Injuries are the number one cause of death for children in the United States. Each year childhood injuries result in 20,000 deaths, 600,000 hospitalizations, and 16 million visits to emergency rooms, with an associated cost of approximately $165 billion.

Almost half of the injury-related deaths of children involve motor vehicles. Other causes of unintentional childhood injuries are drowning, burns and scalds, choking, firearms, falls, poisoning, and sports.

The vast majority of unintentional childhood injuries are preventable. Children at a higher risk of injury include males, children with previous serious injuries, children in families with low income, and children in families with young mothers. Among adolescents, alcohol and drug use are significant risk factors.

For additional information on safety, refer to chapter 26, which deals with counseling children and adolescents on violent behavior and firearms, and to chapter 55 for information about counseling adults about injury prevention.

Recommendations of Major Authorities

  • All major authorities, including American Academy of Pediatrics (AAP), Bright Futures, Canadian Task Force on the Periodic Health Examination, and US Preventive Services Task Force --
  • Age-specific safety counseling should be provided as a part of routine well-child care. American Academy of Family Physicians specifies counseling for accidental injury prevention, including (as appropriate) child safety seats, lap and shoulder belt use, bicycle safety, motorcycle helmet use, poison control center numbers, and driving while intoxicated. AAP specifies unintentional injury counseling as appropriate for traffic safety, burn prevention, fall prevention, poisoning prevention, drowning, water safety, sports safety, and firearm safety.
  • American Academy of Pediatrics and Bright Futures --
  • Healthy, sleeping infants should be positioned on the back, instead of prone, to decrease the risk of sudden infant death syndrome (SIDS).

Basics of Safety Counseling

Encourage parents to learn basic life-saving skills, including cardiopulmonary resuscitation (CPR).

Counsel parents to teach their children to dial 911 or other local emergency numbers.

Encourage parents to teach their children self-esteem and how to handle peer pressure that might result in risk-taking behavior that may interfere with making good safety decisions.

Encourage parents to be good role models for safe behavior. In particular, counsel parents to avoid drinking alcohol before or while driving, to always wear a seat belt and bicycle helmet, and to drive within the posted speed limit.

Be attentive to issues involving limited parental and community access to resources for child safety. Be aware of programs in your practice community offering affordable, reliable equipment, devices, and assistance for parents of limited means, and have referrals to these sources available at the time of counseling.

Specific Safety Topics

Choking and Suffocation

Advise parents to keep objects that can cause suffocation (such as plastic bags) and choking (such as coins, small toy parts, and certain foods, including whole grapes, gum, peanuts, popcorn kernels and pieces of raw carrots, and hot dogs) away from small children.

Drowning

Inform parents that children can drown in small depths of water such asmay be contained in buckets, toilets, bathtubs, and wading pools. Empty and store buckets after use. Never leave infants in the bathtub without supervision.

  • Do not allow children to swim alone.
  • Advise parents to protect their children from drowning by installing fences around swimming pools/spas; fences should be at least 4 ft (1.2 m) high with completely self-closing gates.

Electrical Safety

Advise parents to keep unused electrical outlets covered with plastic guards or to install breaker outlets. Ground fault interrupter circuits (GFIC) should be used in bathrooms and other areas where water is likely to touch bare skin.

Fall Prevention

  • Safety gates: Advise parents to use safety gates (preferably not the accordion type) across stairways (both top and bottom), to install window guards above the first floor, and to move furniture away from upper-story windows so children cannot use the furniture to climb onto the window sill.
  • Baby Walkers: Baby walkers are associated with more injuries each year than any other baby product. If they are used, strict supervision must be maintained to avoid falls down stairwells.

Fire and Burn Prevention

  • Water heaters: Counsel parents to protect their children from scald burns by reducing the temperature setting of their water heater to 49° C (120° F), if possible, or install anti-scald devices on bathroom and kitchen faucets.
  • Smoke detectors : Counsel parents about the importance of using smoke alarms to prevent residential fire injuries. Emphasize proper installation, semiannual battery changes, and monthly checks to make sure they work. Discuss the use of a family fire drill and escape plan.

Firearms

Advise parents about the dangers of keeping a firearm in the home. If a gun is kept in the home, counsel parents to keep it unloaded and locked up separately from the ammunition.

Motor Vehicle Safety

  • Car seats: Use of child safety seats is required by law in all 50 states. Counsel parents to install child safety seats in the rear seat of the car, preferably in the middle, and to use them every time children ride. Safety seats should be used until children weigh at least 40 lbs (18 kg). Safety seats should face backward until children weigh at least 20 lbs (9 kg) or reach 1 year of age. Failure to properly secure either the child in the seat or the seat in the car is common; therefore, urge parents to take particular care when securing both.
  • Booster seats/Seat belts: Advise parents to have their children sit in the rear seat of cars and to use safety belts every time they ride. Until children grow tall enough so that the lap belt stays low on their hips and the shoulder belt crosses their shoulders or until children's ears come above the top of the vehicle seat back, they should use properly secured booster seats. Remind parents that children should not ride in the cargo areas of pickup trucks, vans, or station wagons.
  • Air bags: Infants riding in rear-facing safety seats should never be placed in the front seat of a vehicle equipped with a passenger-side air bag. Children should ride in a car's rear seat. If a vehicle does not have a rear seat, children riding in the front seat should be positioned as far back as possible from an air bag.
  • Impaired driving: Advise children and adolescents to avoid riding in a vehicle driven by anyone who has been or is drinking. Counsel adolescents not to drink and drive.

Poison Ingestion

Remind parents to keep medicines and other dangerous substances locked up and in child-resistant containers, to have the local poison control center telephone number posted in a prominent place near the telephone, and to keep a 1-oz bottle of syrup of ipecac at home and to replace it when it reaches its expiration date. Advise parents not to administer syrup of ipecac without first consulting with a poison control center or health care professional.

Pedestrian Safety

Encourage parents to teach and demonstrate pedestrian safety to their children. Remind them that children younger than aged 9 to 12 years need supervision when crossing streets, depending on the density and speed of traffic.

Recreational Safety

  • A safety helmet approved by the American National Standards Institute (ANSI), Snell Memorial Foundation, or the American Society for Testing Materials (ASTM) should be worn by all persons every time they ride or are a passenger on a bicycle. Helmets should also be worn while using roller skates, in-line skates, and skateboards.
  • Wrist guards, elbow pads, and knee pads should be worn by all children of all ages using roller skates, in-line skates, and skateboards.
  • Personal flotation devices should be worn by every child engaged in any boating activity.

Sudden Infant Death Syndrome (SIDS)

Advise parents that positioning sleeping infants on their backs, rather than prone, may decrease the risk of SIDS.

Patient Resources

  • Auto Safety Hot Line. National Highway Traffic Safety Administration: (800)424-9393.
  • Child Safety: How to Keep Your Home Safe for Your Baby. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • Fun in the Sun: Keep Your Baby Safe; 1995 Family Shopping Guide To Car Seats: Guidelines for Parents. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org
  • Reduce The Risk of Sudden Infant Death Syndrome (SIDS). Brochures available in English and Spanish. Back to Sleep, PO Box 29111, Washington, DC 20040; (800)505-2742.
  • Safe Kids Gear Up Guide; How to Protect Your Child From Injury. These and other injury-prevention magazines, brochures, posters, videos, and other materials are available from the National SAFE KIDS Campaign, 1301 Pennsylvania Ave NW, Suite 1000, Washington, DC 20004; (202)662-0600.
  • US Consumer Product Safety Commission, Publication Requests, Washington, DC 20207. Brochures about preventing injuries from toys, household goods, and other common items. Available in English and Spanish; (800)638-2772.

Provider Resources

  • Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org
  • Centers for Disease Control and Prevention: National Center for Injury Prevention and Control; Internet address: http://www.cdc.gov/ncipc
  • The Injury Prevention Program (TIPP). American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org
  • A Guide to Safety Counseling in Office Practice; Physician's Resource Guide for Bicycle Safety Education; Injury Prevention for Children and Youth. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org
  • National Highway Traffic Safety Administration, Office of Occupant Protection, NTS-13, 400 7th St SW, Washington, DC 20590; (202)366-2727.
  • US Consumer Product Safety Commission, Washington, DC 20207. Recorded messages, in both English and Spanish, (800)638-2772.
  • Injury Control News. Association for the Advancement of Injury Control, 888 17th St NW, Suite 1000, Washington, DC 20006; (202)296-6161.

Selected References

  1. American Academy of Family Physicians, Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Academy of Pediatrics, Committee on Accident and Poison Prevention. Office-based Counseling for Injury Prevention. Pediatrics. . 1994; 94:566–567. [PubMed: 7936874]
  3. American Academy of Pediatrics, Committee on Accident and Poison Prevention. Injury prevention. Selecting and using the most appropriate car seats for growing children: Guidelines for counseling parents. Pediatrics. . 1996; 97:761–763. [PubMed: 8628627]
  4. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for pediatric preventive health care. Pediatrics. . 1995; 96:373–374. [PubMed: 7630705]
  5. American Academy of Pediatrics. The Injury Prevention Program (TIPP) Elk Grove Village, Ill: American Academy of Pediatrics; 1989.
  6. American College of Obstetricians and Gynecologists. Automobile Passenger Restraints for Children and Pregnant Women. Washington, DC: American College of Obstetricians and Gynecologists; 1991. ACOG Technical Bulletin 151.
  7. American Medical Association. Rationale and recommendation: intentional and unintentional injuries. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Ill: American Medical Association; 1994: chap 4.
  8. Baker SP, O'Neill B, Ginsberg, Li G. The Injury Fact Book.New York, NY: Oxford University Press; 1995.
  9. Canadian Task Force on the Periodic Health Examination. Prevention of household and recreational injuries in children (<15 years of age) In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 28.
  10. Canadian Task Force on the Periodic Health Examination. Prevention of motor vehicle accidents. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 44.
  11. Centers for Disease Control and Prevention. Air-bag-associated fatal injuries to infants and children riding in front passenger seats — United States. MMWR. . 1995; 44(45):845–847. [PubMed: 7476837]
  12. Centers for Disease Control. Childhood injuries in the United States. [A priority issue.] Am J Dis Child. 1990;144:627-646View this and related citations using.
  13. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994.
  14. National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge Am J Prev Med. 1989;5(3)(suppl)View this and related citations using.
  15. US Preventive Services Task Force. Counseling to prevent household and recreational injuries. In: Guide to Clinical Preventive Services. Washington, DC: US Department of Health and Human Services; 1996: chap 58.