Aust. Paediatr. J. (1979), 15:255-259
Accidents in the first five years of life: A report from the Dunedin Multidisciplinary Child Development Study J. LANGLEY', J. DODGEZand P. A. SILVA3.
The Dunedin Multidisciplinary Child Development Study, Department of Paediatrics & Child Health, University of O m 0 Medical School, Dunedin, New Zealand.
Langley, J., Dodge, J. and Silva, P. A. (1979). Aust. Paediatr. J., 15, 255-259. Accidents in the first 5 years of life: a report from the Dunedin Multidisciplinary Child Development Study. As part of a longitudinal study of child development, information was collected on all accidents during the first 5 years of life that required medical attention. Four hundred and eighty six of a sample of 991 children had 729 accidents in the first 5 years of life. Sixteen per cent of the children had two or more accidents. Ten per cent of the accidents resulted in a hospitalisation. The more common accidents, those involving falls, POiSOnS, sharp objects, foreign bodies, being caught between objects, and hot substances or objects are described and discussed. We suggest that many accidents could have been prevented. A necessary prerequisite for improved prevention measures is the collection and study of detailed information on the circumstances surrounding accidents. A case is made for an organisation with primary responsibility to monitor the safety of consumer products.
INTRODUCTION Poisonings and burns have been the focus of most studies on accidents among New Zealand children (Meade, 1964; Holdaway, 1972; Allingham, 1975; Wright-St Clair, 1975; Shaw, 1977). There have been only two studies which examined all types of accidents among children. Findlay's (1970) study of domestic accidents represents the most comprehensive source of statistics on accidents among young children in New Zea.land. That report described all domestic accidents which required admission to hospital for the year 1966. The other study (Silva eta/., 1978) differed from Findlay's (1970) in a number of respects. It was longitudinal as opposed to cross-sectional and included non-domestic accidents. It focussed on allaccidents which resulted in medical treatment being sought from a doctor as opposed to only those which resulted in a visit to a hospital. This paper describes an extension of the Silva e t a/. (1978) study. The previous paper described accidents experienced by the sample during the first 3 years of life; this paper describes accidents experienced during the first 5 years. Langley, Dodge, and Silva (1979a) described the accidents and resulting injuries in detail. The purpose of this paper is to summarise the main findings of that report and to outline some of the implications for the future prevention of accidents to children. METHOD The sampfe consisted of 991 five year old children drawn from all surviving metropolitan infants who were born at
Received ~ u l y 21979 . 1. Principal Investigator
2.Principal Investigator 3. Executive Director
Dunedin's one maternity hospital (Queen Mary) between 1 April 1972 and 31 March 1973. Mothers were asked to provide information on all accidents during the first 5 years of life which resulted in medical attention being sought. Information was obtained on the nature of the accident and injury, where the accident occurred, the age of the victim, and whether a hospital admission resulted. The Supplementary Classification of External Causes of Injury and Poisonings of the International Classification of Disease (WHO, 1977) was used to classify the accidents. Further information on the methodology and sample is given in Silva (1979). RESULTS Four hundred and eighty six (49%) of the 991 children surveyed had 729 accidents which required medical treatment in the first 5 years of life. Sixteen per cent of the children surveyed had had two or more accidents. Seventysix (10.4%) of the accidents resulted in the child being admitted to hospital. Eighty per cent of the accidents occurred in or around the home. Table I describes the type of accident by age. Table I1 shows the incidence of the more common accidents. The remainder of this paper will be confined to describing and discussing the accidents in Table II. Falls: Tables I and I1 show that falls were the most common type of accident in all age groups. A fall from one level to another was the most common. There were a great variety of falls within this category. The two most common were: falls from chair or bed (21) and stairs or steps (18). The most common injuries resulting from a fall were wounds (%yo), fractures (30%), and intracranial injury (17%). The head was the most common site of injury. Poisonings: Approximately 11% of the children had been involved in a poisoning incident by their fifth birthday.
AUSTRALIAN PAEDlATRlC JOURNAL
256
TABLE I Type o f Accident By Age (N=991 children for the first five years of life) T y p e o f Accident
Less than 1
1
-
Age (years) 2- 3- 4-5
Falls
28
47
57
47
Poisoning b y drugs, medicaments a n d biologicals
14
23
19
9
Not Stated
Total
%*
189
26
3
17
Poisoning b y other solid a n d l i q u i d substances, gases and vapours
14
22
16
5
Cutting a n d piercing instruments o r objects
15
26
32
27
106
15
Foreign bodies
12
15
13
11
53
7
7
12
16
8
47
6
H o t substance o r object, caustic o r corrosive material and steam
14
9
7
6
43
6
Striking against o r struck b y objects o r persons
6
7
14
11
39
5
M o t o r vehicle traffic
1
-
4
14
19
3
Natural and environmental factors
3
3
5
4
16
2
Struck b y falling object
3
3
3
5
14
2
Other road vehicle
-
3
4
3
11
2
Overexertion and strenuous movements
3
3
3
1
10
1
Fire and flames
2
-
1
-
M o t o r ve hicI e n o n -traffic
-
2
-
-
Explosive material
-
-
-
2
Electric current
1
-
1
-
Water transport
-
-
-
1
Ill defined
1
2
4
3
10
1
N o t specified
8
9
12
5
36
5
132
186
211
162
729
100
Caught in o r between object
Total
31
2
7
Percentage of all accidents
Poisonings accounted for 17% of all the accidents. Eight children were poisoned twice and one child had been poisoned 6 times. Seventeen per cent were admitted to hospital. All except five of the poisonings occurred in the home. Table I shows that poisonings reached their peak in the 2-year-old age group (36% of all the poisonings) and therapeutic substances were involved in half of the cases. A breakdown of other solid and liquid substances showed that 21 were household cleansers and 15 were petroleum products (e.g. kerosene).
Accidents Involving Cutting and Piercing Instruments or Objects A wide variety of objects were involved in this category which had an incidence rate of 9.4%. Sharp edges of furniture and glass were the most frequently mentioned. Accidents Involving Foreign Bodies Accidents involving foreign bodies were the fourth most common type of accidents (Tables I and 11). The inhalation and ingestion of objects other than food which caused
257
ACCIDENTS IN THE FIRST FIVE YEARS OF LIFE
TABLE II Incidence of Common Accidents (N=991 children for the first five years of IifeJ
Type of Accident
Falls Poisonings Cutting and piercing instruments o r objects Foreign bodies Caught i n or between object Hot substance o r object
N. Children
% Incidence in SamDle
160 108
16.1 10.9
93 48 45 40
9.4 4.8 4.5 4.0
obstruction of the respiratory tract was the most common (N=25). Typical objects were coins, buttons, stones, marbles, and toy wheels. Accidents Involving Being Caught In or Between Objects Four and a half per cent had been involved in this type of accident. Sixty eight per cent (32) of these accidents involved fingers being caught in doors. Another 5% involved washing machine wringers. Accidents Involving Hot Substances or Objects Hot liquids were involved in half of the accidents, a quarter involved hot or boiling water. The remaining 21 accidents involved a wide variety of objects, but electric heating appliances were the most common (8).
DISCUSS I0N Falls Langley and Silva (1979a)showed that falls are the most common accidents experienced by children of all ages. This has been confirmed in a number of overseas studies (e.g. Clarke and Keogh, 1975; Lopez and Rennie, 1969; Manheimer et a / . , 1967;and Scougall, 1975).Despite their high incidence and the severity of the resultant injuries, there have been no detailed studies of accidental falls among New Zealand children. The focus of research has been on poisonings (Langley e t a / . , 1979b). There is little evidence on the effectiveness of measures which are designed to prevent falls among children. One notable exception is a programme reported by Speigal and Lindman (1977)which aimed to reduce the incidence of children falling from windows. A major component of the programme was the provision of free, easily installed window guards to families with young children living in high risk areas. A significant reduction in falls resulted, particularly in one area where reported falls declined by 50% from 1973 to 1975. A number of other studies have suggested that attention to hazardous aspects of the environment could result in a reduction of accidental falls. Sheldon (1960)examined the case histories of 500 falls among 202 persons over 50. H e found that 224 of the falls were primarily due to environmental factors. Miller and Esmay (1958),in a study of stairway falls, found that slipping was responsible for twice as many falls as any other single cause and many falls were related to slipping on worn rubber mats. The investigation showed that 75% of the stairways were not uniform in treads or risers and 56% were inadequately lit.
Kravitz e t a / . (1969)in a study of accidental falls by infants from elevated surfaces, suggested that many of the falls could have been prevented by more attention to design features of cribs and dressing tables, and education of mothers on the dangers of falls in infancy. There are many measures which might reduce the incidence of falls or resulting injuries. These include handrails on stairs, anti-skid material on walking surfaces, metal strips for the edges of carpets, guard rails around elevated surfaces, w o o d c h i p s u n d e r p l a y g r o u n d equipment, and ramps in place of steps. Despite the evidence suggesting that many falls may be prevented, there has been no prevention campaigns on this subject in New Zealand. This is in marked contrast to the efforts made to prevent motor vehicle accidents which have included defensive driving courses, drunken driver "blitzes", and traffic education in the schools. In view of their high incidence, the severity of resulting injuries, the lack of in-depth investigations, and the potential for prevention; falls among New Zealand children warrant further investigation. Poisonings Poisonings have been the most common subject of childhood accident research in New Zealand (Langley etal., 1979b) and a common subject of preventive programmes. Despite these efforts, poisonings were ranked as the second most common type of accident among the under fives. The peak incidence around 2 years has also been demonstrated by other New Zealand studies (Allingham, 1975;Findlay, 1970;Meade, 1964;and Wright-St Clair, 1975) and several overseas investigations (e.g. Cann e f a/., 1960; Clements et a/., 1963; McFarland and Moore, 1971; Stallones and Corsa, 1961;and Werhle e t a l . , 1960).Future educational programmes should stress the susceptibility of this age group. The effectiveness of child resistant containers in the prevention has been well documented (e.g. Done et a / . , 1971;Scherz e t a / . , 1969;and Sibert, 1977).A t present the New Zealand Food and Drug Regulations (1973)require a limited range of therapeutic drugs to be packaged this way. In view of the high incidence of poisonings, consideration should be given to extending the coverage of these regulations to other therapeutic substances and toxic household substances. Other countermeasures may need to be developed as Allingham (1975)and Jackson e t a / . ,(1968)have shown that many poisonings occur when the substance is still in use. Further detailed investigation into poisoning incidents should suggest other countermeasures. Accidents Involving Hot Substances or Objects Although not large in number, burns are important because of their serious sequelae. Some burns are permanently disfiguring and require prolonged hosp,italisation and specialised treatment. Burned children and their mothers are especially liable to emotional disturbances (Gladstone, 1972; Long and Cope, 1961 ; Martin 1970;Woodward 1959;and Woodward and Jackson,
1961). This study shows that scalds were the most common cause of burns. Previous New Zealand and overseas studies have shown that hot liquids are the major cause of
AUSTRALIAN PAEDlATRlC JOURNAL
burn injuries among preschoolers (Findlay, 1970; Holdaway, 1972; Biggs and Clarke, 1964; Clarke and Lerner, 1978; Jay e t a / . , 1977; Meyer e t a / . ,1963; Savage and Leitch, 1972; Smith, 1969; Stitz, 1972; Thomson and Shore, 1971; Waller and Manheimer, 1964). Many accidents resulting in burns can be prevented. Sorenson (1974) showed that the fitting of a safety lock to self-service laundry machines, the use of an unbreakabe female plug on vacuum cleaners, and the redesign of coffee filters resulted in dramatic reductions in the number of burns associated with these products. In New Zealand, safety devices have been designed which are intended to decrease the incidence of scalding accidents. In particular, there is a "cage type" of electric jug restraint and a perimeter guard for electric ranges. Langley and Silva (1979b), in a survey of retailers in Dunedin, New Zealand, showed tha these devices were not readily available. The reason for this is unknown. It may reflect a low demand. This requires further study if we are to be effective in such preventive measures. Apart from actually reducing the number of scaldings, we can attempt to reduce the severity. Feldman, Schaller, Feldman, and McMillan (1978), after conducting a study of tap water scalds in children, concluded that the severity of the burns could have been reduced by limiting household water temperatures to less than 52" Centigrade. Lowering the temperature setting on the hot water supply is an attractive preventive measure. It generalises to a wide variety of accident situations and results in immediate savings for the, householders and conservation of energy resources. In view of the relatively low incidence of scalding accidents and the apparent general apathy of the public, a campaign which stressed the savings may be more effective than one which focussed on the possibility of injury. Accidents Involving Cutting and Piercing Instruments or Objects The elimination of recognised hazards in the design of products is one method of preventing injury. This study suggests that i f sharp edges of furniture were eliminated, there would be a reduction in the number of wounds experienced by preschool children. The design of glass can also influence the number of accidents. Oliver and Lawson (1979) demonstrated that the use of safety glazing (laminated glass or toughened glass in new installations and the application of a plastic film to existing glass) in doors, sidelights, windows, and shower screens can decrease the number and severity of lacerations. Accidents Involving Being Caught Between Objects The severity of injuries involving doors might be reduced by fitting constraining devices to doors which do not allow them to be shut suddenly. A reduction of the number of accidents may require a departure from the conventional door mounted on hinges. Sliding doors are one possibility and also increases the floor space of the room, allowing increased flexibility in furniture arrangement. Another, more radical means of reducing this hazard may be the use of 'rubber flap' type doors similar to those used in factories. The introduction of semi automatic and automatic washing machines has reduced the use of wringer type machines. However, wringer type machines can still be purchased and many are still in use. The majority of these
machines have a pressure release arm on both sides of the machine. Parents should be informed about this safety feature. Accidents Involving Foreign Bodies The frequency was fairly uniform throughout the five age groups (Table I). Jones (1975) reported that the circumstances surrounding some of these accidents may change as the child gets older. Infants and toddlers tend to explore their environment by placing objects in their mouth. Older children place objects in their mouth during play without intending to swallow them but may do so if they laugh suddenly, accidentally fall, or are slapped on the back. From an engineering point of view, prevention appears difficult and educational programmes would appear to be the only immediately obvious preventive strategy. The adoption of safety standards similar to Australian Standard AS1647, which deals with safety requirements of children's toys, could also reduce the incidence of accidents. Conclusion Many of the accidents described could h a w been prevented or the severity of the injury reduced. In a nLmber of instances, similar strategies to those quoted can not be adopted until more detailed information is collected on the circumstances under which specific types of accidents occurred. Despite this lack of information, some measures, both educational and engineering, can b e taken immediately to reduce the incidence of accidents andlor injury. One example could be the lowering of thermostat settings on hot water cylinders. Consumer products were involved in many of the accidents and these could have been reduced or eliminated if more attention had been paid to the potentially hazardous aspects of these products. In-depth investigations into accidents can provide information on a limited number of products. Because investigations focus on the more common accidents, a considerable number of injuries occur before action is taken. Thus, products need to be monitored with a view to identifying their potentially hazardous features. There are a number of statutory and other bodies in New Zealand which are concerned with various safety aspects of products. The New Zealand Standards Association draws up safety standards for various products. In some cases the standards received statutory backing through regulations made under various Acts of Parliament. However, few consumer products are covered by safety standards and for many that are, only some of the salient characteristics are specified. An additional problem is that production of a standard is a lengthy process. Another organisation concerned with consumer safety is. the New Zealand Consumers Institute. This organisation has little power to translate its recommendations into law; it relies solely on persuasion and publicity in its attempts to ensure the withdrawal of dangerous products. To be effective in reducing hazards, an organisation is needed whose primary objective is to monitor the safety of consumer products. Such an organisation needs statutory powers to ensure that proven hazards are rapidly eliminated. The value of such a statutory organisation has been demonstrated in Great Britain (Department of Prices and Consumer Protection - Consumer Safety Unit), the
ACCIDENTS IN THE FIRST FIVE YEARS OF LIFE
United States (Consumer Product Safety Commission), and Sweden (The National Swedish Board for Consumer Policies). In view of the high incidence of accidents and their adverse sequelae in children, the establishment of such an organisation is a matter of urgency. This would be justified by reducing the suffering and stress caused by preventable accidents and the reduction of the cost of medical treatment. AC KN 0 W LE DG EM ENTS The Dunedin Multidisciplinary Child Development Study is supported by the Medical Research Council of New Zealand, the Departments of Education and Health, and involves several departments of the University of Otago. Much of the data is gathered by volunteer workers from the Dunedin community. The authors are indebted to the many people whose contribution makes this ongoing study possible. The accidents research is supported by a grant from the Accident Compensation Commission.
REFERENCES Allingham, P. M. (1975), Accidental poisoning in children, N Z. Med. J.. 61: 235. Biggs, J. S.C. and Clarke, A. M (1964). Burns in children: a five-year survey at a burns unit. Med. J. Aust. 1: 787. Cann. H . M., Iskrant, A. P., and Neyman. D. S. (1960), Epidemiologic aspects of poisoning accidents. Am. J. Public Health. 50: 1914. Clarke. M., and Keogh, J. (1975). Community first aid and accident prevention falls and Cuts. In accident Prevention and Community First Aid. NSW. Harrison, G. A. p.614. Clarke, W. R.. and Lerner. D. (1978). Regional burn survey; two years of hospitalised burned patients in Central New York. J Trauma. 18: 524. Clements, F. W., Rowlands, J. 8 , Southby. R., and Veuthey. P. (1963), An analysis at death; accidental poisonings in children aged under 5 years, Med. J. Aust. 2: 649. Done. A. K.. Jung. A. L., Wood. M. C.. and Klamber. M. A . (1971). Evaluations of safety packaging for the protection of children, Pediatrics, 46: 613. Feldman. K. W., Schaller. R . T.. Feldman, J. A,. and McMillan. M. (1978), Tap water scald burns in children, Pediatrics, 62: 1. Findlay, J. P. (1970). Domestic Accidents. N.Z. Department of Health - Special Report 35. Wellington, Government Printer. Gladstone, A . (1972), The burning and healing of children, Psychiatry, 35: 57. Holdaway. M. D. (1972). Accidental burns and poisoning of children in the home, NZMed. J., 75: 280. Jackson, R . G.. Walker, J. H , and Wynne. N. A. (1968). Circumstances of accidental poisoning in childhood Br. Med. J., 4: 245. Jay, K. M . Bartlett. R . H . . Danet. R . . and Allyn, P. A. (1977). Burn epidemiology: A basis for burn prevention, J. Trauma. 17: 943. Jones, P. G. (1975). Swallowed foreign bodies in childhood. In Accident Prevention andcommunity First Aid. NSW. Harrison, G. A. p . 652 Kravitz, H.. Driessen. G.. Gomberg, R., and Korach, A. (1969), Accidental fall from elevated surfaces in infants from birth to one year of age, Pediatrics. 44: 869. Langley. J. D.. and Silva. P A (1979a). Falls - the most common accident experienced by New Zealand children. (In press) Langley. J. D.. and Silva. P. A. (1979b). The availability of three safety devices in Dunedin. (In press) Langley. J. D., Dodge, J., and Silva, P. A. (1979a). Accidents among Dunedin children. A report to the Accident Compensation Commission. Unpublished report from the Dunedin Multidisciplinary Child Development Study, Box 913. Dunedin. Langley. J D , Dodge, J.. and Silva. P. A. (1979b). Domestic accidents among New Zealand children: What is known and what needs to be known. In Proceedings o f MRC Accident a n d Rehabilitation Symposium. Wellington. 1979. Long, R. T., and Cope, 0. (1961). Emotional problems of burned children. N. Engl J. Med., 264: 1121
259
Lopez, W. A.. and Rennie. T. F. (1969). A survey o f accidents to children aged under 15 years seen at a district hospital in Sydney in one year, Med. J. Aust.. 1: 806. McFarland. R . A.. and Moore, R. C. (1971), Childhood accidents and injuries. In Behavioural Science in Pediatric Medicine p. 350-396 Talbot. N. B.. Kayon. J.. and Eisenberg. L.. Toronto, W. B. Saunders Co. Manheimer, D. I., Dewey, J.. Mellinger, G. D., and Corsa, L. (1967). 50.000child years of accidental injuries, Public Health Reports, 81: 519. Martin, H. L. (1970). Parent's and children's reactions to burns and scalds in children, Brit. J. Med. Psychoi., 43: 183. Meade, J. A. (1964), Poisoning young New Zealanders. NZ Med. J., 83: 640. Meyer, R. J., Roelfs, A. A,, Bluestone. J., and Redmond, S. (1963) Accidental injury to the preschool child, J. Pedlatr., 63: 95. Miller, J. A.. and Esmay, M. L. (1958), Stairway falls. Home Safety Review. 16: 23. Oliver, T. I. and Lawson. J. S. (1979), Glass laceration injuries and prevention, Med. J. Aust., 1: 190. Savage, J. P. and Leitch, I. 0. W. (19721, Childhood burns: a sociological survey and injury causation. Med. J. Aust.. 1: 1337. Scherz. R . G., Latham. G. H.. and Stracner. C. E. (1969), Child resistant containers can prevent poisonings. Pediatrics. 4 3 84. Scougall, J. S. (1975), Accidents in the home - paediatric common fractures. In Accident Prevention a n d Community First Aid, NSW. Harrison. G. A. pp. 614-617. Shaw. M. T. M. (1977). Accident poisoning in children: a psychological study, N Z Med. J.. 85: 269. Sheldon, J. A. (1960). On the natural history of falls in old age. Er. Med. J.. lS60: 1685. Sibert. J. R. (1977). Child resistant packaging and accidental child poisoning, Lancet, Aug. 6: 289-290. Silva, P. A. (1979), The Dunedin Multidisciplinary Child Development Study. Selected publications 1973-1978. Available from the University of Otago Medical Library, Dunedin. New Zealand. Silva. P. A., Buckfield. P. M.. Spears, G. F., and Williams, S. (1978), Poisoning, burns, and other accidents experienced by a thousand Dunedin three year olds, NZ Med. J., 67: 242. Smith, E. I.(1969). The epidemiology of burns. The cause and control of burns in children, Pediatrics. 44: 821. Sorenson. B. (1976). Prevention of burns and scalds in a developed country, J. Trauma. 16: 249. Spiegel. C. N. and Lindaman. F. C. (1977). Children can't fly: a programme to prevent childhood morbidity and mortality from window falls, Am. J. Public Health, 67: 1143. Stallones, R. A. and Corsa, L. (1961), Epidemiology of childhood accidents in two California counties, Public Health Reports, 76: 25. Stltz. R . W. (1972), Burns in children: a three year study, Med. J. Aust. 1: 357. Thomson. H . G. and Shore, 8. (1971). The bathtub: a pediatric disaster, Can. J. Surg.. 14: 399. Waller, J. A. and Manheimer. D. I. (1964), Non fatal burns of children in a well defined urban population, J. Pediatr., 64: 863. Werhle, P. F., Day, P. A,, Whalen, J. P., Fitzgerald. J. K.. and Harris. V. G. (19601, Epidemiology of accidental poisoning in an urban population 11, prevalence and distribution, Am. J. Public Health, 50: 1925. Woodward, J. M. (1959), Emotional Disturbances of burned children, Br. Med. J.. 1: 1009-1013. Woodward, J. M and Jackson, D. (1961), Emotional reactions in burned children and their mothers, Br. J. ofPtas. Surg., 13: 316. World Health Organisation (1977), tnternational Classification o f Disease, 1975 Revision. WHO, Geneva. Wright-St. Clair. R. E. (1975). Poisoning and overdosage. NZMed. J., 81: 193.
Correspondence to Dr. P. A . Silva, The Dunedin Multidisciplinary Child Development Study, Department of Paediatrics and Child health, University of Otago Medical School, P.O. Box 913, Dunedin, New Zealand.
Accidents in the first five years of life: A report from the Dunedin Multidisciplinary Child Development Study J. LANGLEY', J. DODGEZand P. A. SILVA3.
The Dunedin Multidisciplinary Child Development Study, Department of Paediatrics & Child Health, University of O m 0 Medical School, Dunedin, New Zealand.
Langley, J., Dodge, J. and Silva, P. A. (1979). Aust. Paediatr. J., 15, 255-259. Accidents in the first 5 years of life: a report from the Dunedin Multidisciplinary Child Development Study. As part of a longitudinal study of child development, information was collected on all accidents during the first 5 years of life that required medical attention. Four hundred and eighty six of a sample of 991 children had 729 accidents in the first 5 years of life. Sixteen per cent of the children had two or more accidents. Ten per cent of the accidents resulted in a hospitalisation. The more common accidents, those involving falls, POiSOnS, sharp objects, foreign bodies, being caught between objects, and hot substances or objects are described and discussed. We suggest that many accidents could have been prevented. A necessary prerequisite for improved prevention measures is the collection and study of detailed information on the circumstances surrounding accidents. A case is made for an organisation with primary responsibility to monitor the safety of consumer products.
INTRODUCTION Poisonings and burns have been the focus of most studies on accidents among New Zealand children (Meade, 1964; Holdaway, 1972; Allingham, 1975; Wright-St Clair, 1975; Shaw, 1977). There have been only two studies which examined all types of accidents among children. Findlay's (1970) study of domestic accidents represents the most comprehensive source of statistics on accidents among young children in New Zea.land. That report described all domestic accidents which required admission to hospital for the year 1966. The other study (Silva eta/., 1978) differed from Findlay's (1970) in a number of respects. It was longitudinal as opposed to cross-sectional and included non-domestic accidents. It focussed on allaccidents which resulted in medical treatment being sought from a doctor as opposed to only those which resulted in a visit to a hospital. This paper describes an extension of the Silva e t a/. (1978) study. The previous paper described accidents experienced by the sample during the first 3 years of life; this paper describes accidents experienced during the first 5 years. Langley, Dodge, and Silva (1979a) described the accidents and resulting injuries in detail. The purpose of this paper is to summarise the main findings of that report and to outline some of the implications for the future prevention of accidents to children. METHOD The sampfe consisted of 991 five year old children drawn from all surviving metropolitan infants who were born at
Received ~ u l y 21979 . 1. Principal Investigator
2.Principal Investigator 3. Executive Director
Dunedin's one maternity hospital (Queen Mary) between 1 April 1972 and 31 March 1973. Mothers were asked to provide information on all accidents during the first 5 years of life which resulted in medical attention being sought. Information was obtained on the nature of the accident and injury, where the accident occurred, the age of the victim, and whether a hospital admission resulted. The Supplementary Classification of External Causes of Injury and Poisonings of the International Classification of Disease (WHO, 1977) was used to classify the accidents. Further information on the methodology and sample is given in Silva (1979). RESULTS Four hundred and eighty six (49%) of the 991 children surveyed had 729 accidents which required medical treatment in the first 5 years of life. Sixteen per cent of the children surveyed had had two or more accidents. Seventysix (10.4%) of the accidents resulted in the child being admitted to hospital. Eighty per cent of the accidents occurred in or around the home. Table I describes the type of accident by age. Table I1 shows the incidence of the more common accidents. The remainder of this paper will be confined to describing and discussing the accidents in Table II. Falls: Tables I and I1 show that falls were the most common type of accident in all age groups. A fall from one level to another was the most common. There were a great variety of falls within this category. The two most common were: falls from chair or bed (21) and stairs or steps (18). The most common injuries resulting from a fall were wounds (%yo), fractures (30%), and intracranial injury (17%). The head was the most common site of injury. Poisonings: Approximately 11% of the children had been involved in a poisoning incident by their fifth birthday.
AUSTRALIAN PAEDlATRlC JOURNAL
256
TABLE I Type o f Accident By Age (N=991 children for the first five years of life) T y p e o f Accident
Less than 1
1
-
Age (years) 2- 3- 4-5
Falls
28
47
57
47
Poisoning b y drugs, medicaments a n d biologicals
14
23
19
9
Not Stated
Total
%*
189
26
3
17
Poisoning b y other solid a n d l i q u i d substances, gases and vapours
14
22
16
5
Cutting a n d piercing instruments o r objects
15
26
32
27
106
15
Foreign bodies
12
15
13
11
53
7
7
12
16
8
47
6
H o t substance o r object, caustic o r corrosive material and steam
14
9
7
6
43
6
Striking against o r struck b y objects o r persons
6
7
14
11
39
5
M o t o r vehicle traffic
1
-
4
14
19
3
Natural and environmental factors
3
3
5
4
16
2
Struck b y falling object
3
3
3
5
14
2
Other road vehicle
-
3
4
3
11
2
Overexertion and strenuous movements
3
3
3
1
10
1
Fire and flames
2
-
1
-
M o t o r ve hicI e n o n -traffic
-
2
-
-
Explosive material
-
-
-
2
Electric current
1
-
1
-
Water transport
-
-
-
1
Ill defined
1
2
4
3
10
1
N o t specified
8
9
12
5
36
5
132
186
211
162
729
100
Caught in o r between object
Total
31
2
7
Percentage of all accidents
Poisonings accounted for 17% of all the accidents. Eight children were poisoned twice and one child had been poisoned 6 times. Seventeen per cent were admitted to hospital. All except five of the poisonings occurred in the home. Table I shows that poisonings reached their peak in the 2-year-old age group (36% of all the poisonings) and therapeutic substances were involved in half of the cases. A breakdown of other solid and liquid substances showed that 21 were household cleansers and 15 were petroleum products (e.g. kerosene).
Accidents Involving Cutting and Piercing Instruments or Objects A wide variety of objects were involved in this category which had an incidence rate of 9.4%. Sharp edges of furniture and glass were the most frequently mentioned. Accidents Involving Foreign Bodies Accidents involving foreign bodies were the fourth most common type of accidents (Tables I and 11). The inhalation and ingestion of objects other than food which caused
257
ACCIDENTS IN THE FIRST FIVE YEARS OF LIFE
TABLE II Incidence of Common Accidents (N=991 children for the first five years of IifeJ
Type of Accident
Falls Poisonings Cutting and piercing instruments o r objects Foreign bodies Caught i n or between object Hot substance o r object
N. Children
% Incidence in SamDle
160 108
16.1 10.9
93 48 45 40
9.4 4.8 4.5 4.0
obstruction of the respiratory tract was the most common (N=25). Typical objects were coins, buttons, stones, marbles, and toy wheels. Accidents Involving Being Caught In or Between Objects Four and a half per cent had been involved in this type of accident. Sixty eight per cent (32) of these accidents involved fingers being caught in doors. Another 5% involved washing machine wringers. Accidents Involving Hot Substances or Objects Hot liquids were involved in half of the accidents, a quarter involved hot or boiling water. The remaining 21 accidents involved a wide variety of objects, but electric heating appliances were the most common (8).
DISCUSS I0N Falls Langley and Silva (1979a)showed that falls are the most common accidents experienced by children of all ages. This has been confirmed in a number of overseas studies (e.g. Clarke and Keogh, 1975; Lopez and Rennie, 1969; Manheimer et a / . , 1967;and Scougall, 1975).Despite their high incidence and the severity of the resultant injuries, there have been no detailed studies of accidental falls among New Zealand children. The focus of research has been on poisonings (Langley e t a / . , 1979b). There is little evidence on the effectiveness of measures which are designed to prevent falls among children. One notable exception is a programme reported by Speigal and Lindman (1977)which aimed to reduce the incidence of children falling from windows. A major component of the programme was the provision of free, easily installed window guards to families with young children living in high risk areas. A significant reduction in falls resulted, particularly in one area where reported falls declined by 50% from 1973 to 1975. A number of other studies have suggested that attention to hazardous aspects of the environment could result in a reduction of accidental falls. Sheldon (1960)examined the case histories of 500 falls among 202 persons over 50. H e found that 224 of the falls were primarily due to environmental factors. Miller and Esmay (1958),in a study of stairway falls, found that slipping was responsible for twice as many falls as any other single cause and many falls were related to slipping on worn rubber mats. The investigation showed that 75% of the stairways were not uniform in treads or risers and 56% were inadequately lit.
Kravitz e t a / . (1969)in a study of accidental falls by infants from elevated surfaces, suggested that many of the falls could have been prevented by more attention to design features of cribs and dressing tables, and education of mothers on the dangers of falls in infancy. There are many measures which might reduce the incidence of falls or resulting injuries. These include handrails on stairs, anti-skid material on walking surfaces, metal strips for the edges of carpets, guard rails around elevated surfaces, w o o d c h i p s u n d e r p l a y g r o u n d equipment, and ramps in place of steps. Despite the evidence suggesting that many falls may be prevented, there has been no prevention campaigns on this subject in New Zealand. This is in marked contrast to the efforts made to prevent motor vehicle accidents which have included defensive driving courses, drunken driver "blitzes", and traffic education in the schools. In view of their high incidence, the severity of resulting injuries, the lack of in-depth investigations, and the potential for prevention; falls among New Zealand children warrant further investigation. Poisonings Poisonings have been the most common subject of childhood accident research in New Zealand (Langley etal., 1979b) and a common subject of preventive programmes. Despite these efforts, poisonings were ranked as the second most common type of accident among the under fives. The peak incidence around 2 years has also been demonstrated by other New Zealand studies (Allingham, 1975;Findlay, 1970;Meade, 1964;and Wright-St Clair, 1975) and several overseas investigations (e.g. Cann e f a/., 1960; Clements et a/., 1963; McFarland and Moore, 1971; Stallones and Corsa, 1961;and Werhle e t a l . , 1960).Future educational programmes should stress the susceptibility of this age group. The effectiveness of child resistant containers in the prevention has been well documented (e.g. Done et a / . , 1971;Scherz e t a / . , 1969;and Sibert, 1977).A t present the New Zealand Food and Drug Regulations (1973)require a limited range of therapeutic drugs to be packaged this way. In view of the high incidence of poisonings, consideration should be given to extending the coverage of these regulations to other therapeutic substances and toxic household substances. Other countermeasures may need to be developed as Allingham (1975)and Jackson e t a / . ,(1968)have shown that many poisonings occur when the substance is still in use. Further detailed investigation into poisoning incidents should suggest other countermeasures. Accidents Involving Hot Substances or Objects Although not large in number, burns are important because of their serious sequelae. Some burns are permanently disfiguring and require prolonged hosp,italisation and specialised treatment. Burned children and their mothers are especially liable to emotional disturbances (Gladstone, 1972; Long and Cope, 1961 ; Martin 1970;Woodward 1959;and Woodward and Jackson,
1961). This study shows that scalds were the most common cause of burns. Previous New Zealand and overseas studies have shown that hot liquids are the major cause of
AUSTRALIAN PAEDlATRlC JOURNAL
burn injuries among preschoolers (Findlay, 1970; Holdaway, 1972; Biggs and Clarke, 1964; Clarke and Lerner, 1978; Jay e t a / . , 1977; Meyer e t a / . ,1963; Savage and Leitch, 1972; Smith, 1969; Stitz, 1972; Thomson and Shore, 1971; Waller and Manheimer, 1964). Many accidents resulting in burns can be prevented. Sorenson (1974) showed that the fitting of a safety lock to self-service laundry machines, the use of an unbreakabe female plug on vacuum cleaners, and the redesign of coffee filters resulted in dramatic reductions in the number of burns associated with these products. In New Zealand, safety devices have been designed which are intended to decrease the incidence of scalding accidents. In particular, there is a "cage type" of electric jug restraint and a perimeter guard for electric ranges. Langley and Silva (1979b), in a survey of retailers in Dunedin, New Zealand, showed tha these devices were not readily available. The reason for this is unknown. It may reflect a low demand. This requires further study if we are to be effective in such preventive measures. Apart from actually reducing the number of scaldings, we can attempt to reduce the severity. Feldman, Schaller, Feldman, and McMillan (1978), after conducting a study of tap water scalds in children, concluded that the severity of the burns could have been reduced by limiting household water temperatures to less than 52" Centigrade. Lowering the temperature setting on the hot water supply is an attractive preventive measure. It generalises to a wide variety of accident situations and results in immediate savings for the, householders and conservation of energy resources. In view of the relatively low incidence of scalding accidents and the apparent general apathy of the public, a campaign which stressed the savings may be more effective than one which focussed on the possibility of injury. Accidents Involving Cutting and Piercing Instruments or Objects The elimination of recognised hazards in the design of products is one method of preventing injury. This study suggests that i f sharp edges of furniture were eliminated, there would be a reduction in the number of wounds experienced by preschool children. The design of glass can also influence the number of accidents. Oliver and Lawson (1979) demonstrated that the use of safety glazing (laminated glass or toughened glass in new installations and the application of a plastic film to existing glass) in doors, sidelights, windows, and shower screens can decrease the number and severity of lacerations. Accidents Involving Being Caught Between Objects The severity of injuries involving doors might be reduced by fitting constraining devices to doors which do not allow them to be shut suddenly. A reduction of the number of accidents may require a departure from the conventional door mounted on hinges. Sliding doors are one possibility and also increases the floor space of the room, allowing increased flexibility in furniture arrangement. Another, more radical means of reducing this hazard may be the use of 'rubber flap' type doors similar to those used in factories. The introduction of semi automatic and automatic washing machines has reduced the use of wringer type machines. However, wringer type machines can still be purchased and many are still in use. The majority of these
machines have a pressure release arm on both sides of the machine. Parents should be informed about this safety feature. Accidents Involving Foreign Bodies The frequency was fairly uniform throughout the five age groups (Table I). Jones (1975) reported that the circumstances surrounding some of these accidents may change as the child gets older. Infants and toddlers tend to explore their environment by placing objects in their mouth. Older children place objects in their mouth during play without intending to swallow them but may do so if they laugh suddenly, accidentally fall, or are slapped on the back. From an engineering point of view, prevention appears difficult and educational programmes would appear to be the only immediately obvious preventive strategy. The adoption of safety standards similar to Australian Standard AS1647, which deals with safety requirements of children's toys, could also reduce the incidence of accidents. Conclusion Many of the accidents described could h a w been prevented or the severity of the injury reduced. In a nLmber of instances, similar strategies to those quoted can not be adopted until more detailed information is collected on the circumstances under which specific types of accidents occurred. Despite this lack of information, some measures, both educational and engineering, can b e taken immediately to reduce the incidence of accidents andlor injury. One example could be the lowering of thermostat settings on hot water cylinders. Consumer products were involved in many of the accidents and these could have been reduced or eliminated if more attention had been paid to the potentially hazardous aspects of these products. In-depth investigations into accidents can provide information on a limited number of products. Because investigations focus on the more common accidents, a considerable number of injuries occur before action is taken. Thus, products need to be monitored with a view to identifying their potentially hazardous features. There are a number of statutory and other bodies in New Zealand which are concerned with various safety aspects of products. The New Zealand Standards Association draws up safety standards for various products. In some cases the standards received statutory backing through regulations made under various Acts of Parliament. However, few consumer products are covered by safety standards and for many that are, only some of the salient characteristics are specified. An additional problem is that production of a standard is a lengthy process. Another organisation concerned with consumer safety is. the New Zealand Consumers Institute. This organisation has little power to translate its recommendations into law; it relies solely on persuasion and publicity in its attempts to ensure the withdrawal of dangerous products. To be effective in reducing hazards, an organisation is needed whose primary objective is to monitor the safety of consumer products. Such an organisation needs statutory powers to ensure that proven hazards are rapidly eliminated. The value of such a statutory organisation has been demonstrated in Great Britain (Department of Prices and Consumer Protection - Consumer Safety Unit), the
ACCIDENTS IN THE FIRST FIVE YEARS OF LIFE
United States (Consumer Product Safety Commission), and Sweden (The National Swedish Board for Consumer Policies). In view of the high incidence of accidents and their adverse sequelae in children, the establishment of such an organisation is a matter of urgency. This would be justified by reducing the suffering and stress caused by preventable accidents and the reduction of the cost of medical treatment. AC KN 0 W LE DG EM ENTS The Dunedin Multidisciplinary Child Development Study is supported by the Medical Research Council of New Zealand, the Departments of Education and Health, and involves several departments of the University of Otago. Much of the data is gathered by volunteer workers from the Dunedin community. The authors are indebted to the many people whose contribution makes this ongoing study possible. The accidents research is supported by a grant from the Accident Compensation Commission.
REFERENCES Allingham, P. M. (1975), Accidental poisoning in children, N Z. Med. J.. 61: 235. Biggs, J. S.C. and Clarke, A. M (1964). Burns in children: a five-year survey at a burns unit. Med. J. Aust. 1: 787. Cann. H . M., Iskrant, A. P., and Neyman. D. S. (1960), Epidemiologic aspects of poisoning accidents. Am. J. Public Health. 50: 1914. Clarke. M., and Keogh, J. (1975). Community first aid and accident prevention falls and Cuts. In accident Prevention and Community First Aid. NSW. Harrison, G. A. p.614. Clarke, W. R.. and Lerner. D. (1978). Regional burn survey; two years of hospitalised burned patients in Central New York. J Trauma. 18: 524. Clements, F. W., Rowlands, J. 8 , Southby. R., and Veuthey. P. (1963), An analysis at death; accidental poisonings in children aged under 5 years, Med. J. Aust. 2: 649. Done. A. K.. Jung. A. L., Wood. M. C.. and Klamber. M. A . (1971). Evaluations of safety packaging for the protection of children, Pediatrics, 46: 613. Feldman. K. W., Schaller. R . T.. Feldman, J. A,. and McMillan. M. (1978), Tap water scald burns in children, Pediatrics, 62: 1. Findlay, J. P. (1970). Domestic Accidents. N.Z. Department of Health - Special Report 35. Wellington, Government Printer. Gladstone, A . (1972), The burning and healing of children, Psychiatry, 35: 57. Holdaway. M. D. (1972). Accidental burns and poisoning of children in the home, NZMed. J., 75: 280. Jackson, R . G.. Walker, J. H , and Wynne. N. A. (1968). Circumstances of accidental poisoning in childhood Br. Med. J., 4: 245. Jay, K. M . Bartlett. R . H . . Danet. R . . and Allyn, P. A. (1977). Burn epidemiology: A basis for burn prevention, J. Trauma. 17: 943. Jones, P. G. (1975). Swallowed foreign bodies in childhood. In Accident Prevention andcommunity First Aid. NSW. Harrison, G. A. p . 652 Kravitz, H.. Driessen. G.. Gomberg, R., and Korach, A. (1969), Accidental fall from elevated surfaces in infants from birth to one year of age, Pediatrics. 44: 869. Langley. J. D.. and Silva. P A (1979a). Falls - the most common accident experienced by New Zealand children. (In press) Langley. J. D.. and Silva. P. A. (1979b). The availability of three safety devices in Dunedin. (In press) Langley. J. D., Dodge, J., and Silva, P. A. (1979a). Accidents among Dunedin children. A report to the Accident Compensation Commission. Unpublished report from the Dunedin Multidisciplinary Child Development Study, Box 913. Dunedin. Langley. J D , Dodge, J.. and Silva. P. A. (1979b). Domestic accidents among New Zealand children: What is known and what needs to be known. In Proceedings o f MRC Accident a n d Rehabilitation Symposium. Wellington. 1979. Long, R. T., and Cope, 0. (1961). Emotional problems of burned children. N. Engl J. Med., 264: 1121
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Lopez, W. A.. and Rennie. T. F. (1969). A survey o f accidents to children aged under 15 years seen at a district hospital in Sydney in one year, Med. J. Aust.. 1: 806. McFarland. R . A.. and Moore, R. C. (1971), Childhood accidents and injuries. In Behavioural Science in Pediatric Medicine p. 350-396 Talbot. N. B.. Kayon. J.. and Eisenberg. L.. Toronto, W. B. Saunders Co. Manheimer, D. I., Dewey, J.. Mellinger, G. D., and Corsa, L. (1967). 50.000child years of accidental injuries, Public Health Reports, 81: 519. Martin, H. L. (1970). Parent's and children's reactions to burns and scalds in children, Brit. J. Med. Psychoi., 43: 183. Meade, J. A. (1964), Poisoning young New Zealanders. NZ Med. J., 83: 640. Meyer, R. J., Roelfs, A. A,, Bluestone. J., and Redmond, S. (1963) Accidental injury to the preschool child, J. Pedlatr., 63: 95. Miller, J. A.. and Esmay, M. L. (1958), Stairway falls. Home Safety Review. 16: 23. Oliver, T. I. and Lawson. J. S. (1979), Glass laceration injuries and prevention, Med. J. Aust., 1: 190. Savage, J. P. and Leitch, I. 0. W. (19721, Childhood burns: a sociological survey and injury causation. Med. J. Aust.. 1: 1337. Scherz. R . G., Latham. G. H.. and Stracner. C. E. (1969), Child resistant containers can prevent poisonings. Pediatrics. 4 3 84. Scougall, J. S. (1975), Accidents in the home - paediatric common fractures. In Accident Prevention a n d Community First Aid, NSW. Harrison. G. A. pp. 614-617. Shaw. M. T. M. (1977). Accident poisoning in children: a psychological study, N Z Med. J.. 85: 269. Sheldon, J. A. (1960). On the natural history of falls in old age. Er. Med. J.. lS60: 1685. Sibert. J. R. (1977). Child resistant packaging and accidental child poisoning, Lancet, Aug. 6: 289-290. Silva, P. A. (1979), The Dunedin Multidisciplinary Child Development Study. Selected publications 1973-1978. Available from the University of Otago Medical Library, Dunedin. New Zealand. Silva. P. A., Buckfield. P. M.. Spears, G. F., and Williams, S. (1978), Poisoning, burns, and other accidents experienced by a thousand Dunedin three year olds, NZ Med. J., 67: 242. Smith, E. I.(1969). The epidemiology of burns. The cause and control of burns in children, Pediatrics. 44: 821. Sorenson. B. (1976). Prevention of burns and scalds in a developed country, J. Trauma. 16: 249. Spiegel. C. N. and Lindaman. F. C. (1977). Children can't fly: a programme to prevent childhood morbidity and mortality from window falls, Am. J. Public Health, 67: 1143. Stallones, R. A. and Corsa, L. (1961), Epidemiology of childhood accidents in two California counties, Public Health Reports, 76: 25. Stltz. R . W. (1972), Burns in children: a three year study, Med. J. Aust. 1: 357. Thomson. H . G. and Shore, 8. (1971). The bathtub: a pediatric disaster, Can. J. Surg.. 14: 399. Waller, J. A. and Manheimer. D. I. (1964), Non fatal burns of children in a well defined urban population, J. Pediatr., 64: 863. Werhle, P. F., Day, P. A,, Whalen, J. P., Fitzgerald. J. K.. and Harris. V. G. (19601, Epidemiology of accidental poisoning in an urban population 11, prevalence and distribution, Am. J. Public Health, 50: 1925. Woodward, J. M. (1959), Emotional Disturbances of burned children, Br. Med. J.. 1: 1009-1013. Woodward, J. M and Jackson, D. (1961), Emotional reactions in burned children and their mothers, Br. J. ofPtas. Surg., 13: 316. World Health Organisation (1977), tnternational Classification o f Disease, 1975 Revision. WHO, Geneva. Wright-St. Clair. R. E. (1975). Poisoning and overdosage. NZMed. J., 81: 193.
Correspondence to Dr. P. A . Silva, The Dunedin Multidisciplinary Child Development Study, Department of Paediatrics and Child health, University of Otago Medical School, P.O. Box 913, Dunedin, New Zealand.
