Leading Causes of Fatal and Nonfatal Unintentional Injury for Children and Teens and the Role of Lifestyle Clinicians: A Commentary

Abstract

Unintentional injury and death as a public health concern has not been established in the pediatric population. This is a commentary on a review of epidemiological data of unintentional deaths and injuries with a focus on age, sex, and racial differences in this population. The review takes in-depth look at children aged 0-19 years in the US, followed by a discussion of strategies suggested to address mechanisms of these injuries/deaths. Lifestyle clinicians have a significant role in educating this population and their parent/guardians. Therefore providing insight into the interpretation of the data can support practical education and prevention interventions.

‘Children’s limited ability to recognize hazards and to escape these dangers are key reasons for drownings and suffocations.’

Unintentional injury and death as a public health concern has been established predominantly in adult populations.^1-4 Dellinger and Gilchrist⁵ did an excellent job of framing this public health problem in children and teens. The statistics presented were staggering, yet compel the reader to determine their personal role in reducing these numbers. The purpose of the review was to assess epidemiological data of unintentional deaths and injuries, with a focus on age, sex, and racial differences. The presentation of data, which includes an in-depth review of children 0 to 19 years old in the United States, is followed by a discussion of strategies suggested to address mechanisms of these injuries/deaths.

The decline of unintentional deaths over the 5 years assessed in the article will be less than the decade before if it stays on its current track. The authors are subtly trying to point out the following: Can lifestyle clinicians help reduce these deaths/injuries in the upcoming decade? Can they make a difference to match the current decline noted in nonfatal unintentional injury, that is already greater than the previously analyzed decade? The title indicates that “role of lifestyle clinicians” is a key concept. Yet this does not emerge in the writings. It may be that because of the readership of the journal, it goes without question what the role of this clinician is in terms of the data analyzed. However, the hope would be that this article extends past the journal’s subscribers to personnel on the “front lines”: pediatricians, police, parents, athletic trainers, school counselors, and teachers (just to name a few).⁶ For those naïve readers, lifestyle clinicians are individuals who address risk behaviors and unhealthy patterns and provide resources for targeted populations to stop behaviors identified in injury risk. Many of the “front line” individuals just mentioned, or a team of them, may serve this role in addition to the many responsibilities they already hold.⁷ Researchers and lifestyle clinicians are key role players in the cycle of prevention: (1) understand current trends of injuries/deaths, (2) determine mechanisms and factors that play a role, (3) introduce best evidence-based strategies, and (4) determine the effectiveness of prevention strategies by repeating the initial steps.⁸

Presenting the data by age, as Dellinger and Gilchrist⁵ point out, trends are not lost as would be the case if results had been presented in age groups. Unintentional deaths were the focus of this article because they were the number 1 cause of death in children 1 to 19 years old. Yet caution is warranted because these data need to be explored statistically to truly frame this public health problem. Other causes of death can, and should be, the focus of follow-up articles. Of the other causes of death, suicide, respiratory disease, and influenza/pneumonia should be explored further because their mechanisms match the criteria set forth by the authors as amendable to having prevention strategies implemented.^9,10

The authors draw in 2 important factors to frame unintentional death/injury: child development and behavior. Children’s limited ability to recognize hazards and to escape these dangers are key reasons for drownings and suffocations.¹¹ For teens, these same developmental concerns in addition to peer influences result in transport¹² and drug-related poisonings.¹³ Within the results, the opioid drug-related deaths among teens is obviously a new trend that lifestyle clinicians should examine closer. This public health concern has been in the media and government agendas significantly as of late.¹⁴ This article provides persuasive numbers to support that this is not just a problem in the adult population¹ but the child and teen populations as well. Similar to the adult population,¹ the authors point out that a quarter of the deaths were associated with prescription opioids in 18- to 19-year-olds. An important statistic provided in the article that readers should pay attention to is the likelihood for teens to abuse opioids after high school graduation if used during high school. Health care providers who prescribe medications to this age group should consider these statistics and their implications when determining best treatment for this age group.

Interestingly, the number of unintentional deaths among boys was more than that among girls, at every age presented. This trend is important to point out to readers because one may assume that this difference does not emerge until the teenage years because of engaging in risky behavior.¹⁵ Emphasizing that this is true at every age can allow lifestyle clinicians to provide focused prevention strategies earlier. Racial group observations of mild decreases and increases over time in whites, blacks, and Asians/Pacific Islanders should be statistically explored to help determine if there are clinical implications. Yet the highest number of unintentional deaths occurred among American Indians/Alaska Natives over the past 5 years, which is consistent with the decade prior.¹⁶ With the article geared to understanding the potential role of lifestyle clinicians, one needs to ask, “Are the clinicians in these areas able to provide lifestyle education and prevention strategies to these populations in order to reduce this health disparity?” Research has certainly identified this population as high risk^16-18 but has not examined the demands placed on those clinicians providing care to this population and if they have time to truly address risk behaviors in children.

Dellinger and Gilchrist⁵ bring up a beneficial point regarding the burden of unintentional nonfatal injuries on emergency departments. Once again, are clinicians able to provide lifestyle medicine education in the emergency department setting? These clinicians have immediate knowledge of the incident and the risk factors that led to the mechanism; therefore, providing education at the time of discharge would be valuable with directed information. Research has examined this concept in a variety of specific conditions, such as asthma and alcohol abuse,^19,20 but not unintentional injuries. Hospitals that analyze their personal data and determine that unintentional injuries/deaths are frequent in their emergency department, should consider lifestyle medicine as a possible intervention during checkout procedures.

With unintentional injury as the number 1 reason for nonfatal injuries starting at age 11 till 16 years, it follows that sports should surely be at the forefront of possible causes (which the authors discuss in the Methods section). This age group represents children who start specializing in sport,²¹ yet their bodies and brains are still developing.^22,23 Also, on-site medical care (ie, athletic trainers) are not the norm for this age group (recreation teams, middle school and junior varsity teams). Fractures and concussions are frequent acute injuries that occur in youth athletes,^24,25 most because of unintentionally being struck by sporting equipment or another player. Recent media and government concern regarding sport-related concussions,²⁶ paired with the data presented by Dellinger and Gilchrist,⁵ mean that attention should rightfully be given to this potential public health problem.

The ability of clinicians to provide resources during patient encounters, with electronic health records providing prompts based on the age of the patient, is discussed. Expanding on that idea is to consider prompts sent directly to the parents or teenager via email or text. This has been preliminarily explored in adults taking medication and teenagers known for risky driving behavior.^27,28 This type of prevention strategy comes with its own set of barriers because it would require permissions gained within the primary health care provider’s office and the patient having access to these electronic resources, but it could provide education longitudinally instead of only annually. The authors suggest providing parents with program information of organizations that provide bassinets, car seats, helmets, and so on. Further development of this notion is to use software that can generate handouts with this information along with workshops/seminars being hosted by these programs in the upcoming 2 months to be given at well visits, once again reducing time burden on the clinician and placing prevention responsibility in the hands of parents or teens.

Surprisingly, the authors point out that only 2 states currently require restraints for children up to 8 years. Clinicians will need to explain why state law differs from best-practice recommendations and why it is important to follow the more restrictive guideline. Yet this process could be time-consuming for the clinician. Law makers need to understand what they owe to the public who rely on them to uphold best practices by passing up-to-date legislation,²⁹ particularly in regard to car seats and teen license restrictions.^29,30

In conclusion, the authors do an admirable job of highlighting the frequency and preventability of unintentional deaths/injuries in children and teens and why it deserves to be considered a public health problem. Even though it is not the purpose of this article, money and accessibility to support prevention strategies needs to be considered and solutions presented in the future. As the authors concur, with the top causes of death/injury changing with every year of life, so too must the prevention strategies. Development of education strategies that also change with age and how they are delivered should be a team effort between lifestyle clinicians, health care providers, secondary school staff, and legislators.