Childhood trauma, disability, hospital charges and prevention

Introduction

Trauma to children and especially head trauma is a public health concern. A recent study of head injury in children from Nigeria [1] showed an age range from 7 months to 18 years with a mean of 8.66 years. Road traffic accident represented 63.15% of the cases, while pedestrian accident was more frequent among preschool and school children. The most common post-traumatic effect was seizure (15.79%). A good functional outcome was seen in 92.1%.

As in most industrialized countries, injuries in Israel are the primary cause of mortality in children and youth with the loss of potential years of life. Motor vehicle accidents are the most common cause of injury-related death. In 2011, in the age group of 5–9 years, 816 children were injured in car-related accidents with nine fatalities and 87 severe injuries. Each injury must be seen as a public health concern as it usually results in an emergency room visit, hospitalization and transient, or permanent, disability.

Between 30%–50% of pediatric emergency department visits are injury-related with 10% of the children hospitalized and one out of 90 children hospitalized with injuries dying. The hospitalization rate of injured children aged 1–4 years is the highest among age ranges. Of all the hospitalizations due to unintentional injuries, the most common are falls (43%), road accidents (24%), blunt trauma (9%) and burns (7%).

The impact of injuries is enormous including short- and long-term disabilities, suffering and the economic burden on society. Over 70% of injuries are preventable by the use of simple means, and interventions have resulted in reduction of injury-related mortality. William Haddon, Jr. (1926–1985), the founding father of injury prevention research, found that injury is a result of interaction between the person, the product, the environment and the socioeconomic milieu, and with proper intervention in these four components, injury can be prevented or minimized before, at the time of or following the event.

A national survey was conducted a few years ago with a randomized sample of the Jewish population residing in cities and towns with more than 20,000 inhabitants [2] to survey the knowledge of Israeli parents of children up to 15 years of age about car safety and their behavior regarding their children. Seven hundred and five Jewish families with at least one child at home younger than 15 years (a total of 1345 children) were selected for telephone interviews (with only a 31% response rate for the phone calls). Concerning knowledge about injury prevention, the rate of incorrect answers was high, 64% with regard to the proper age for car seats and 84% with regard to the proper for booster seats. Sixty-five percent of parents did not know what a booster seat was and 54% did not know that the proper place for children was in the back seat. Concerning car safety behavior, 60% of babies and 38% of toddlers were not restrained properly. Only 9.8% of parents of toddlers knew what a booster seat was. Forty-nine percent of parents who restrained their toddlers properly did not know about the booster seat as the recommended seat for children between 4 and 10 years. Just 41% of the parents who restrained children of 4–10 years with a belt knew about booster seats [2].

Concerning the Arab population in Israel, the mortality rate for Arab children under 8 years is twice that of Jewish children. A cross-sectional observational study was conducted in eight settlements in the Nazareth district and 835 children traveling in 400 vehicles were observed [3]. Forty-seven percent were unrestrained, while 60% of the drivers wore seat belts. Proper restraint ranged from 64% among infant-seat eligible children to 9% among booster-seat eligible children. Sixty-four percent of the drivers did not know about booster seat recommendations.

Booster seat

A booster seat is a seat cushion that is used to elevate children in cars so that the seat belt fits better over the chest and not over the neck. In general, most booster seats can be used for children who are between 4 and 12 years of age and between 100 and 150 cm (40–59 inches) tall. Children under 40 inches are usually too small to use booster seats and must use a car seat (a child-safety seat with its own seat belt system used for children under the ages of 4–6 years).

The American Academy of Pediatrics in their recent guidelines from 2011 [4] recommended that “all children whose weight or height is above the forward-facing limit for their car-safety seat should use a belt-positioning booster seat until the vehicle lap-and-shoulder seat belt fits properly, typically when they have reached 4 feet 9 inches (149 cm) in height and are between 8 and 12 years of age”. In children aged 4–7 years, booster seats are estimated to reduce the odds of sustaining clinically significant injuries during a crash by 59%, when compared to using ordinary vehicle seat belts. Despite this evidence of effectiveness, many children are not restrained in age-appropriate booster seats.

Several studies [5, 6] from the United States, where nearly all states have implemented laws for children to use booster seats (besides from Florida and South Dakota), have shown that state booster seat laws were associated with decreased fatality rates in children aged 4–7 years. Utilization of booster seats are very much related to the attitudes of parents [7].

Economic considerations

The Crash Outcome Data Evaluation System (CODES) is a multistate program facilitated by the National Highway Traffic Safety Administration to link police crash reports and hospital databases for traffic safety analyses [8]. Eleven states (Connecticut, Georgia, Kentucky, Maryland, Minnesota, Missouri, Nebraska, New York, Ohio, South Carolina, and Utah) submitted data to CODES during 2005–2008.

Optimal restraint use in the back seat declined with child’s age (1 year: 95.9%, 5 years: 95.4%, 7 years: 94.7%, 8 years: 77.4%, 10 years: 67.5%, 12 years: 54.7%). Child restraint use was associated with driver restraint use; 41.3% of children riding with unrestrained drivers also were unrestrained compared with 2.2% of children riding with restrained drivers. Child restraint use also was associated with impaired driving due to alcohol or drug use; 16.4% of children riding with drivers suspected of alcohol or drug use were unrestrained compared with 2.9% of children riding with drivers not suspected of such use. Optimally restrained and suboptimally restrained children were less likely to sustain a traumatic brain injury than unrestrained children [8].

The 90th percentile hospital charges for children aged 4–7 years who were in motor vehicle crashes were $1630.00 and $1958.00 for those optimally restrained in a back seat and front seat, respectively, $2035.91 and $3696.00 for those suboptimally restrained in a back seat and front seat, respectively and $9956.60 and $11,143.85 for those unrestrained in a back seat and front seat, respectively.

Conclusion

Road traffic accidents are a public health issue. Proper car seat, booster seat, and seat belt use among children in the back seat prevents injuries and deaths, as well as hospital charges.

As always the parental role is very important in prevention, but legal intervention is an important aspect of prevention. Effective interventions for increasing proper child restraint use should be a foremost concern to prevent motor vehicle-related injuries among children and their resulting costs.