By Pediatric Emergency Medicine Physicians Jeffrey P. Louie, MD, FAAP, and Ronald A. Furnival, MD, FAAP,
University of Minnesota Masonic Children’s Hospital
In 2013, the Centers for Disease Control (CDC) listed the leading causes of unintentional pediatric deaths: suffocation, (under age 1); drowning (ages 1 to 4); and motor vehicle accidents (ages 5 to 19). The Minnesota Department of Health (MDH) also publishes data on the leading causes of death, and not surprisingly, the groups are identical. Between 2004 and 2013, there were 169 suffocation deaths, 36 drowning deaths, and 1,085 deaths from motor vehicle crashes among children in Minnesota.
The Minnesota State Trauma Advisory Council (STAC) was established in 2005 within MDH to supervise and improve trauma care across the state. Of 130 medical facilities across Minnesota (128 hospitals and 2 free-standing emergency centers), a total of 123 are designated trauma centers, certified to accept and treat injured patients. In 2014, the Minnesota STAC published its most recent annual report on all injury hospitalizations in the state. For children 15 and younger, trauma centers treated 1,880 admissions, with 28 percent injured from falls, and 12 percent from motor vehicle accidents. The most common type of injury was a fracture of the shoulder or upper arm (11 percent). followed by traumatic brain injuries (8 percent), forearm and elbow fractures (8 percent), and upper leg and thigh fractures (7 percent). Nine percent of Minnesota pediatric trauma victims were classified as severe (defined as an Injury Severity Score of 25 or greater) and death occurred in fewer than 1 percent of all cases.
Head Injuries
In 2013, there were approximately 3,600 Emergency Department visits in Minnesota for pediatric head injury. Appropriate utilization of head CT for diagnosis, and reducing pediatric radiation exposure with its subsequent cancer risk, has been a treatment goal for many years. A 2009 multi-center benchmark study by Kupperman, et al in Lancet, defined clinical guidelines for CT use in children. These CT guidelines included mechanism of the head injury, age, and symptoms, and were very effective for identifying children at risk for a CiTBI (clinically important traumatic brain injury) defined as the following: children who die, who require neurosurgery intervention, who are intubated, or require two nights in the hospital for observation. With negative predictive values as high as 99 percent, these guidelines help health care providers manage head-injured children without unnecessarily exposing them to radiation, while also directing the use of CT scans only for those children who are at the most risk for a CiTBi.
Child Abuse
Child abuse is one of the leading causes of infant mortality in Minnesota, and its prevention and detection is a responsibility for all pediatric care providers. In 2012, there were 4,820 substantiated cases, 51 (1.1 percent) for medical neglect, 3,070 (63.7 percent) for non-medical neglect, 815 (16.9 percent) for physical abuse, 30 (0.6 percent) for psychological maltreatment, and 854 (17.7 percent) for sexual abuse. Minnesota has four facilities statewide offering child abuse and neglect expertise, which can be found on the AAP website (www2.aap.org/sections/childabuseneglect/Minnesota.cfm). In the Twin Cities metro area, Dr. Nancy Harper is developing a new collaboration among the University of Minnesota Masonic Children’s Hospital, Hennepin County Medical Center and Children’s Hospitals and Clinics of Minnesota to coordinate and unify child maltreatment evaluations and care.
Anticipatory Guidance
Improved Minnesota trauma system organization and trauma care can only go so far. Anticipatory guidance and injury prevention is the only real antidote for pediatric trauma. Parental education must start early and address the most frequent preventable causes of pediatric death and injury. Suffocation, the most common traumatic cause of death for infants under 1 year of age, can be reduced with safe sleep positioning, the use of safe bedding, and by avoiding co-sleeping. Toddlers and school-age children are most frequently killed or injured as pedestrians, in motor vehicle crashes, from drowning, and from falls from height. Educating parents and children about car seats, seat belts, pedestrian safety, water safety (including the bathroom), and secure windows and stairways can reduce these common injuries. Parents of older children and adolescents can be encouraged to promote bike safety and helmet use, as well as helmet use in sports, and to prevent distracted driving, the most frequent preventable causes of injury and deaths for children as they mature.
Advocacy
What else can we pediatricians do to reduce injury among Minnesota’s children? In 2012, MDH produced a plan for injury reduction: “Preventing unintentional injury in Minnesota: A working plan for 2020” (www.minnesotasafetycouncil.org/2020Plan/). We can become involved in hospital and community education and injury prevention efforts; we can speak on behalf of our patients for improved regulation, legislation, and allocation of resources for childhood safety; and we can become more involved in the care of injured children in our local settings as the pediatric experts. We must not be complacent. We need to be proactive. Child safety is not someone else’s responsibility; we all need to watch out for the safety of every child.
