www.elsevier.com/locate/jsr Journal of Safety Research 38 (2007) 609 – 612 www.nsc.org Special Report from the CDC Unintentional injuries among infants age 0–12 months☆ Karin A. Mack ⁎, Julie Gilchrist, Michael F. Ballesteros Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 4770 Buford Hwy NE, Mailstop K 63, Atlanta, GA 30341, USA Received 16 August 2007; accepted 16 August 2007 Available online 14 September 2007 The Journal of Safety Research has partnered with the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA, to briefly report on some of the latest findings in the research community. This report is the eighth in a series of CDC articles. Abstract Each year an estimated 328,500 infants age 0–12 months are treated for unintentional injuries in emergency departments (EDs): one infant every minute and a half. The leading cause, overall and by month of age, was fall-related injury. The second leading cause was ‘struck by or against.' The majority of patients were injured at home. Younger infants were more likely to be hospitalized than older ones and more males than females were injured. Gender differences suggest that parenting practices may play a role, but ecological approaches should be considered in an effort to understand the connection between injuries and an infant's developmental stage. National Safety Council and Elsevier Ltd. All rights reserved. Keywords: Unintentional injury; Infants 1. Introduction The leading causes of non-fatal unintentional injury in children aged b15 years treated in emergency departments (EDs) are falls, struck by/against, and overexertion (Ballesteros, Schieber, Gilchrist, Holmgreen, & Annest, 2003). For children b1 year of age, the five leading causes are falls, struck by/against, fire/burn, foreign body, and bite/sting injuries. In addition, Ballesteros et al. (2003) suggest that fall injury rates were highest among infants because of their limited coordination, exploratory nature, and potential home hazards. Although Sudden Infant Death Syndrome has been studied expansively (Overpeck et al., 2002; Sullivan & Barlow, 2001), unintentional injury among infants is reported in the literature largely with product specific studies (e.g., bathtub seats (Thompson, 2003), strollers/shopping carts (Powell, Jovtis, & Tanz, 2002b; Vilke et al., 2004), baby carriers (Pollack-Nelson, 2000), high chairs (Powell, Jovtis, & Tanz, 2002a)). Rates of pediatric injuries in 3-month intervals for children age 0–3 years were reported with California data (Agran et al., 2003) and rates for infants as one group were reported using national data (Powell & Tanz, 2002). Gender differences in rates of unintentional head injury in infants less than 3 months of age were assessed with national data (Greenes, Wigotsky & Schutzman, 2001). National estimates of unintentional injuries by month of age have not ☆ Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the CDC. ⁎ Corresponding author. Tel.: +1 770 488 4389; fax: +1 770 488 1317. E-mail address: email@example.com (K.A. Mack). 0022-4375/$ - see front matter. National Safety Council and Elsevier Ltd. All rights reserved. doi:10.1016/j.jsr.2007.08.001 610 K.A. Mack et al. / Journal of Safety Research 38 (2007) 609–612 Table 1 Disposition of nonfatal unintentional injuries for infants (age 0–12 months) treated in U.S. emergency departments, NEISS-AIP, 2001–2004 Case disposition Age Treated and released Transferred Hospitalized Observation Left w/o being seen Unknown (in months) Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) 1⁎ 91.4 (89.2–93.2) 3.2 (2.1–4.8) 3.7 (2.7–5.3) 0.9 (.4–1.8) 0.7 (.3–1.5) 2 92.3 (89.3–94.5) 2.3 (1.0–5.3) 4.7 (3.3–6.0) 0.2 (.1–.5) 0.4 (.1–1.4) 0.2 (0–1.3) 3 93.7 (90.3–95.9) 2.4 (1.2–4.6) 2.6 (1.4–5.0) 0.2 (.1–.6) 0.9 (.3–2.6) 0.2 (0–1.2) 4 94.1 (91.7–95.9) 2.7 (1.5–4.8) 2.4 (1.3–4.5) 0.3 (.1–1.1) 0.4 (.1–1.4) 5 95.7 (93.6–97.2) 0.7 (.3–1.8) 2.1 (1.1–3.9) 0.7 (.2–2.3) 0.8 (.4–1.7) 6 96.0 (94.5–97.2) 1.1 (.6–2.0) 2.1 (1.2–3.8) 0.1 (0–.3) 0.6 (.3–1.3) 7 94.6 (93.0–95.9) 1.5 (.9–2.5) 2.2 (1.4–3.6) 0.6 (.3–1.3) 0.9 (.4–1.7) 0.1 (0–.8) 8 96.1 (94.6–97.1) 1.1 (.6–2.1) 1.9 (1.2–2.9) 0.2 (.1–.7) 0.7 (.3–1.3) 9 96.0 (94.7–97.1) 0.9 (.5–1.7) 2.1 (1.2–3.6) 0.2 (.1–.6) 0.5 (.3–1.1) 0.2 (0–.6) 10 95.8 (94.8–96.7) 1.4 (.9–2.3) 1.4 (1.0–2.0) 0.4 (.1–.9) 0.9 (.6–1.5) 11 96.6 (95.7–97.4) 1.0 (.6–1.6) 1.4 (.9–2.0) 0.1 (0–.2) 0.8 (.4–1.6) 0.1(0–.4) 12⁎ 96.4 (95.6–97.0) 1.2 (.8–1.7) 1.3 (.8–2.1) 0.4 (.2–.8) 0.8 (.4–1.5) ⁎The one month old group includes infants 0–7 weeks and the 12 month old group includes infants 48–55 weeks. been reported. This study presents national estimates of unintentional injuries for infants by month of age and identifies potential risk factors involved in the injury events. 2. Methods Data come from the 2001–2004 National Electronic Injury Surveillance System—All Injury Program (NEISS-AIP). NEISS- AIP is a stratified probability sample of all hospitals in the United States and its territories having at least six beds and providing 24- hour emergency services. NEISS-AIP is a collaborative effort between the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control and the U.S. Consumer Product Safety Commission. Data elements include cause, gender, diagnosis, disposition, brief narrative, body part injured, location of injury, month/day of ED visit, and age (in months). NEISS-AIP has been described in more detail in previously published reports (Quinlan et al., 1999; Vyrostek, Annest, & Ryan 2004) and more information is available at http://www.cdc.gov/ncipc/wisqars/nonfatal/datasources.htm. Estimates were weighted and analyses conducted using SPSS Complex Samples to account for the sampling design. 3. Results Each year, an estimated 328,500 infants age 0–12 months are treated for unintentional injuries in emergency departments (EDs). The leading cause, overall and by month of age, was fall-related injury. About 168,500 infants are seen in U.S. EDs annually for injuries sustained in unintentional falls. The second leading cause was ‘struck by or against' resulting in an estimated 44,663 visits annually. The majority of patients were injured at home (68.5%; 95% CI = 62.2-74.2%). More than one-fourth (27.1%) of the patients were 12 months of age (95% CI = 21.1-34.1%) compared to 3.5% that were 2 months of age (95% CI = 3.1-4.0%). Nearly one-fifth of the infants could be classified as having a traumatic brain injury (TBI) (17.8%), and 87% of the TBIs resulted from a fall. Younger infants were more likely to be hospitalized than older ones (Table 1). Nearly 4% (3.7%) of infants b 1 month were hospitalized (95% CI = 2.7-5.3%) compared with 1.3% of those 12 months of age (95% CI = 0.8-2.1%). Younger infants were also more likely to be transferred (3.2% of those b 1 month; 85% CI = 2.1-4.8) than older infants (1.2% of those 12 months of age; 95% CI = .8-1.7%) Causes significantly higher among the hospitalized than the non-hospitalized included motor-vehicle crashes, poisoning, inhalation/suffocation, drowning, and foreign body. Overall, the patients were more likely to be male (55.2%; 95% CI = 54.5-55.8%) than female (44.8%; 95% CI = 44.1- 45.5%). Lacerations were slightly higher in males than females. Dislocations were slightly higher in females than males. We observed no other differences in diagnoses by gender. 4. Conclusions Every minute and a half, an infant age 0–12 months is seen in an emergency department for a nonfatal unintentional injury. Falls were the leading cause of unintentional injury for infants at every month of age. These findings corresponded with K.A. Mack et al. / Journal of Safety Research 38 (2007) 609–612 611 previous work (Agran et al., 2003; Ballesteros et al., 2003; Powell & Tanz, 2002). We found that younger infants were more likely to be hospitalized than older ones. The severity of the injury may be part of the reason, but another explanation could be that physicians exercise more caution when treating the youngest infants. Patients were more likely to be male than female. These results are consistent with Greenes et al. (2001). Gender differences at even this young age suggest that parenting practices may play a role (Greenes et al., 2001). Results of this study are subject to limitations. First, NEISS-AIP only includes injuries treated in hospital EDs and excludes those treated in homes, physician offices, or outpatient clinics. Thus, our results are an undercount of the total injuries sustained by infants in the United States. About 31% of children younger than 15 years of age are treated in EDs, and the remaining 69% are treated in primary care offices, surgical specialty offices, medical specialty offices, and outpatient departments (Centers for Disease Control and Prevention [CDC], 2006). Therefore, the number of infants medically treated for injuries each year may approach one million. Second, NEISS-AIP only provides national estimates—not state or local estimates. Yet, causes and circumstances of infant injuries may vary by community and location. Finally, NEISS-AIP does not provide detailed sociodemographic information on individuals, limiting our ability to analyze key factors such as socioeconomic status or family structure. These results represent only unintentional injuries and do not include injuries to infants related to violence. Our results set the stage for future research on unintentional injury prevention during the first year of life. Applying an ecological model of life course development to prevention suggests that the safety of infants during the first 12 months depends primarily on two factors: adequate parenting and safe environments, implying the need for interventions at home and in the community (Doll, Bonzo, Mercy, & Sleet, 2007; Mercy, Sleet, & Doll, 2006). Safety attributes most likely to influence injuries among infants include strong emotional bonds between infant and caregivers, use of positive reinforcement to promote safe behaviors, high caregiver awareness and knowledge of home safety measures, active supervisory style by the caregiver, absence of home hazards, environmental protection, and home visitation programs (Sleet & Mercy, 2003). Our study showed the need to understand the connection between these factors and an infant's developmental stage. For example, changes in mobility in the first year of life present an enormous challenge. Attributes that increase safety in homes and communities must be adapted for the infant's stage of development. References Agran, P. F., Anderson, C., Winn, D., Trent, R., Walton-Haynes, L., & Thayer, S. (2003). Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics, 111(6 Pt 1), e683−e692. Ballesteros, M. F., Schieber, R. A., Gilchrist, J., Holmgreen, P., & Annest, J. L. (2003). Differential ranking of causes of fatal versus non-fatal injuries among U.S. children. Injury Prevention, 9(2), 173−176. Centers for Disease Control and Prevention [CDC]. (2006). Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 2001–02. Maryland DHHS Publication No. (PHS) 2006-1730. Hyattsville, MD: Author. Doll, L., Bonzo, S., Mercy, J. A., & Sleet, D. A. (Eds.). (2007). Handbook of injury and violence prevention. New York: Springer. Greenes, D. S., Wigotsky, M., & Schutzman, S. (2001). Gender differences in rates of unintentional head injury in the first 3 months of life. Ambulatory Pediatrics, 1(3), 178−180. Mercy, J. A., Sleet, D., & Doll, L. (2006). Developmental factors and injuries to children and youth. In K. Liller (Ed.), Injury prevention for children and adolescents: Research, practice and advocacy (pp. 1−14). Washington, DC: American Public Health Association. Overpeck, M. D., Brenner, R., Cosgrove, C., Trumble, A., Kochanek, K., & MacDorman, M. (2002). National underascertainment of sudden unexpected infant deaths associated with deaths of unknown cause. Pediatrics, 109(2), 274−283. Pollack-Nelson, C. (2000). Fall and suffocation injuries associated with in-home use of car seats and baby carriers. Pediatric Emergency Care, 16(2), 77−79. Powell, E. C., Jovtis, E., & Tanz, R. (2000a). Incidence and description of stroller-related injuries to children. Pediatrics, 110(5), e62. Powell, E. C., Jovtis, E., & Tanz, R. (2002b). Incidence and description of high chair-related injuries to children. Ambulatory Pediatrics, 2(4), 276−278. Powell, E. C., & Tanz, R. (2002). Adjusting our view of injury risk: The burden of nonfatal injuries in infancy. Pediatrics, 110(4), 792−796. Quinlan, K. P., Thompson, M., Annest, J., Peddicord, J., Ryan, G., Kessler, E., et al. (1999). Expanding the national electronic injury surveillance system to monitor all nonfatal injuries treated in U.S. hospital emergency departments. Annals of Emergency Medicine, 34(5), 637−645. Sleet, D. A., & Mercy, J. A. (2003). Promotion of safety, security, and well-being. In M. H. Bornstein, L. Davidson, C. L. M. Keyes, K. A. Moore, & T. C. f. C. Well-being (Eds.), Well-being: Positive development across the life course (pp. 81−98). Mahwah, NJ: Erlbaum. Sullivan, F. M., & Barlow, S. M. (2001). Review of risk factors for sudden infant death syndrome. Paediatric and Perinatal Epidemiology, 15(2), 144−200. Thompson, K. M. (2003). The role of bath seats in unintentional infant bathtub drowning deaths. Medscape General Medicine, 5(1), 36. Vilke, G. M., Stepanski, B., Ray, L., Lutz, M., Murrin, P., & Chan, T. (2004). 9-1-1 responses for shopping cart and stroller injuries. Pediatric Emergency Care, 20(10), 660−663. Vyrostek, S. B., Annest, J., & Ryan, G. (2004). Surveillance for fatal and nonfatal injuries-United States, 2001. MMWR Surveillance Summaries, 53(7), 1−57. Karin A. Mack, received her Ph.D. in Sociology from the University of Maryland and is currently a Behavioral Scientist at CDC’s Injury Center. Dr. Mack’s recent research focuses on fall prevention in older adults, unintentional injuries in children, and the factors of a healthy home. 612 K.A. Mack et al. / Journal of Safety Research 38 (2007) 609–612 Dr. Julie Gilchrist is a Pediatrician and Medical Epidemiologist with the National Center for Injury Prevention and Control at the CDC. She graduated from Rice University with degrees in Human Physiology and Sports Medicine before attending U.T. Southwestern Medical School in Dallas, TX. She completed a pediatrics residency at the University of Pennsylvania’s Children’s Hospital of Philadelphia and an epidemiology fellowship at CDC. She has been with CDC since 1997. In her current work at the CDC’s Injury Center, she is responsible for research and programs in drowning prevention, sports and recreation-related injury prevention, and dog bite prevention. Michael F. Ballesteros, Ph.D. joined the Centers for Disease Control and Prevention (CDC) in 2001 as an Epidemic Intelligence Service Officer stationed for two years in CDC's National Center for Injury Prevention and Control (NCIPC) in the Division of Unintentional Injury Prevention. He is presently an epidemiologist and a team lead at NCIPC. Dr. Ballesteros received a Ph.D. in epidemiology from the University of Maryland at Baltimore and is the author of over 25 peer-reviewed publications.
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