Agran Phyllis F, Anderson Craig, Winn Diane, Trent Roger, Walton-Haynes Lynn, Thayer Sharon
University of California, Center for Health Policy and Research, Pediatric Injury Prevention Research Group, Irvine, California 92697-5800, USA.
Pediatrics. 2003 Jun;111(6 Pt 1):e683-92. doi: 10.1542/peds.111.6.e683.
Mortality and morbidity data on childhood injury are used to construct developmentally appropriate intervention strategies and to guide pediatric anticipatory counseling on injury prevention topics. Effective anticipatory guidance depends on detailed injury data showing how risks change as children develop. Conventional age groupings may be too broad to show the relationship between children's development and their risk of various causes of injury. Previous studies revealed differences in overall rates and specific causes of injury by year of age. However, single year of age rates for children younger than 4 years may not reflect the variations in risk as a result of rapid developmental changes. This study was designed to analyze injury rates for children younger than 4 years by quarter-year intervals to determine more specifically the age period of highest risk for injury and for specific causes.
We used data from 1996-1998 California hospital discharges and death certificates to identify day of age and external cause of injury (E-code) for children younger than 4 years. The number of California residents for each day of age was estimated from US Census of estimates of California's population by year of age for the midpoints (1996-1998). Rates were calculated by 3-month intervals. We grouped the E-codes into major categories that would be particularly relevant for developmentally related risks of injury specific to young children. The categorization took into account physical, motor, behavioral, and cognitive developmental milestones of children 0 to 3 years.
There were a total of 23,173 injuries; 636 resulted in death. The overall annual rate for children aged 0 to 3 years was 371/100,000. Beginning at age 3 to 5 months, the overall rate of injury rapidly increased with increased age, peaking at 15 to 17 months. The mean injury rate calculated for each single year of age did not reflect the variation and the highest rate of injury by quarter year of age for children younger than 1 year, 1 year, and 2 years. The leading major causes of injury in descending order were falls, poisoning, transportation, foreign body, and fires/burns. The overall rate of the major category of falls exceeded poisoning, the second leading cause of injury, by a factor of 2. Age-related differences were detected within each major cause of injury. For children 0 to 12 months of age, there was a different leading cause of specific injury for each 3-month period: other falls from height (0-2 months), battering (3-5 months), falls from furniture (6-8 months), and nonairway foreign body (9-11 months). Hot liquid and vapor injuries were the leading specific causes for children 12 to 17 months. Poisoning by medication was the leading specific cause of injury for all age groups from 18 to 35 months and exceeded poisoning by other substances. Pedestrian injury was the leading specific cause of injury for all age groups from 36 to 47 months. Fall from furniture has the highest rates of specific causes of falls from age 3 to 47 months. Fall from stairs peaked at age 6 to 8 months and 9 to 11 months. Fall from buildings was highest at 24 to 26 months. Poisoning by medication peaked at age 21 to 23 months, but poisoning by other substances peaked at 15 to 17 months. The motor vehicle occupant injury rates were fairly stable over the age span of this study. The pedestrian injury rate increased beginning at age 12 to 14 months and by 15 to 17 months was double that of the motor vehicle occupant. Foreign body had a marked peak at age 9 to 11 months. Both battering and neglect rates were highest among infants 0 to 2 and 3 to 5 months. Bathtub submersions had a narrow peak at age 6 to 11 months. Other submersions peaked at 12 to 14 months and remained high until 33 to 35 months.
We departed from usual groupings of E-codes and devised groupings that would be reflective of age-related developmental characteristics. Differences in rates by narrow age groups for young children can be related to developmental achievements, w can be related to developmental achievements, which place the child at risk for specific causes of injury. We found marked variability in both rates and leading causes of injury by 3-month interval age groupings that were masked by year of age analyses. Children aged 15 to 17 months had the highest overall injury rate before age 15 years. This coincides with developmental achievements such as independent mobility, exploratory behavior, and hand-to-mouth activity. The child is able to access hazards but has not yet developed cognitive hazard awareness and avoidance skills. A remarkable finding was the high rate of battering injury among infants 0 to 5 months, suggesting the need to address potential child maltreatment in the perinatal period. Poisoning was the second major leading cause of injury; more than two thirds were medication. Cultural factors may influence views of medications, storage practices, use of poison control system telephone advice, and risk of toddler poisoning. The pedestrian injury rate doubled between 12 and 14 months and 15 and 17 months and exceeded motor vehicle occupant injury rates for each 3-month interval from 15 to 47 months. Pedestrian injury has not received sufficient attention in general and certainly not in injury prevention counseling for children younger than 4 years. Anticipatory guidance for pedestrian injury should be incorporated before 1 year of age. Effective strategies must be based on the epidemiology of childhood injury. Pediatricians and other pediatric health care providers are in a unique position to render injury prevention services to their patients. Integrating injury prevention messages in the context of developmental assessments of the child is 1 strategy. These data can also be used for complementary childhood injury prevention strategies such as early intervention programs for high-risk families for child abuse and neglect, media and advocacy campaigns, public policies, and environmental and product design.
儿童伤害的死亡率和发病率数据用于制定适合儿童发育阶段的干预策略，并指导儿科医生就伤害预防主题进行预期性咨询。有效的预期性指导依赖于详细的伤害数据，以显示随着儿童成长风险如何变化。传统的年龄分组可能过于宽泛，无法显示儿童发育与其各种伤害原因风险之间的关系。先前的研究揭示了按年龄划分的伤害总体发生率和特定原因的差异。然而，4岁以下儿童按单一年龄计算的发生率可能无法反映由于快速发育变化导致的风险差异。本研究旨在按季度间隔分析4岁以下儿童的伤害发生率，以更具体地确定伤害及特定原因的最高风险年龄阶段。
我们使用了1996 - 1998年加利福尼亚州医院出院记录和死亡证明的数据，以确定4岁以下儿童的年龄和伤害外部原因（E编码）。加利福尼亚州各年龄日的居民人数是根据美国人口普查对加利福尼亚州按年龄中点（1996 - 1998年）估算的人口数来估计的。发生率按3个月间隔计算。我们将E编码分为主要类别，这些类别与幼儿发育相关的特定伤害风险特别相关。分类考虑了0至3岁儿童的身体、运动、行为和认知发育里程碑。
共有23173起伤害事件；636起导致死亡。0至3岁儿童的总体年发生率为371/100,000。从3至5个月开始，伤害总体发生率随着年龄增长迅速上升，在15至17个月达到峰值。计算得出的每个单一年龄的平均伤害发生率并未反映出1岁以下、1岁和2岁儿童按季度年龄划分的发生率变化及最高发生率。伤害的主要主要原因按降序排列为跌倒、中毒、交通、异物和火灾/烧伤。跌倒这一主要类别的总体发生率超过中毒（第二大伤害原因）两倍。在每种主要伤害原因中都检测到了与年龄相关的差异。对于0至12个月的儿童，每3个月期间特定伤害的主要原因各不相同：从高处跌落（0 - 2个月）、殴打（3 - 5个月）、从家具上跌落（6 - 8个月）和非气道异物（9 - 11个月）。热液和蒸汽伤害是12至17个月儿童的主要特定原因。药物中毒是18至35个月所有年龄组伤害的主要特定原因，且超过其他物质中毒。行人伤害是36至47个月所有年龄组伤害的主要特定原因。从家具上跌落是3至47个月跌落特定原因发生率最高的。从楼梯上跌落的发生率在6至8个月和9至11个月达到峰值。从建筑物上跌落的发生率在24至26个月最高。药物中毒在21至23个月达到峰值，但其他物质中毒在15至17个月达到峰值。在本研究的年龄范围内，机动车乘客伤害发生率相当稳定。行人伤害发生率从12至14个月开始上升，到15至17个月时是机动车乘客伤害发生率的两倍。异物伤害在9至11个月有明显峰值。殴打和忽视发生率在0至2个月和3至5个月的婴儿中最高。浴缸溺水在6至11个月有一个狭窄峰值。其他溺水在12至14个月达到峰值，并一直保持高位直至33至35个月。
我们偏离了通常的E编码分组方式，设计了能够反映与年龄相关发育特征的分组。幼儿按狭窄年龄组划分的发生率差异可能与发育成就有关，而发育成就会使儿童面临特定伤害原因的风险。我们发现按3个月间隔年龄分组的发生率和主要伤害原因存在显著差异，而按年龄年分析则掩盖了这些差异。15至17个月的儿童在15岁之前总体伤害发生率最高。这与诸如独立活动、探索行为和手口活动等发育成就相吻合。儿童能够接触到危险，但尚未发展出认知危险意识和避免技能。一个显著的发现是0至5个月婴儿中殴打伤害发生率很高，这表明需要在围产期关注潜在的儿童虐待问题。中毒是第二大主要伤害原因；超过三分之二是药物中毒。文化因素可能会影响对药物的看法、储存习惯、使用中毒控制系统电话咨询以及幼儿中毒风险。行人伤害发生率在12至14个月和15至17个月之间翻倍，并且在15至47个月的每个3个月间隔中都超过机动车乘客伤害发生率。一般而言，行人伤害尚未得到足够关注，在4岁以下儿童的伤害预防咨询中肯定也未得到足够重视。应在1岁之前纳入针对行人伤害的预期性指导。有效的策略必须基于儿童伤害的流行病学。儿科医生和其他儿科医疗服务提供者处于为患者提供伤害预防服务的独特地位。将伤害预防信息融入儿童发育评估背景下是一种策略。这些数据还可用于补充性的儿童伤害预防策略，如针对虐待和忽视儿童的高危家庭的早期干预项目、媒体和宣传活动、公共政策以及环境和产品设计。
