Safe care/safe play: child care as a site for injury prevention

Children Today, March-April, 1990 by Matia Finn-Stevenson, J. John Stevenson

Injuries are the leading cause of death among children and youth in the United States. Each year, approximately 8,000 children ages 1 to 14 are killed as a result of accidental injuries. Nonfatal accidental injuries are also significant and second only to acute infections as the reason for visits to the doctor. In an analysis of studies on pediatric trauma, Gratz found that one-fourth of children's visits to emergency rooms are injury related. Other data indicate that three out of ten children suffer accidental injuries severe enough to restrict their activities and require medical attention. I Young children are especially at risk; 48.6 percent of the total childhood deaths from accidental injuries occur among children ages four and under. Since an increasing number of children in this age group are in child care facilities, it is important to consider day care as an environment where children spend a significant portion of their day and, as such, a place where childhood injury prevention efforts may take place. In this article, we describe a state-based injury prevention initiative that focuses on child care environments. Before we discuss this program and related information regarding injuries to children in day care, it is important to briefly review what is known about how and where serious childhood injuries occur. An Overview An examination of the research indicates that there are conscious efforts on the part of investigators in the field to avoid using the term "accident" by itself, and to refer instead to unintentional or accidental injuries. The term "injury" implies control over the problem, whereas the term " accident" implies a random and unpredictable occurrence over which we have no control. One of the significant advances of the research has been the documentation that we do indeed have control over "accidents" or injuries and an ability to predict their occurrence. Additionally, a great deal of knowledge has been amassed in the area, delineating specific factors that increase a child's risk for injury.

A comprehensive review of the research is beyond the scope of this paper, but we will highlight some of the available information and show how an understanding of injuries leads to efforts toward prevention. In general, the research on injuries emphasizes three areas of investigation: identification of the agent involved in the injury, documentation of the characteristics of the victim, and an examination of the physical and social environment in which injuries are likely to occur.

In the first line of inquiry, the identification of the agent of accidental injuries, several products have been implicated. These include bicycles, swimming pools, selected toys or toy parts, children's furniture, playground equipment, and potentially poisonous plants, chemicals and medications. Although efforts to modify or remove these and other hazardous objects from the environment have not been uniformly successful, some effective preventive measures have been developed and implemented. For example, an analysis of the causes of childhood poisoning led to the introduction of child resistant bottle caps, which have resulted in a 6 percent reduction in child deaths from aspirin poisoning alone.8 Similarly, federal regulation of pacifiers requiring these to adhere to specific manufacturing and design guidelines-has virtually eliminated deaths caused by swallowed pacifiers. A profile of the child at risk for injury demonstrates that the child's sex, behavioral characteristics, and developmental stage play significant roles. Among children under age five, boys are nearly 50 percent more likely than girls to die of accidental injuries;9 active and temperamental children are more likely than other children to be repeatedly injured;10 and young children are at risk for different types of injuries than older children. Infants and toddlers, for example, are at risk for choking, suffocation, and poisoning because they tend to explore their surroundings and frequently suck on small objects that can be easily swallowed. Children in the primary grades are vulnerable to pedestrian injuries from automobiles which, contrary to popular belief, do not occur at major intersections, but rather, in relatively traffic free residential areas and in and around driveways.

The family's educational and income level, as well as stressful life events, are also factors in childhood injuries. Serious illness, frequent family moves, unemployment or frequent job changes by the father, and divorce, have been cited as determinants of childhood injuries. Horwitz and her colleagues found several other factors, such as a mother working more than 15 hours a week, to be related to injuries to children. Other researchers indicate that children in large families are more prone to injuries in and around the home, perhaps because in large families, it is difficult for parents to keep an eye on all children simultaneously.

In examining the environment in which injuries occur, researchers note that although motor vehicle injuries are a significant cause of death in about half the states, there are variations among the states in the type of injury children are likely to sustain. Using childhood mortality data from 1980 to 1985, Baker and Waller found that drowning was the most significant cause of childhood deaths in western states and in Florida, and that house fires were significant causes of deaths among children in the mid-Atlantic and several northern states.