INTRODUCTION dedicated trauma centres or dedicated paediatric unit

 

INTRODUCTION
AND EPIDEMIOLOGY

Epidemiology of paediatric trauma is related to the
collection of data in relation to mechanism of injury, place of injury,
demographic details of the victim of the trauma and analysing the data. After
analysing the injury epidemiology it has been identified trauma as one of the
leading cause of morbidity and mortality in the paediatric age group. Children
are not just miniature adults. There are anatomical , physiological
and emotional difference between children and adults
that make the care and management of paediatric
population different from that of adult. In 1960 WHO regional office for Europe
shared their view that in high income countries trauma had become the leading
cause of death in children aged more than 1 year. (1) The mechanism for pediatric trauma encompasses
both intentional and unintentional
injuries. Intentional injuries occur because of violence, conflicts, war,
suicides and child abuse. Unintentional injuries occur because of vehicular
accident, fall, sport related injuries, poisoning, burns and drowning. The
pattern and cause of pediatric trauma has changed over the period of time with globalization,
urbanization and motorization. (2)
 There is a difference in pattern and
cause of injuries in developed and developing country and also between urban
and rural area.

The mechanism of injury is found to be different for
different age groups. The agent factors responsible to pediatric trauma have
rarely been investigated and currently there are no injury prevention programmes
for pediatric population in India and other developing countries as well. (3) One of the major reasons
for this lacuna could be the dearth of dedicated trauma centres or dedicated
paediatric unit in the existing trauma centres in these countries. (4) Such type of facilities
exists in the western world which had contributed to the improved survival of
pediatric trauma patients.

 

 

 

 

HISTORICAL
AND SOCIAL PERSPECTIVES

Historically communicable diseases and malnutrition were the leading
causes of mortality in the pediatric age group. The advent of immunisation,
improvement of social and economic conditions, and national programmes
targeting infectious diseases and nutritional deficiencies has reduced the
incidence of childhood mortality. At the same time trauma has emerged as the most
important causative factor for childhood mortality. Those children who are saved
from communicable diseases, malnutrition are becoming victims of trauma. Walter
F Pizzi (5) in 1968 observed that the margin between survival and death
is very narrow in most trauma victims; hence emergency departments must be
geared up to widen this margin. For that he stressed for care of trauma victims
in each phase of emergency from ambulance to operation theatre as well as a
team approach in emergency. The concept of trauma system and trauma centre was
started in reference with the publication of an important US government report in
the year 1970 “Accidental Death and Disability: The Neglected Disease of Modern
Society,” which was prepared by the Committees on Trauma and Shock, Division of
Medical sciences, National Academy of Sciences, National research Council.
(6)  The first pediatric trauma
centre established in US soon after adult centres in the 1970s and 80s. Although
trauma centres and integrated trauma systems are in place in many areas of
United States but only a few dedicated pediatric trauma centres are available
to cater all major pediatric trauma cases under one roof. (7)
The land mark convention on the Right of Child was adopted by United Nation
General Assembly on 20 November 1989. In one of its article states that children around the world have a right for safe environment
and to get protection for injury and violence.  In 2000 United
Nations resolved to achieve a two third reduction in the 11 million deaths reported
among under five children by the year 2015. Reduction in deaths due to injury
and violence which is the leading cause of death in children after first year
will be an important aspect for achieving this goal.(8) In May 2002,
the United Nations General Assembly held a special session on children and came
out with a document: A World Fit for children.
  One of the specific goals that was adopted in
this action plan was to “reduce child injuries due to accidents or other causes
through development and implementation of appropriate preventive measures.
(9)

Many
studies from different countries and also from major cities in India have found
that boys are more commonly injured than girls. This may be because boys are
given more freedom, opportunities in comparison to girls in our society. Also
they are more exposed to potential risk factors like playing on roads, climbing
on trees. (10)

Non-accidental trauma is also a major cause morbidity and mortality among
children.  Though various studies outlined
that it accounts for 3%- 7.3% of all traumatic injuries evaluated at trauma
centres it may still be under reported. (11, 12) Trauma causes profound unpleasant late effects on
the injured children and their families. Even one or more years after injury
almost 75% of the children have to contend with disabilities. (13) Effect on family is
also striking though sometimes it is difficult to recognise. Relation between
the injured child and his siblings and parents become more fragile. Changes in
psychosocial behaviour of the patient especially after head injury also affects
sibling and parents. Family finances also get affected. Sometimes one of the
family members has to stop working to take care of the injured child. Sometimes
trauma to child can be the cause of marital conflicts between parents.
Uninjured siblings also develop some emotional reactions, learning problem and
personality changes. (13)

It
is very difficult to estimate the actual cost paediatric trauma as it not only
involves cost of hospitalisation but also involves loss of productivity of
families and income. Those patients who underwent major surgical procedure for
trauma have more cost of care as compared to those who underwent minor surgical
procedure or managed conservatively. There was also a positive correlation
between increasing hospital cost and increasing trauma score. (14)

MAGNITUDE OF PROBLEM
(MORBIDITY AND MORTALITY)

Pediatric
trauma is strongly related to social determinants of the society. The burden of
injury on children is unequally distributed in overall world. Children in low
income group of countries and those from poor families in better-off countries
are the most vulnerable. More than 95% of all child injury deaths occur in
low-income and middle-income countries. Although the child injury death rate is
much lower in high-income countries, injuries still account for about 40% of
all child deaths in these countries.(2)

Paediatric
trauma occurs worldwide and is becoming a global health problem. The reasons
may be: a significant proportion (around half) of worldwide population is now younger
than 25 years old and social, economic and technical development has resulted
in increased vehicular traffic. Additionally presence of armed conflicts around
the world involves children as innocent victims. (15) Injury is one of the leading causes of death after
infancy. More than 260000 children and teenagers die from road traffic injuries
each year. That is about 718 children deaths per day. Approximately 10 million
more are non-fatally injured. In high-income countries most children who die are
occupants of vehicles while in low-income and middle-income countries they are
usually pedestrians or cyclists. Injury
and violence are the major killer of children under the age of 18 years
throughout the world and are responsible for approximately 950 000 deaths.
About 830 000 (90%) of these deaths are categorized as
“unintentional”.(2) Road
traffic injuries and drowning together account for nearly half of all
unintentional injury related child deaths. According
to latest data made available by government of India about road accidents, 1,
46,133 deaths and 5, 00,279 injuries occurred due to road accidents in the year
2015. Out of 1, 46,133 persons who died in the accidents 5937 (4.1%) persons
were between the age group of 0-14 yrs and 6652 (4.55%) persons were between
age group of 15-17 yrs. (16) National
crime record Bureau (NCRB) data reveals that out of 413457 total accidental
deaths in the year 2015, 17861 were between the age group of 0-14 yrs and 26736
were between the age group of 14-18 years. Age group 0-18 years comprises of
10.7% of total accidental deaths. (17) Accidental fall is also one of the
leading causes of presentation of trauma victims to emergency department.
Around 47000 children die due to fall every year. But this is only a tip of
iceberg as for each death due to fall there are another 690 children who either
miss school or seek treatment and 4 children suffer from a permanent
disability.(2)

In
2013 unintentional injuries of all types and penetrating trauma caused 6489
deaths among children in the age group of 1-19 years which represented 34% of
all pediatric deaths and a mortality rate of 8.3 per 100000 per year. (18) According to data
available in CDC for 2015, in United States unintentional injuries is the fifth
most common cause of death in less than 1 year age group. Between the age group
of 1-14 yrs unintentional injuries is the most common cause of death. (19)

Combined
result of South and East Asia documented suffocation as the main mode of injury
related death in children under 1 year of age. Road traffic accident is the
most common mode of trauma in boys followed by fall and assault. In contrast to
boys, fall is the most common mode of trauma in girls followed by road traffic
accident.(3) Fall while
playing at home or at play area is the most common mode followed by fall on
ground , fall from roof and fall from stairs, fall from bed , fall from tree. (3) Overall for pediatric
injuries road traffic accident is the commonest cause of death followed by fall
related injuries. Most mortalities occurred in polytrauma patients followed by patients
with head injuries.(20) The
most common category of unintentional injury requiring hospitalisation  suffered by children under age of 15 years
are fractured extremities. (21)

 

Each year around 10 million children get injured or
disabled as a result of road traffic accidents. Data estimate from South-East
Asia shows that for every child who dies, 254 need hospital treatment and four
of whom are left with a permanent disability. Most common injuries include head
injuries and fractured limbs. Around 10–20% of children involved in road
traffic crashes sustain multiple injuries. (2)

Road traffic injury is a leading cause of permanent disability
for children estimating 20 per 100 000 children aged 1–17 years in South-East
Asia. Road traffic accident can lead to psychological effect and mental health
impairment in children, such as post-traumatic stress disorder. By 2030 it is
predicted that road traffic accidents will be the fifth leading cause of death
worldwide, and the seventh leading cause of Disability Adjusted Life Years
(DALY) lost. (2)

RISK FACTORS

The
increase risk of paediatric injury is associated with single parentage, large
family, poorly builded houses and parenteral drug abuse. Young maternal age
also can increase the risk of paediatric injuries because of her lack of
experience and maturity. Stairs, balconies and rooftop without railings and
easily accessible, open windows without grills can be the risk factors for
fall. Uncovered wells, lack of isolation fencing for kid’s swimming pool
increases the risk of drowning.

When
we consider road traffic injuries risk factors at host level are male gender,
young age, and behavioural issues such as substance abuse, high speed driving, and
not wearing helmets or seat-belts. The use of devices like mobile phones, headphone,
and loud car music has also been associated with increased risks of road
traffic injuries. Physiological conditions such as sleep disorders, use of medications
causing drowsiness may also impair the individual’s ability to function safely
in the traffic environment. Lack of experience, lack of knowledge about road traffic
rules can also contribute to increased risks of injury.

At
the level of the vehicle, the absence of safety features such as seat-belts or
airbags, vehicle size and height of the centre of gravity are also related with
varying risks of injury. Larger vehicles constitute a higher risk for pedestrians
and for smaller vehicles. Environmental conditions like traffic congestion, proper
signage, engineered safety barriers and traffic calming devices also contribute
to modulating risks.

PREVENTION ASPECTS

Primary prevention is the most cost
effective method of addressing the problem of pediatric trauma. Prevention of pediatric
trauma have classical model which include primary prevention, secondary
prevention and tertiary prevention. The Haddon Matrix developed by William Haddon Jr. in 1970 is the
most commonly used tool in the injury
prevention field for road traffic accidents. Primary prevention means
to prevent new injuries. Separate road for pedestrian and cyclist, windows bar,
railing for balconies, rooftop and stairs, covered wells are a part of primary preventive
strategy of pediatric trauma. Banning manufacture and sell of the unsafe and harmful
products also is a part of primary prevention. Secondary prevention which is
mean to reduce the severity of injury can happen in the form of  use of vehicle 
seat belt, child passenger restrain,  speed reduction , use of helmet , smoke alarms
in home, soft surfaces at playground .  Tertiary
prevention is mean to reduce the consequence after injury. This is done through
adequate prehospital care and triage in emergency and optimal use of Golden
hour of tauma. Legislation and enforcement of law is important and powerful
tool in prevention of the trauma.

 

SUMMARY

Trauma
is emerging as the leading cause of death in paediatric age group. Majority of paediatric
injuries are preventable which stress for increased awareness in the society
and robust preventive strategies to reduce the incidence of paediatric trauma.

References

1.
The prevention of accidents in childhood. Report of a seminar, Spa, Belgium
16–25 July 1958. Copenhagen, World Health Organization Regional Office   for Europe, 1960 .

2.
Peden M et al., eds. World report on injury prevention. World Health
Organisation, Geneva, 2008.

3.  KundalVK, Debnath PR,Sen A. Epidemiology of
Pediatric Trauma and its Pattern in Urban India: A Tertiary Care Hospital-Based
Experience.JIAPS.2017Jan-Mar;22(1):33-37.

4.
WHO/UNICEF. Child and Adolescent Injury Prevention: A Global Call to Action,Geneva,Switzerland:WHO;2005.

5.
Pizzi W F. The management of multiple injury patients. J Trauma 1968;
8(1):91-103.

6.
Committee on Trauma and Committee on Shock. Division of Medical Sciences.
National Academy of Sciences. National Research Council. Accidental Death and
Disability: The Neglected Disease of Modern Society. Public Health Service
Publication Number 1071-A-13.Sixth Printing September 1970.

7.
Wesson DE. Pediatric Trauma Centers Coming of Ages. Texas Heart Institute
Journal 2012.39:871-73.

8.
United Nations Millennium Declaration.
New York, NY, United Nations,    2000(A/RES/55/2)
(http://www.un.org/millennium/declaration/ares552e.htm)

9. A world fit for children. New York, NY,
United Nations General Assembly, 2002(A/RES/S-27/2)(htpp://www.unicef.org/specialsession/docs_new/documents/A-RES-S27-2E.pdf)

10.
Sharma M, Lahoti BK, Khandelwal G, Mathur RK, Sharma SS, Laddha A.
Epidemiological trends of pediatric trauma: A single-centre study of
791patients.JIAPS.2011 Jul-Sept;16(3):88-92.

11.Roaten
JB, Partrick DA, Nydam TL, Bensard DD, Hendrickson RJ, Sirontak AP, Karrer FM.
Nonaccidental trauma is a major cause of morbidity and mortality among patients
at a regional level 1 pediatric trauma center. J Pediatric Surg.2006Dec.;41(12):2013-5.

12.
Cox CS. Trauma from child abuse. In: Wesson DE(ed). Pediatric Trauma.  New York. Taylor
and Francis; 2006. pn73

 

13.
Harris BH, Schwaitzberg SD, Seman TM, Herrmann C. The Hidden Morbidity of
Pediatric Trauma. J Pediatric Surg.1989;24(1):103-106.

14.
Harris BH, Bass KD, O’Brien MD. Hospital reimbursement for peidatric trauma
care. J Pediatric Surg.1996 Jan;31(1):78-80.

15.
Sharar SR. The ongoing and worldwide challenge of pediatric trauma. Int J Crit
Illn Inj Sci. 2012 Sep-Dec; 2(3):111-113.

16.
Road accidents in India 2015. (Report by Government of India Ministry of Road
Transport and Highways Transport Research Wing) .

17.
National Crime Records Bureau Ministry of Home Affairs Government of India .
Accidental Deaths and Suicides in India 2015 .

18.
Osterman MJK, Kochanek KD, MacDorman MF, Stobino DM, Guyer B. Annual summary of
vital statistics: 2012-13. Pediatrics .2015; 135:1115-1125.

 

19.National
Centre for Injury preventionand Control (CDC). 10 Leading causes of Injury
Deaths by Age Group Highlighting Violence – Related Injury Deaths, United
States 2015.

20.
Simon R, Gilyoma JM,Dass RM,Mchembe MD, Chalya PL. Paediatric injuries at
Bugando Medical Centre in Northwestern Tanznia: A prospective review of 150
cases. J Trauma Manage Outcome. 2013; 7:10.

21.
The Global Burden of Disease:  2004
Update.  World Health Organisation 2008 .