Jewellery- and ornament-related injuries in children and adolescents

Abstract

BACKGROUND:

Unintentional injuries are the leading cause of mortality and morbidity in children and teenagers in Canada. Few publications have addressed injuries caused by jewellery and ornaments in children.

OBJECTIVES:

To examine the mechanisms and the incidence of injuries caused by jewellery and ornaments in children and teenagers, to identify children at high risk for these type of injuries and to recommend specific injury prevention strategies.

METHODS:

Data were analyzed from a Canadian database (Canadian Hospitals Injury Reporting and Prevention Program) of a tertiary paediatric centre. All patients between zero and 18 years of age who were diagnosed in the emergency department with jewellery- and ornament-related injuries during a 10-year period (1997 to 2006) were identified. Patients were categorized according to six age groups (younger than one year of age; one to two years of age; two to four years of age; five to nine years of age; 10 to 14 years of age, and 15 to 18 years of age). For each case, the context and the mechanism of injury were investigated.

RESULTS:

From a total of 150,771 reported injury cases, 380 (0.25%) were jewellery related. Unlike with most trauma, girls predominate in this kind of injury (n=288; 75.8% of cases). Over one-half of cases (58.1%) were reported for children four years of age or younger. Emergency physicians reported the presence of jewellery as a foreign body in a natural orifice (mouth, nose, ear or genitourinary tract) in 308 cases (81%). No case of intestinal obstruction, strangulation or death was reported. Eleven cases (2.9%) required emergency hospitalization, all for endoscopic evaluation of a foreign body in the airway or in the digestive tract. In the adolescent group, five cases of injuries secondary to piercing were reported.

CONCLUSION:

The present study demonstrates that, although jewellery-related injuries are relatively infrequent, some can cause severe injuries that could compromise patients’ health. As a primary prevention strategy, doctors and health professionals working with children should make parents and caregivers aware of the possibility of trauma in children wearing or playing with jewellery, especially in the zero- to four-year-old group requiring closer supervision. Specific anticipatory guidance concerning piercing may be helpful to adolescents.

A joint report (1) from the WHO and UNICEF revealed that approximately 830,000 children die annually due to unintentional injuries, and that one-half of these children could potentially have had their lives saved by preventive measures. There are another 10 million children injured annually by preventable traumas (1). In Canada, unintentional injuries are the main cause of mortality, morbidity and incapacity in children (2–5). Because children have a natural tendency toward oral exploration of their environment, choking and suffocation are the fourth leading causes of morbidity and mortality due to injury in Canadian children (6).

Few publications (7–10) have addressed the problem of injuries caused by jewellery and ornaments. The present study investigates this problem by identifying the injury mechanisms, their frequencies and the profile of children at risk. The conclusions of the present study are aimed at paediatricians and family doctors to help them advise their patients on preventive measures to avoid jewellery- and ornament-related injuries.

METHOD

Retrospective data were extracted and analyzed from a database of a tertiary paediatric centre (CHU Sainte-Justine, Montreal, Quebec) through the Canadian Hospitals Injury Reporting and Prevention Program. All patients between zero and 18 years of age, inclusively, who were diagnosed with jewellery- and ornament-related injuries during a 10-year period (1997 to 2006) were identified. Patients were categorized into six age groups (younger than one year of age, one to two years of age, two to four years of age, five to nine years of age, 10 to 14 years of age and 15 to 18 years of age). For each case, the context and the mechanism of injury as well as the clinical outcome (ie, treatment and follow-up) were investigated.

RESULTS

A total of 150,771 injury cases were reported from the emergency room of the tertiary paediatric hospital. Three hundred eighty cases were jewellery related (medallion, earrings, brooch, hair pin, ring, pendant, pearl, butterfly clasp, bracelet, chain and necklace). Jewellery-related injuries represented 0.25% of the total number of patients seen at the emergency room for injuries. The vast majority of jewellery-related injury cases involved girls (n=288 [75.8%]) (Table 1).

TABLE 1.

Age groups at risk of injury

Children, age (year)	Number			%
	Male	Female	Total
<1	6	34	40	10.5
<2	10	39	49	12.9
2–4	38	94	132	34.7
5–9	26	86	112	29.5
10–14	8	27	35	9.2
15–18	4	8	12	3.2

In children two years of age and younger (n=89), 74 (83%) swallowed a jewellery item, of whom six had to be hospitalized. Children two to four years of age tended to insert jewellery in their natural orifices: in the nose 50 times (37.8%), in the ear 47 times (35.6%) and in the mouth 25 times (18.9%). In children five to nine years of age (an age group in which they are supposed to be more aware of dangers), the same reasons were found for consultation. In 66 children (58.9%), the foreign body was lodged in the ear, 17 (15%) introduced it into one of their nostrils and 19 (17%) swallowed the item (Figure 1).

Figure 1).

Misplaced foreign body by age group

For the 47 older children (10 to 18 years of age), the causes of injury were different. The most frequent cause of injury in the adolescent age group (n=27 [57.4%]) was an embedded earring. The second most frequent cause (n=9 [19.1%]) was a tight ring that had to be extirpated. The third cause was injury related to body piercings: five cases (10.6%) including two in the nose, one in the lip, one in the eyebrow and one in the tongue, with none involving infection.

In 81% of the 380 cases (n=308), the jewellery was found in a natural opening, either the mouth, the nose or the ear, and once in the vaginal cavity. An injury caused by penetration of the skin or incrustation of jewellery occurred in 25 cases (6.6%). Nine children (2.4%) had signs of choking, suffocation or other indicators of upper airway obstruction. The remaining cases were mainly superficial lesions such as pricks, abrasions, lacerations of the face and hands, and one corneal abrasion. In total, the database reported three cases of severe injuries to the fingers, including one case necessitating amputation. No major complications such as intestinal occlusion, volvulus, severe bleeding, perforation, strangulation, neurological damage or death were identified in the 380 cases. The therapeutic interventions required included 11 hospitalizations, all for endoscopic evaluation and treatment of foreign bodies lodged in the respiratory (n=3) or digestive tracts (n=8). Eight of the children requiring endoscopy were four years of age or younger. Three hundred eighteen cases (83.7%) required immediate care and 61 (16.1%) needed an additional follow-up visit in the outpatient clinic. The remaining 11.8% of cases only needed medical advice without intervention or follow-up.

DISCUSSION

Unlike other published studies on unintentional injuries, the majority of cases of jewellery and ornamental injuries were in girls. Boys are usually widely over-represented when accidents are being reported (1,11,12). Not unexpectedly, the main cause of jewellery-related unintentional injuries in children two years of age and younger occurred when the child put the object in his/her mouth and swallowed it. It was somewhat unexpected that this was the second most frequent problem in children five to nine years of age (13). The context in which these injuries occurred was often during free play, at which time the child would swallow the object. In the group of preteenagers and teenagers, the context and the mechanisms were totally different. Body art dominated including body piercings (14).

Even if jewellery-related injuries are infrequent when compared with other reasons for consultation to the emergency room (15), these unintentional injuries are costly to the provincial health system. For the 11 cases hospitalized in our teritiary care centre, estimated costs amounted to more than $20,000 (based on $1,925 per diem). Initial consultations at the emergency room entail expenses estimated at $187,000 and, for a second consultation, an additional $29,520 can be added. In total, those expenses represent an economic burden for society amounting to approximately $240,000, without accounting for indirect expenses (16).

The present study has certain limitations. Because it is a retrospective study, certain data are not available. The data registered in the Canadian Hospitals Injury Reporting and Prevention Program database did not contain the sociodemographic characteristics of the patients and their families. We know that there is an index of psychosocial adversity (17), placing certain families at higher risk than others. Similar to injuries secondary to poisoning in the article by Laursen et al (17), choking injuries are more common in children of younger mothers and mothers with lower education. These parents may have more trouble supervising children properly or controlling their environment, thus placing their children at an increased risk for exposure to choking hazards such as small toys or jewellery.

Also, we do not know the temperament of the accident victims, their capacities of attention or inattention, their tendency toward risk-taking behaviours, the parent-child relationship and the level of security of the environment in which the victims lived. It is known that young people who have difficulties in the spheres of temperament and behaviour have 1.5 times more risk of incurring injuries (18,19). The neurological status, swallowing function and presence of pathological behaviour of the children included in the present study were also not assessed.

Although we reported only patients who consulted an emergency room, the true prevalence of jewellery- and ornament-related injuries may be higher in the general population. Also, our data are only from a children’s hospital emergency department and older children are more likely to be seen at adult emergency departments or clinics. Another limitation of the study is that certain, very real dangers related to jewellery were not documented in the injury database. These include allergic (20,21) or inflammatory reactions and infectious complications (22–24). It is well established that local contact allergic reactions due to metal in jewellery, especially nickel, may become complicated by infections due to streptococci, staphylococci or Pseudomonas (22) (10% to 20%) or by inflammatory reactions such as keloid formation (25,26).

As for piercings – a fashion of self-expression that has become more frequent without necessarily implying a deviant behaviour (14,27) – it is not surprising that in our group of teenagers, we found problems associated with them. Numerous risks are associated with piercings (14,20–31) such as bleeding, tissue trauma, secondary infections such as chondritis (32), bacteremia (23) and also gingivodental complications (33,34). In the emergency room, the extraction of a piercing, if necessary, can be technically challenging (35). In our study, no data were available to document the frequency of this problem.

Another category of unidentified problems attributable to certain jewellery is lead poisoning (36–38). In spite of warnings by Health Canada, approximately 12,000 ornamental objects containing lead were sold between 2006 and 2008 (39). In our study, again no data were available on this problem.

CONCLUSION

Over a 10-year surveillance period, 0.25% of total injuries seen in the emergency department of a paediatric centre were related to jewellery items. Even if those injuries are relatively rare, they still result in visits to the emergency room because of foreign bodies in natural openings, skin trauma, choking and suffocation. As a primary prevention strategy (40–46), doctors and health professionals working with children should make parents and their caregivers aware of the possibility of trauma in children wearing or playing with jewellery.

In this year of the 20th Anniversary of the United Nations Convention on the Rights of the Child, it is important to point out that one key element of this document signed by approximately 200 countries is the requirement for a safe environment in which children live (article 24). Every doctor who treats children should address prevention issues during the periodic examinations (38–40). An example of primary prevention (41) is condemning wearing of jewellery by children younger than four years of age to reduce risks of swallowing a foreign body, choking and suffocation (42,43). Health care professionals should educate families about the signs of upper airway obstruction due to a foreign body including jewellery.

Jewellery has been fashionable through the centuries in most cultures. This fashion is here to stay and it would behoove physicians to limit the possible risks and to inform the parents about it. Body piercing also has a long history. Clinicians should discuss the issue with adolescents, targeting messages about effective decision making and evaluation of risks.