'3).

some of the different areas of risk, but is not ofgreat help in explaining why accidents occur inthese different locations.There are interesting minor variations in the

frequency of accidents by time of day and dayof week: afternoons and weekends are slightlymore likely to be the time when home accidentsoccur, indicating that fatigue or presence ofmore people in the home may play a minor part

in the cause of some accidents.

Social environment Since the preschool childis almost always under the supervision ofsomeone else (his social environment) it isreasonable to examine the role of these super-

visory persons in accidents occurring in thisgroup. Bronzi and Johnson'7 studied in detail

Host differencesDifferences in host factors have naturallyintrigued investigators in accident research buthave proved the most elusive and difficult to

describe accurately. McFarland and Moore20have reviewed the human factors in relation to

highway accidents, but similar extensivestudies regarding childhood home accidents,have yet to be completed.The clearest evidence of the great import-

ance of the host factors in childhood accidentsis the marked contrast in the rate of specificaccidents at different ages of childhood, forclearly the child is a quite different host atdifferent ages. During the first year of life,when the child is relatively immobile, thehazards are unlike those of the beginningrunabout, and these in turn are distinct fromthose of the nursery school child. Table 3, fromthe New Bedford study, is a valuable indicationof the different accident risks at various ages

Table 3 Accidents (fatal and non-fatal) according to nature of injury by age, New Bedford, Massachusetts 1954

Children Children Children Children Children<1 year 1-4 years 5-9 years 10-14 years 15-16 years

Cause of accident All ages of age of age of age of age of age Age not stated

No of No of No of No of No of No of No ofaccidents Percentage accidents accidents accidents accidents accidents accidents

All causes 2097 53 708 720 442 133 41Falls 818 39 0Same level 405 3 122 152 96 25 7Different level 413 29 175 116 67 18 8

Impact 585 28-0 9 141 236 135 57 7Cutting or piercing 225 10 7 1 42 95 63 12 12Animal bites 143 6-8 - 38 63 36 3 3Poison 75 3 6 2 71 - 2 - -Burn 71 3-4 7 36 8 14 4 2Crushing 61 2 9 - 29 23 6 3Foreign body 32 1 5 1 22 3 4 1 1Other 87 4 1 1 32 24 19 10 1

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and, although based on a relatively small sam-ple, does not have the defect of containingquestionable diagnoses (such as mechanicalsuffocation) as the national mortality figuresdo.'

HOME ACCIDENTS AT DIFFERENT AGESUnder 1 year, falls from different levels are themost common home accident and involve theinfant rolling from a bed, table, chair orbathinette, or toppling from a high chair. Theseacts usually occur when the parents believe thattheir child is still unable to roll or climb, orwhen the supervising person temporarilyleaves the room. Although less frequent, burnsare usually more serious. They involve theinfant as an 'innocent bystander' in homeconflagrations, or his contact with electricity,open fires, radiators, stoves, or scalding fromhot liquids. Poisonings in this age group aremore likely to be mistakes in administration ofmedication than accidental ingestion by thechild, but the precocious baby who becomesambulatory early is certainly a candidate foraccidental poisoning.

Children 1 through 4 years are usuallygrouped together in accident statistics; yetwithin this narrow age range there are widevariations in the motor and intellectual abilitiesand consequently in the types ofaccidents. Themajority of poisonings occur in the children 1and 2 years old, whereas by 4 years of age thishazard has markedly decreased as the childlearns increasing discrimination. Deaths fromdrownings, falls, and bums continue at a highlevel throughout this age group, indicating asomewhat different pathogenesis for theseaccidents from that of poisoning. Falls con-tinue as a very common but less lethal type ofaccident, and collision with various objectsplays a major part. Mammalian bites are quitecommon2' but unlikely to be fatal.During the schoolyears the increasing motor

skills, knowledge, and longer absence from thehome lead to diminished incidence of all homeaccidents, with an increase in other accidentsoutside the home - drownings, motorvehicles, and firearms.From these marked variations in types of

accidents at different ages, it appears that thedevelopmental level of the child (hostdifferences) would influence his susceptibilityto accidents, and although this question isunder study in several places, results have notbeen reported.The presence of a physical disability as

another host factor has been suggested asimportant in the etiology of accidents; yetLossing and Goyette22 found only 2.5% ofhome accident victims suffering from such aphysical defect.The sex difference in rates for almost all

types of home accidents is another intriguingexample of host differences, for the generallygreater number of accidents among boys2'suggests that personality, motor skills, andchild rearing of boys is a causal factor. The factthat only accidental deaths under 1 year of ageand those from fires, explosions, and scalds at

all ages of childhood fail to show this sexdifference (all accidents in which the child isusually only a passive victim to some adultaction) adds weight to this argument.

Broussard,24 in a study of 1168 accidents inFlorida, again demonstrated the preponder-ance of males in childhood accidents and sug-gested that parental attitudes toward boys,rather than simple physical factors such asagility, may be the important variable in caus-ing more accidents in males.

Investigations to determine if there is indeeda difference in the personality of children whosustain accidents have concentrated on the'accident repeater' as the epitome of anaccident-prone child, if there is such an entity.The extent ofaccident repeaters, however, is indoubt. Allan and Williams,'8 in Australia,found that 22% of 419 children seen forpoisonings had previously swallowed apoisonous substance. These authors charac-terize the child likely to ingest poisons as'intelligent, very active and mischievous . . .'.Jacobziner,25 on the other hand, stated that only1 9% of a large series of accidental poisoningsreported to the New York Poison ControlCenter occurred in 'repeaters'.

Others have investigated specific types ofpatients in an effort to define personality char-acteristics of the accident-prone child. Craig,26in England, studying 25 children seen foraccidental poisonings and 25 'normal controls',found that 'exaggerated oral traits' were pres-ent in 76% ofthe former and in only 28% oftheso-called normal group.

Several other studies2729 have similarly char-acterized the child to whom accidents are likelyto occur as one who 'has superior gymnasticskill and strengths, more aggressive behavior,attempts to dominate social situations, is a poorloser, is less popular, rude, overactive, restlessand impulsive'. All these studies suffer fromsmall size, inadequate controls, or methods ofevaluation not accepted by all workers. Thegeneral consistency of the findings, however,suggests that further large scale, well controlledstudies in this field might be productive of amore precise definition of the role of certainpersonality types in the etiology of childhoodaccidents.Yet to be studied are the family incidence of

accidents, the effects of various child rearingpractices, the child's previous experience withaccidents, the parents' values and attitudes andthe effect of such socially disruptive events asbroken homes, frequent moves, or other illnessin the home in the etiology of accidents.

It seems apparent from these studies, whichrepresent the majority of reported work on theetiology of home accidents in childhood, thatexact definition of a single causal factor prob-ably is not a reasonable expectation, since thereare so many quite different types of childaccidents, each with a multiplicity of possiblecauses. The concept of 'multiple causation' isthus an attractive one to explain these manyvariations more adequately, with a differentweighting of the variables of agent, host andenvironment in each case. The concept of 'totalaccident situation' (fig 6)3° is useful to an

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111. Intermediate factorsV. Measurable

(recognizable) results1. Background factors 11. Initiating factors IV. Immediate factors

^ 1-) , ^ ,^_

Persons

Training,Experience,Judgment:Physiologicmental fact(Sight, heariHealth,CoordinatioImpairmentEtc

HomeDwelling,Yard,Etc:Equipment,Appliances,Materials,Etc

High

|\ ~~~~~Change in__Accident pattern:

suscepti- Little attention, Machine breakdbility ~~Etc Baby cries,(unsafe person) 'Get by' attitude Telephone rings

I ~~~~~Distraction,fl\No supervision Etc

Low

:al andprs: Patterns ofing, L. operation This person

p (behavior) This day)n, within given This activityts, environment

High Knowledge,optimumattention, et

Aciet 'goodAccidentia housekeepi(Unsafe condition)

Low

,goods,

Automatic controls,Guards,Etc

Specialphysiologicaland mental

Jown, factors:Illness,

s, Emotional upset,Alcohol and drugs,Etc

~77

No recognitionof danger:Continuesusualpattern,'Take a chance'

Increase insusceptibility

Decrease inpotential

skill, IiAgent of Environmental 'Makeshifts'tc, accident: factors:

nGas leak Darkness,

ng' Grease on floor, ExplosiveFlammable mixture, gas-airCurled up rug, mixture,Hot liquid, EtciMop on stairs,Etc

-, InterventionAnother Safety Automaticperson awareness cut offs, etc

Reverses Y Restoresflow contro

N Return to normal procedure, etc

- Accident prevention (safety) efforts up to this point o- A-:,

Description

> Personalinjury:Nature,Extent ofseverity,Death

> Agent ofinjury ordamage

> Propertydamage:Fire,Explosion,Collapse,Etc

Mitigating No injuryfactor: or damageCatches, (or negligible)Handrail,Another person, ySupports,Etc 'Near

accident'

1- Total accident situation

Figure 6 Dynamics of home accidents (reproduced with permission from Uniform Definition of Home Accidents30).

understanding of how the multiples of back-ground, initiating, intermediate, andimmediate factors all converge in certain per-sons to lead to an accident. Everyone has dailyexperiences that could combine to produce anaccident. What is not known is why interven-tion of one type or another occurs, in mostcases, to prevent the accident entirely, ormitigating factors intervene to make the injurynegligible. When thought of in this broaderconcept, accidents are thus part of daily living:their seriousness may vary from time to time inthe same person, or in different persons, mak-ing one accident a 'statistic' whereas theremainder are entered only in the experiencefile of each.

Emergency treatment of common homeaccidents in childhoodWhatever his future role in prevention, thephysician will continue to play a major part inthe therapy of accidents. It is beyond the scopeof this review to discuss the details of manage-ment of the many different types of accidents.Every physician who treats acute problems ofchildhood, however, will be called upon fre-quently to render emergency care to the acci-dent victim. The Committee on AccidentPrevention of the American Academy ofPediatrics has recently published a very brief

outline of recommended emergency care ofchildhood skeletal trauma and burns, which issummarized below.3'

Emergency care of childhood skeletal trauma1. Evaluate and splint where they lie before moving. Do

not attempt reduction.2. Move cervical injuries face up on a rigid support with

manual traction applied gently by cupping chin at thetime of moving. Sandbags on either side of neck toprevent turning, if possible.

3. Spine injuries should not be flexed in transportation.4. Lower leg injuries, transport in pillow strapped with

belt.5. Upper leg injuries, transport with both legs and

trunk bound to board without circulatoryinterference.

6. Lower arm injuries, transport with splint such asrolled newspaper, gentle compression wrapping andsling.

7. Upper arm can be bound to chest with lower armsupporting in sling.

8. Open injuries or open wounds, cover with steriledressing, do not dust with antibiotic, but systemicantibiotic is useful. Do not attempt to retract boneback under skin. Get to surgical care promptly.

9. Do not cover distal tips of extremities if it can beavoided, thus allowing a circulation check to be madefrom time to time.

Emergency care of burns1. Burns are due to thermal agents (scalds or fire);chemical agents (battery acid or lye); radiation (sunburnor nuclear); and electrical energy.

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2. Even small burns may be followed by infection,tetanus, excessive scarring, and disfigurement. Largeburns may represent an immediate threat to life fromshock. Arrest of the circulation and respiration mayoccur following electrocution.3. Flames should be smothered if possible with childhorizontal; children who have been scalded should havetheir clothing removed immediately; chemical burns(except phosphorus) should be washed with large quan-tities ofrunning water. Chemical burns ofthe eye shouldbe flushed with saline solution or water. Patients shouldbe removed from source of radiant energy.4. Fresh burns are relatively clean. They should becovered by a clean cloth immediately and should not beuncovered until the patient is delivered to a hospitalemergency room or a doctor's office. Such coveringshould be loosely applied without constriction.5. Ointments, greases, powders, etc, should not be usedin the emergency treantent of burns. Leave this man-agement to the physician who will care for the patient.6. Shock may be combated by keeping the patient flat,reassuring him, and keeping him warm during thetransportation to the hospital.7. Pain is usually not a serious problem in theemergency treatment of a burn and drugs for painshould not be administered except by the physician whowill care for the burn.8. Patients with burns of the face, hands, feet or areassurrounding a joint, as well as any burn equivalent tomore than 5% of the body surface, should be hos-pitalized after emergency treatment.9. Electrical burns accompanied by electrocution andfailure of respiration and circulation should receiveartificial respiration for an indefinite period and untilordered to stop by a physician.

The evaluation and emergency therapy ofheadinjuries is well outlined in a recent textbook,32which emphasizes the most significant featurein the management of all patients with closedhead injuries - namely, 'repeated, carefulnotation of the vital signs and neurologicalstatus at regular intervals until completerecovery has occurred'. This generally meanshospitalization for children rendered uncon-sious by the injury. Other patients with mildercases may be followed at home if the parents arecapable of the frequent observations necessary.Depressed fractures, compound fractures, orsigns of increasing intracranial pressure areobviously indications for neurosurgical consul-tation.

Certain principles in the early management ofaccidental poisons have been outlined33:identification of the toxic agent; promptremoval of the agent; institution of generalsupportive measures; and use of specificantidotes when available.

If precise identification of the potentiallytoxic agents is not possible from the label,consultation with one of the more than 200poison information centers34 in the UnitedStates may be of great help.Recent work35 has demonstrated that

induced emesis is a far more effective means ofremoving ingested poisons than the traditionallavage. If certain precautions are taken (forexample, no induced vomiting after ingestion ofcaustics or hydrocarbons, and the child's headbeing held down), this is a safe procedure forparents to perform on a physician's advice, forvaluable time can be saved and more effectiveremoval of the toxic agent accomplished.

General supportive measures such as main-taining an airway, blood pressure and respira-

tions, and sedatives for convulsions aregenerally the most important aspect oftherapy,for there are relatively few specific antidotesavailable. Recently, exchange transfusion orartificial kidney hemodialysis has been success-fully employed to remove a great variety ofpoisons from the blood stream.

Specific antidotes such as BAL (dimercap-rol) for mercury or arsenic, n-allyl morphinefor opiate and atropine or 2-PAM (pyridineald-oxide methiodide) for phosphate esterinsecticide poisonings should be promptlyemployed when indicated.

PreventionIn the present state of incomplete knowledgeconceming all the factors in the etiology ofaccidents, prevention cannot be expected to becomplete. In fact there is little question thatminor accidents are a necessity for the growingchild to learn about his environment and hisown capabilities. The problem is to learn howto prevent the life threatening or cripplingaccidents without imposing such restrictionson the development of the child that seriousemotional problems ensue.Few studies have been reported on the

effectiveness of various preventive measures.One indirect attempt to determine thisinvolved an evaluation of an extensive educa-tional effort by a state health department.36 Byorganization of parent groups throughout thestate and distribution of a questionnaire onaccident hazards, over 35 000 households werealerted to the accident hazards in the home.Whether changed behavior occurred as a resultcould not be determined.

In another evaluation of a large scale educa-tional program by the Michigan HealthDepartment,37 it was found that 27% of thehouseholds surveyed stated that they had fol-lowed some of the safety advice given. Evenmore impressive was the fact that the homeaccident death rate for the state dropped by50-400 one year after the institution of thecampaign. Although this was not a controlledstudy and many other variables could haveaccounted for the reduction, it is one ofthe veryfew reports actually to show a decrease inaccidents after any preventive program.How effective education alone can be in

reducing home accidents is not known. Fromwhat has been discussed of the many causalfactors, however, it seems reasonable that asignificant reduction in childhood accidentscould be achieved if parents became aware ofthe normal development at different ages ofchildren, the specific hazards dependent uponthese developmental levels, and the particularcapacities and limitation of their own children.

Dietrich38 has written very dramatically ofthe practical aspects of a method of preventionthat can be utilized by health practitioners,physicians, public health nurses, and othermembers of the health team. The essence ofthis method is depicted in figure 7,38 whichindicates that almost complete protectionagainst accident hazards must be carried outduring the first year of life; after this period

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gradual reduction in protection and increase ineducation must occur, or the child may arrive atschool age over protected and unprepared forthe realistic hazards of road accidents, games,swimming ponds and so forth.

Specific hazards common to each age groupand dependent primarily upon thedevelopmental level of the child at each ofthese

100

8- 50

00 1 2 3 4 5 6

Age (years)

Figure 7 Theory of accident prevention (reproducedfrom Dietrich38 with the permission of the publishers).

Table 4 Accident risks andprecautions at various age levels*

Normal behaviorTypical accident characteristics Precautions

I1st year:Falls

Burns

Inhalation oringestion offoreign objectsPoisoningsDrowning

2nd year:Falls

Burns

Drowning

Poisonings

2-4 years:Falls

DrowningPoisoningsBurns and cuts

FirearmsMotor vehicle

5 -9 years:Motor vehicleBicycle accidents

Drowning

BurnsFirearmsFalls

10- 14 years:Motor vehicles

DrowningBumsFalls

Rolls over about 4 mo. of age;creeps, stands and may walkbetween 6 and 12 mo.

Is helpless to leave (burninghouse) source of burn

Puts everything in mouth

Is helpless in water

Is able to walk; can go up anddown stairs

Reaches for any utensils onstove or table

Is helpless in water

Has great curiosity; putseverything into mouth

Is able to open doors; can runand climb, can throw ball,ride tricycle

Investigate closets and drawers

Plays with mechanical gadgets

Is daring and adventurousControl more advanced over large

than over small muscles

Loyalty to group makes himwilling follow older leaders

Need for strenuous physicalactivity

Plays in hazardous placesNeed for approval of agemates I

leads to daring or hazardousfeats

Do not leave alone on tables,beds or bathinette; keep cribsides up

Keep electric cords and appliancesaway; do not leave in housealone; test water in bath

Keep small objects and poisonsout of reach

Do not leave alone in bath

Keep screens on windows andgate at stairs

Keep handles of pots and pans onstove out of each and hot foodsaway from edge of table; keepelectric cords out of reach;cover unused electric outlets; donot leave alone in house

Keep in enclosed space when out-doors or not in company ofadult

Keep medicines, householdcompounds and small, sharpobjects out of reach

Keep doors locked where dangerof falls - cellar, screens onwindows; teach risks of throwingsharp objects

Keep knives and electric equip-ment out of reach

Keep firearms locked upTeach safety in street and

driveway

Teach traffic and bicycle safety

Encourage but do not pushswimming skills

Keep firearms locked up

Teach rules of pedestrian andtraffic safety; prepare forautomobile driving by settinggood example

Provide safe and acceptablefacilities for recreation andsocial activities

*Modified from Shaffer.39

age groups have been well summarized byShaffer39 (table 4). These can be relativelyeasily incorporated into the periodic healthexaminations as part of the anticipatoryguidance of children. Helpful check lists havebeen prepared by several insurance com-panies4O-43 that may be effectively distributed toparents after a discussion of the particularhazards and preventive points peculiar to thechild involved. This approach seems, theoreti-cally, to be a most effective method of accidentprevention, for then the many variations inindividual child development, parent know-ledge, personality, and home environmentcould be taken into account. As stated above,whether this is actually an effective method hasyet to be proved by appropriate studies.

Dietrich has argued that unpleasant experi-ence be utilized as part of the education of thechild to promote avoidance of accidents. Whenthe child reaches for hot but not very dangerousobjects, he urges parents to say, 'That's hot',but to realize that the child will touch, will bemade uncomfortable, and will learn thatalthough they tried to warn him, he had anunpleasant experience. In addition, it seemswise to let the child learn that minor accidentsare part of living and not to shower specialattention and false love upon him at these times- this may prevent his developing a sense ofsecondary gain to be derived from accidents. Acommon sense recommendation for parents, asso well put by Dietrich,44 is as follows:

... don't rob your child of the educational valueof his minor injuries. Ifyou reward him (his tearsor his bruises or his bleeding) with honeyedwords or sweets, he will probably forget hislesson, and may only remember that playing withfires begets cookies.

Role of the individual physician in acci-dent preventionIn spite of the large part many other profes-sionals may play in the ultimate control ofaccidents, physicians by their close contactwith individual families can probably do a greatdeal to limit the accident toll in childhood bythe following means:

Incorporating the anticipatory guidanceprinciples listed in table 4 in the routine care ofpatients, and using the pamphlet40-43 availableto assist in this education program, as well asoffice bulletin boards with clippings andposters concerning accidents.Lending their professional prestige and

knowledge to community-wide programs inaccident prevention on television or radio prog-rams and at various parent meetings.

Utilizing the emotionally 'ripe' time duringtreatment of patients with injuries to transmitpreventive principles- during home visits thiscan be very effective as actual environmentalhazards are demonstrated.

Giving careful instructions, when prescrib-ing medicine, for its proper and safe storage andprescribing only enough for the individualillness; sugar coated, candylike pills are prob-ably unwise.

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Research in progressFrom the foregoing summary of the state ofknowledge about the causes and especially theprevention of childhood home accidents, it isapparent that there is a very extensive amountof research yet to be done before answers arefound to most of the questions raised. It isgratifying to see the beginnings of this type ofresearch, and although it was impossible tolearn of all such projects, a description of thegeneral nature of the studies now in progress orplanned may be found useful. These can beconveniently grouped as follows:

COMMUNITY BASED STUDIESThe family injury survey of the ConnecticutState Department of Health will involve collec-tion of information on accidental injuries to allmembers of 2000 randomly selected house-holds in Norwich, Connecticut (correlation ofenvironmental and personality data withdetails of each injury will be performed).

The New Bedford accident prevention prog-ram, a four year longitudinal study ofup to 700births of primigravidas, to determine the ratesand types of accidents correlated with the manybackground factors in each patient.

Accidental poisoning as a case finding proce-dure is a study by the San Jose City HealthDepartment to determine if the homes in whichaccidental poisonings occur are also the ones inwhich there is a greater likelihood that otheraccidents will occur (if this proves to be true, avery useful method of selected case finding willbe available to indicate where the greatestefforts at prevention should be concentrated).

Research projects on accidents by the New YorkCity Department of Health are designed toobtain epidemiologic data on many types ofaccidents in the preschool group by survey ofchildren attending child health conferences inNew York City and the cases reported to theNew York Poison Control Center.

Survey of accidental home injuries in Philadel-phia is designed to determine the types ofaccidents and the environmental, physical andpsychologic factors that contribute to them.A study of the number and circumstances of

fatal and non-fatal accidents tofarm residents inPennsylvania by the Pennsylvania Rural SafetyCouncil.

INDIVIDUAL BASED STUDIESStudies of children showing injury patterns atTulane University School of Medicine isdesigned to investigate the personality charac-teristics and family constellations of children 6to 10 years of age who have repeated accidents.

Epidemiologic study of accidental poisonings inchildhood by the Department of of Pediatrics,University of Louisville School of Medicine, isan investigation of patients reported to thepoison control center at the institution.A pilot study of the details of the accident

sequence in salicylate poisoning is designed todetermine some of the child-rearing practices,parental attitudes and developmental levels ofthe child involved, as reported to the BostonPoison Information Center.

Summary and conclusionsThe important role of accidents in general, andhome accidents in particular, in childhoodmortality and morbidity is outlined. The con-cept that best expresses the present state ofknowledge concerning accident etiology is thatof multiple causation, in which the variables ofhost, environment, and agent all play a part ineach accident, but the importance of each ofthese factors varies from accident to accident.In children the marked difference in accidenthazards at different developmental levels offersthe most convincing evidence that differencesin the host are of importance in etiology.The most logical approach to prevention of

accidents at present involves the integration ofmany members of the health teamrphysicians, nurses, public health personnel,health educators, and lay groups. The role ofthe physician seems to be primarily in instruc-tion of individual families in the accidenthazards at different ages. His close relation tofamilies and his familiarity with their home andpersonal characteristics indicate the crucialpart that he can play in such prevention. Muchresearch remains to elucidate the precise role ofthe various causes in different accidents, theidentification of the susceptible host and themost effective means of prevention. Evidencethat this type of research is at last beginningoffers hope that accidents may eventually yieldto control measures.

1 Accidentfacts: 1958 edition. Chicago: National Safety Coun-cil, 1958: 96 pp.

2 United States Department of Health, Education and Wel-fare. Public Health Service, National Office of VitalStatistics. Vital statistics of the United States: 1955. Vol 2.Mortality data. Washington, DC: Government PrintingOffice, 1957: 317 pp.

3 Accident prevention program. Prepared by Department ofHealth, Education and Welfare. Public Health Service,Division of Special Health Services, February 1958.

4 United States Department of Health, Education and Wel-fare. Public Health Service. Health statistics from theUnited States national health survey. Washington DC:Government Printing Office 1958: 24 pp (publication No584-135).

5 McFarland RA. Epidemiologic principles applicable tostudy and prevention of child accidents. Am I PublicHealth 1955; 45: 1302-8.

6 Rice RG, Starbuck GW, Reed RB. Accidental injuries tochildren. N Engl J Med 1956; 255: 1212-9.

7 Accidents reported January 1-December 31, 1954. Preparedby Greater New Bedford Children's Accident PreventionProgram, New Bedford, Massachusetts. (Mimeographedpublication.)

8 Woolley PV. Mechanical suffocation during infancy: com-ment on its relation to total problem of sudden death. JPediatr 1945; 26: 572-5.

9 Adelson L, Kinney ER. Sudden and unexpected death ininfancy and childhood. Pediatrics 1956; 17: 663-97.

10 Bleck EE. Causes of bums in children: study of full-thickness burns in 457 patients from North CarolinaOrthopedic Hospital, Gastonia. JAMA 1955; 158:100-3.

11 Colebrook L, Colebrook V. Prevention of burns and scalds:review of 1000 cases. Lancet 1949; ii: 181-8.

12 Accidents in children: facts as basis for prevention. Tech RepWorld Health Organ 1957; 118: 1-40.

13 Curry JI, Sternfeld L. Summary of home accident preventionproject, City of Cambridge, Massachusetts, 1951-1956.Cambridge: Cambridge Department of Public Health.1956; 23 pp. (Mineographed publication.)

14 Rowntree G. Accidents among childre under two years ofage in Great Britain (some findings of national question-naire inquiry). J Hyg 1950; 48: 323-37.

15 Seiter HE, Ramsey CB. Home accidents. Practitioner 1954;172: 628-36.

16 Britten RH. New light in relation of housing to health. AmJPublic Health 1942; 32: 193-9.

17 Bronzi EI, Johnson GC. Study of fifty home accidents bypublic health nurses: comparison with previous studies.Epidemiology of home accidents, and health counseling.Thesis: Harvard School of Public Health, Cambridge,Massachusetts, 1967.

18 Allan J, Williams H. Social study of accidental poisoning.Med J Aust 1956; i: 213-6.

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19 Backett EM, Johnston AM. Social patterns to road accidentsto children. BMJ 1959: i: 409-13.

20 McFarland RA, Moore RC. Human factors in highwaysafety: review and evaluation. N Engl J Med 1957; 256:792-9, 837-45 and 890-7.

21 Carithers HA. Mammalian bites of children: problem inaccident prevention. J Dis Child 1958; 95: 150-6

22 Lossing EH, Goyette RB. Review of 1000 home accident.Can J Public Health 1957; 48: 131-40.

23 Berfenstam R. Critical review on different types of accidentmorbidity studies. Courrier 1957; 7: 349-61.

24 Broussard ER. Relationship of sex to childhood accidents. JFla Med Assoc 1958; 44: 1343.

25 Jacobziner H. Accidents- major health problem. J7 Pediatr1955; 46: 419-36.

26 Craig JO. Oral factors in accidental poisoning. Arch DisChild 1955; 30: 419-23.

27 Birnback SB. Cited by McFarland,' p 1304.28 Fuller EM. Injury-prone children. Am J Orthopsychiatry

1948; 18: 708-23.29 Langford WS, Gilder R, Wilking VN, Genn MM, Sherrill

HH. Pilot study of childhood accidents: preliminaryreport. Pediatrics 1953; 11. 405-15.

30 United States Department of Health, Education and Wel-fare. Public Health Service. Uniform definition of homeaccidents. Washington, DC: Government Printing Office,1958; 14 pp (publication No 577).

31 Report: Committee on Accident Prevention: emergency careof childhood skeletal trauma and bums. Pediatrics 1957;20: 565.

32 Ingraham FD, Matson DD. Neurosurgery of Infancy andchildhood. Springfield, Illinois: Thomas, 1954: 1: 159(456 pp).

33 Procedure book for the management of childhood poisoning.Prepared by Boston Poison Information Center, Boston,Massachusetts, 1956: 35 pp.

34 Cann HM, Neyman DS, Verhulst HL. Control ofaccidentalpoisoning: progress report. JAMA 1958; 168: 717-24.

35 Arnold FJ Jr, et al. Evaluation of efficacy of lavage and

induced emesis in treatment of salicylate poisoning.Pediatrics 1959: 23: 286-301.

36 Zindwer R. Educational project in childhood accidentprevention. AmJ7 Public Health 1955; 45: 438-41.

37 Prothro WB. Home accident prevention: research program.Am J Public Health 1951; 41: 954-8.

38 Dietrich HF. Accidents, childhood's greatest physicalthreat, are preventable. JAMA 1950; 144: 1175-9.

39 Shaffer TE. Symposium on clinical advances: accidentprevention. Pediatr Clin North Am 1954; 1: 421-32.

40 Child safety suggestions. Prepared by Greater New BedfordChildren's Accident Prevention Program with coopera-tion of New Bedford Medical Society, New Bedford,Massachusetts.

41 A formula for child safety. Prepared by Metropolitan LifeInsurance Company, New York City, New York, 1955:14pp.

42 United States Department of Health Education, and Wel-fare, Food and Drug Administration, Division ofMedicine. Protectyourfamily against poisoning. Washing-ton, DC: Govermment Printing Office, 1956.

43 AM-man says: 'Your home can be as safe as you make it'.Prepared by American Mutual Liability Insurance Com-pany, Wakefield, Massachusetts, 1958.

44 Dietrich HF. Your child's safety. Prepared by NationwideInsurance Company, Columbus, Ohio, 1955.

Additional references

Roberts HL, Gordon JE. Home accidents in Massachusetts:study in epidemiology oftrauma. NEnglJMed 1949; 241:435-41.

Rosenfield AB. Childhood mortality from accidents. Minn Med1952; 35: 424-9.

Starbuck GW. Recent trends in accident prevention. Pediatrics1958; 22: 761-73.

Wheatley GM. Prevention of accidents in childhood. AdvPediatr 1956; 8: 191-215.

Editorial Board Member: briefbiography

BERNARD GUYER

Bernard Guyer, MD, MPH, isProfessor and Chair of theDepartment of Maternal andChild Health and an AssociateDirector of the Center for

_ Injury Research and Policy,*.EA ^ Johns Hopkins School of

Hygiene and Public Health.He trained in pediatrics and

preventive medicine andserved as an EIS officer at theCenters for Disease Control.From 1979 to 1986, Dr Guyerserved as the Director of the

Maternal and Child Health agency in the MassachusettsDepartment of Public Health, where he directed theMassachusetts Statewide Childhood Injury PreventionProgram (SCIPP). SCIPP carried out landmark researchon the epidemiology of childhood injuries and evaluatedinjury prevention programs in the community. Dr Guyerhas published more than 20 research papers on injuryspanning a broad array of topics including: injuryepidemiology in Massachusetts, community basedinterventions, injury program implementation and evalua-tion, the epidemiology of burns in Ghana, and pedestriansafety.From 1986 to 1989 Dr Guyer was an associate professor

of MCH and Director of the Injury Prevention Center atthe Harvard School of Public Health. He has been active inmaternal and child health and childhood injury policy atthe national level. He is currently a member of the Instituteof Medicine's Board on Children and Families. Dr Guyerchaired the National Committee on Injury Prevention thatpublished Injury Prevention; Meeting the Challenge. DrGuyer's areas of injury research include the epidemiologyofchildhood injury, pedestrian injuries, and the implemen-tation and evaluation of injury prevention programs.

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