1. Residential Injury in US Children and Adolescents Kieran J. Phelan, MD, MSc Assistant Professor of Pediatrics Cincinnati Children’s Hospital Medical Center

2. Pen & Ink Illustration of Samuel Clemen’s House in Hartford, Connecticut, circa 1890 “...it is less trouble and more satisfaction to bury two families than to select and equip a home for one.” Mark Twain’s Autobiography

3. Pediatric Injury Leading cause of morbidity and mortality in US children after the first year of life Leading mechanisms are motor vehicle crashes and firearm-related injury Leading location of injury has not been examined since mid-1980’s

4. Definition - Injury Damage to cells and organs from energy exposure or depletion that have sudden discernible effects  exposures can be acute or chronic  can result in varying degrees of cellular and tissue dysfunction

5. Why Residential Injuries? Researchers have implicated the home as the predominant location of injury  Pollock 1984 Mortality Data Tapes  Rivara 1989 King, Co. ED visits / Hosp.  Scheidt 1995 Child Hlth Suppl to NHS

6. Fatal Injuries by place of occurrence, among children < 15 years, United States, 1984 Home 61% Other 26% Unspecified 12% * Pollock DA, MMWR 1988;37:13-20.

7. Fatal Injuries in U.S. Children < 15 years of age, 1978-1984* * Pollock DA, MMWR 1988;37:13-20.

8. Residential Injury & Haddon Matrix Example: Residential Stairway Fall

9. Focusing Injury Prevention Efforts Frequent Severe Preventable

10. Injury Severity Death is the the most severe outcome of energy transfer to human soft tissue and represents ‘the tip of the iceberg’ Hospital admissions and ED visits are less severe subsets of the injury pyramid and represent a substantial health services burden for US children Severity scoring (AIS) by anatomic location of tissue injury represents a means for comparisons of injury and injury outcomes over time and between location

11. Injury Pyramid Deaths Hospitalizations Emergency Visits Events, office calls, office visits

12. Emergency Visits and Hospitalizations for US Children after Residential Injury National Hospital Ambulatory Medical Care Survey (NHAMCS) Probability sample of US Hospitals, emergency departments (EDs), clinics within hospitals, and patient visits within EDs / clinics National estimates of injury ED visits for US children 1993 - 99

13. Phelan KJ et al. (unpublished data).

14. Average annual number (in thousands), rate (per 100), and 95% confidence intervals (CI) for estimates of United States ED visits for residential injuries according to demographics, location, season, and hospital admissions: NHAMCS, 1993-99. * p<0.0001, for <1 year and 1-4 year age groups compared to 10-14 and 15-19 years

15. Average annual number (in thousands), rate* (per 100), and 95% confidence intervals (CI) for estimates of United States ED visits for residential injuries according to demographics, location, season, and hospital admissions: NHAMCS, 1993-99. ***p=0.03 April – June compared to October-December

16. Leading mechanisms of unintentional residential injury: US children < 20 years, NHAMCS 1993-99. Rate (per 100,000) by age group of emergency department visits.

17. Number (in thousands), rate (per 100,000), and distribution of AIS scores for Residential Injuries in US Children <20 years, NHAMCS 1993-1999.

18. Number (in millions), rate (per 10, 000), and 95% confidence intervals (CI) of residential Injuries according to body region: US ED visits NHAMCS, 1993-97

19. Number (in millions), rate (per 10, 000), and 95% confidence intervals (CI) of residential injuries according to type of injury, NHAMCS 1993 - 99.

20. Number (in thousands) and rate (per 100,000) for hospitalizations for residential unintentional injury: US children <20 years NHAMCS 1993-99

21. Residential Injury-related Mortality in US Children & Adolescents NCHS Mortality data tapes 1985 - 97 Collaborative effort with Batelle Institute (Columbus, OH) Jyothi Nagaraja, John Menkedick (Battelle) Bruce Lanphear, Jane Khoury, Kieran Phelan (Cincinnati Children’s)

22. Place of Occurrence of Death for US Children and Adolescents, 1985 - 1997 * Nagaraja J et al. (in progress).

23. Proportion of Injury Deaths in the Home Among U.S Children and Adolescents, by Age, 1985 to 1997 * Nagaraja J et al. (in progress).

24. Fatal Residential Injuries among U.S. Children, 1985 to 1997 Mortality Rate (/100,000) * Nagaraja J et al. (in progress). Year

25. * Nagaraja J et al. (in progress). Mortality Rate (/100,000) Year

26. * Nagaraja J et al. (in progress). Mortality Rate (/100,000) Year

27. Average Annual Residential Injury Outcomes in US Children & Adolescents <20 yrs. 1985 - 99 Deaths Vital Stats Hospitalizations NHAMCS Emergency Department Visits NHAMCS Events, Office calls, Clinic Visits NHIS N = 2, 822 N = 74, 285 N = 4,009,692 N = 13, 592, 000

28. Conclusions Injury is a residential hazard with HUGE attributable risk  Accounts for 40% of all ED visits for US Children <20 yrs.  The home environment accounts for 40% of all unintentional injuries  25% of US children and adolescents will have an ED visit for an unintentional residential injury each year  Interventions to reduce early childhood injury should be targeted to the home environment

29. Prevention of Morbidity and Mortality from Residential Hazards Shift from over-reliance on educational to environmental or more passive interventions. Multi-disciplinary approach to research, evaluation, and control of residential hazards Controlled Trials are necessary to assess efficacy of hazard controls on child health outcomes. Health-based standards are needed to protect children from residential hazards.