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Injuries in Children and Young People

Summary

Injuries are a leading cause of hospitalisation and represent a major cause of premature mortality for children and young people. They are also a source of long-term health issues, including physical and mental health issues. The human and financial cost of childhood injuries is significant and there is a strong health and economic case for preventing childhood injuries.

South Gloucestershire has significantly lower unintentional injury hospital admission rates among children than regional and national averages. Hospital admission rates for those aged 0-15 have fluctuated over recent years but rates for those aged 0-4 have risen. Children under five account for a disproportionately high number of deaths and a large number of hospital admissions.

On average 180 children aged 0-4 years had an emergency hospital admission for deliberate and unintentional injuries each year between 2010 and 2014; 270 5-14 year olds; and 430 15-24 year olds. This is only the ‘tip of the iceberg’, as many more children than this had injuries requiring medical attention, but weren’t admitted into hospital.

The data show that there are clear inequalities in the number of children and young people affected by unintentional injury. Children who live in more deprived areas are at greater risk of all types of injury. The children most likely to suffer unintentional injury are those who have a disability or impairment, belong to certain ethnic minority groups, come from low-income families, or live in poorer quality housing. Emergency hospital admission rates due to injury are around 60% higher in the most deprived communities when compared to the least deprived. (This social gradient is more marked for 0-4 year olds and 15-24 year olds than 5-14 year olds).  Addressing these inequalities through targeted prevention work is a priority.

A number of services play an important role in child injury prevention including Health Visitors, Children’s Centres, and the Council through road safety education and road engineering measures. There is an active Child Injury Prevention (CHIP) group in South Gloucestershire which aims to reduce death and unintentional injury in children from birth to 19 years living in South Gloucestershire. Commissioners should support the implementation of this action plan and ensure that sufficient resources are available to achieve objectives.

Recommendations for consideration

Action is required to continue to identify the causes and locations of unintentional injuries and to undertake appropriate interventions with target groups, or in identified neighbourhoods; continue to expand the capacity for injury prevention training for all staff who regularly work with children; delivery of the successful free safety equipment scheme to the most vulnerable South Gloucestershire families, and thereby help reduce the risk of injuries in the home.

Author: Sarah Weld, Public Health Consultant, South Gloucestershire Council; Molly Gilbert, Specialist Health Improvement Practitioner, South Gloucestershire Council

Who is at risk and why?

This JSNA section covers unintentional injury which is defined as injury occurring as a result of an unplanned and unexpected event which occurs at a specific time from an external cause. The section should be read in conjunction with sections on child poverty, safeguarding, mental health and self-harm and urgent care.

Unintentional injury is defined as injury occurring as a result of an unplanned and unexpected event which occurs at a specific time from an external cause.

Children and young people are at particularly high risk of unintentional injury, with most injuries occurring in the home and on the road.

Unintentional injuries include:

  • Falls
  • Road traffic accidents
  • Injuries associated with leisure / sporting activities
  • Burns, scalds and smoke inhalation
  • Drowning
  • Choking, suffocation and strangulation (e.g. through blind cords)
  • Electrocution
  • Poisoning from gases including carbon monoxide
  • Poisoning from chemicals and drugs (excluding food poisoning)

‘Injuries do not occur by chance. They are largely preventable, non-random events, and not ‘accidents’. Certain groups of people with certain characteristics are more likely to be injured’. Source: Injury Prevention, British Medical Association, 2001

This JSNA does not include intentional injuries, whether self-inflicted or inflicted by others. Nevertheless, it is recognised that there are some common risk factors associated with certain unintentional and intentional injuries particularly in relation to child protection and adult safeguarding.

Injuries are a leading cause of hospitalisation and represent a major cause of premature mortality for children and young people. They are also a source of long-term health issues, including physical and mental health issues. The burden of unintentional injuries to affected individuals and society as a whole is immense (Royal Society for the Prevention of Accidents (ROSPA), 2013).

The causes of unintended injuries are not all the same. Some arise as a result of child development; sometimes parents do not anticipate their child’s development nor realise that the risk of their child having an injury can change very quickly as their child learns new skills. For example, as babies start to wriggle and roll, they may fall from beds and other furniture where they may have been placed. Mobility also allows access to objects. It is natural for babies and young children to explore taste and texture by putting things into their mouths, risking ingestion, suffocation and poisoning. Injuries such as serious burns can occur when young children reach out for mugs of hot drinks on low tables or pan handles on cookers (Keeping Children Safe at Home, 2014).

Other causes of child injury include the physical environment in the home with overcrowding or homelessness being particularly significant risk factors; the knowledge and behaviour of parents and other carers (including literacy) and the availability of home safety equipment. As they grow older, children of adolescent age are especially prone to take risks which place them at higher risk of injury.

Children are also at particularly high risk of injuries on the road. Because of their small stature, it can be difficult for children to see surrounding traffic and for drivers and others to see them. In addition if they are involved in a road traffic crash, their softer heads make them more susceptible to serious head injury than adults. Younger children may have difficulties interpreting various sights and sounds, which may impact on their judgement regarding the proximity, speed and direction of moving vehicles. In general roads are planned without sufficient consideration of the specific needs of children (Keeping Children Safe at Home, 2014). The largest hourly numbers of serious and fatal school age child pedestrian injuries occur in the afternoon and early evening following school (Public Health England, 2014).

There are significant health inequalities to child injury; children who live in more deprived areas are at greater risk of all types of injury. Research shows that children from the most disadvantaged families are more likely to be treated by a GP or Emergency Department for an injury; admitted to hospital as a result of unintentional injury; and to be admitted with more severe injuries. This is more marked for 0-4 year olds than 5-14 year olds. The children most likely to suffer unintentional injury are those who have a disability or impairment, belong to certain ethnic minority groups, come from low-income families, or live in poorer quality housing.

The level of need in the population

Every year there are millions of non-fatal injuries in the UK. The figure below illustrates that deaths due to injury are just the tip of the iceberg. For each person who dies many more are admitted to hospital, attend Emergency Departments or visit their GP.

Pyramid of Injury
chart showing Pyramid of Injury
South Gloucestershire has generally lower unintentional injury hospital admission rates among children than regional and national averages, but local rates have risen in recent years. Children under five account for a disproportionately high number of deaths and a large number of hospital admissions. On average 180 children aged 0-4 years had an emergency hospital admission for deliberate and unintentional injuries each year between 2010 and 2014; 270 5-14 year olds; and 430 15-24 year olds. In 2014, 441 children aged 0-15 were admitted to hospital as a result of a deliberate or unintentional injury.

The charts below present data on hospital admissions caused by unintentional and deliberate injuries in children and young people. This data is taken from the Public Health Outcomes Framework (Public Health England, 2015) and includes both unintentional and deliberate injuries. Although the focus of this JSNA section is on just unintentional injuries data on all injuries is included in Public Health England datasets to take in to account uncertainties around injury intent when coded by clinician and ensure that all injury data is captured.

Figure 1: Trends in hospital admissions for injury in children aged 0-14

chart showing Trends in hospital admissions for injury in children aged 0-14

Source: Public Health Outcomes Framework

Figure 2: Trends in hospital admissions for injury in children aged 0-14

chart showing Trends in hospital admissions for injury in children aged 0-14

Source: Public Health Outcomes Framework

Rates of Emergency Department (ED) and Minor Injuries Unit (MIU) attendances also provide information about the prevalence of injuries in children and young people in South Gloucestershire.

The chart below shows that rates are higher in children and young people than most other age groups and are particularly high in 0-4 year olds. This is likely to be due in part to higher concern about injuries in younger children.

Figure 3: ED and MIU attendances per 100 000 population by age and Deprivation, South Gloucestershire, 2013-2014

chart showing ED and MIU attendances per 100 000 population by age and Deprivation, South Gloucestershire, 2013-2014

Source: SUS data

The chart also shows differences in attendance rates between deprivation quintiles. This social gradient is particularly strong in 0-4 year olds as seen in more detail in the chart below. This association is also apparent in 15-24 year olds but not in 5-14 year olds.

In 0-4 year olds hospital admission rates are more than 60% higher in the most deprived communities when compared to the least deprived.

Figure 4: Emergency admissions for injury by deprivation decile – age 0-4 in South Gloucestershire

chart showing Emergency admissions for injury by deprivation decile – age 0-4 in South Gloucestershire

Source: SUS data

Figure 5: Emergency admissions for injury by deprivation decile – age 5-14 in South Gloucestershire

chart showing Emergency admissions for injury by deprivation decile – age 5-14 in South Gloucestershire

Source: SUS data

In 15-24 year olds hospital admission rates are again around 60% higher in the most deprived communities when compared to the least deprived.

Figure 6: Emergency admissions for injury by deprivation decile – age 15-24 in South Gloucestershire

chart showing Emergency admissions for injury by deprivation decile – age 15-24 in South Gloucestershire

Source: SUS data

Analysis of data by deprivation decile tells just part of the story. Analysis of data by Social Housing decile shows that emergency admission rates for injuries are particularly high in areas with a lot of social housing (housing affordable to people on low incomes). Between 2012-2014, the highest decile of social housing has a hospital admission rate of 248 hospital admissions per 10 000 amongst 0-14 year olds in South Gloucestershire, this compares to the average for England over the same time period of 11.4 hospital admissions per 10 000 pooled.

Figure 7: Emergency admissions for injury by social housing decile – age 0-14 in South Gloucestershire

chart showing Emergency admissions for injury by social housing decile – age 0-14 in South Gloucestershire

Source: SUS data

Figure 8: Emergency admissions for injury by social housing decile – age 15-24 in South Gloucestershire

chart showing Emergency admissions for injury by social housing decile – age 15-24 in South Gloucestershire

Source: SUS data

There is significant geographical variation in Emergency Department attendance rate for preventable injuries as can be seen in the map below. Evidence suggests that this variation is in part due to proximity to services as well as deprivation.

map showing 0-14 year olds by residence

Further analysis undertaken of Emergency Department attendance rates by Lower Super Output Area has helped to identify geographical areas where injury rates in South Gloucestershire are particularly high. This work has led to some targeted local injury prevention work which has enabled the Public Health and Wellbeing team to develop further insight in to injury prevention in Priority Neighbourhoods.

For example analysis identified a ‘hotspot’ area in Staple Hill where ED attendances were significantly higher than in neighbouring areas as shown in the map below.

0-4 child injury attendance rate: Staple Hill hotspot

map showing 0-4 child injury attendance rate: staple hill hotspot

Hospital data also provides information about cause of injury and where they occur. National data tells us that unintentional injuries in and around home are a major cause of death and disability among children under five years and there is a transition to accidents in the leisure environment around the age of five or six years. As children get older the number killed or seriously injured on the road increases.

Public Health England analysis of national injury and mortality data have identified five causes of unintentional injuries among the under-fives that should be prioritised. This grouping includes the most severe and preventable injuries including those that result in high death rates and the largest number of emergency hospital admissions. They are:

  • Choking, suffocation and strangulation
  • Falls
  • Poisoning
  • Burns and scalds
  • Drowning

Interpretation of local data on these types of injury is limited because numbers are very small. Analysis of pooled data from 2008/09 to 2012/13 indicate that emergency hospital admission rates for most causes are similar to or lower than the England average but that rates for emergency hospital admissions due to hot water burns were higher (76.4 per 100,000 compared to 38.4 per 100,000 England average – 60 admissions during the five year period. In number terms falls from furniture accounted for the highest number of admissions; 71 in the five year period whilst poisoning from admissions resulted in 40 admissions.

As children get older the number killed or seriously injured on the road increases. 10-14 year olds are the age group most likely to be injured as a pedestrian or cyclist. Rates are highest for 11 year olds; the age at which children usually start secondary school. Males are at greater risk of being killed in traffic; more than three male children or young people die on the road for every female child or young person who dies. The highest rates of both emergency hospital admissions and police-reported serious and fatal casualties result immediately after young people can start legally using cars and motorcycles.

South Gloucestershire data shows that road related injuries were recorded in 681 males and 473 females under 25 years between 2008 and 2012. This includes 11 fatalities. Rates were highest in those from the most deprived areas of South Gloucestershire.

Current services and assets in relation to need

Evidence shows that when injury prevention is embedded in existing services there is potential to get across messages from a trusted source.

There are a number of services in organisations that already play an important role in injury prevention in South Gloucestershire. For example Health Visitors lead and support delivery of the Healthy Child Programme (HCP), which has injury prevention at its core, and children’s centres are key partners.

Road safety is a priority for the Council which offers road safety education to children and young people as well as road engineering measures to reduce vehicle speeds and activities to enforce traffic law.

The Public Health team have a  lead Specialist Health Improvement Practitioner for child injury prevention who co-ordinates a Child Home Safety Equipment Scheme, offers training to health professionals and others with a role to play in child safety, and delivers targeted prevention and awareness initiatives in the community.

There is an active Child Injury Prevention (CHIP) group in South Gloucestershire which was established in 2015, building on the previous work and experience of AVONSAFE. The group’s focus is on reducing death and serious injury from unintentional injury within young children from birth to 19 years living in South Gloucestershire and includes partners from the local authority and other statutory services, the voluntary sector and service users.

The group has developed an action plan to achieve its key objectives to:

  • Reduce the incidence of unintentional injuries amongst children under 5 years in the home.
  • Reduce the incidence of road traffic accidents.
  • Increase pedestrian/cyclist safety.
  • Reduce the incidence of falls amongst children
  • Raise awareness of how to prevent injuries, particularly amongst vulnerable groups and in disadvantaged areas

Projected service use and outcomes in first 5 years and 5-10 years

The majority of unintentional injuries are preventable and there is great opportunity to reduce the number of children killed and injured through prevention measures. Injury prevention can be low cost and there is a tremendous return for in terms of preventable years of life lost and disability adjusted life years.

Evidence of what works

There is good evidence for what works in terms of preventing injuries in children and young people. Reports include:

  • Keeping Children under Five Safe at Home Briefing report (July 2014) –UWE & Nottingham Universities.
  • Public Health England report (June 2014) – Reducing unintentional injuries on the road among children & young people under 25 years. June 2014
  • Public Health England report (June 2014) – Reducing unintentional injuries in and around the home among children under five years.
  • ROSPA – The Big Book of Accident Prevention, (2012) Delivering Accident Prevention, at local level in the new Public Health System.
  • Public Health Outcomes Framework for England (2013 – 16)
  • NICE guidelines
    • PH29 Strategies to prevent unintentional injuries among the under 15s.
    • PH30 Reducing unintentional injuries among the under 15s in the home.
    • PH31 Preventing unintentional road injuries among under 15s.

Together these documents recommend:

  • Child Injury Prevention programmes led by a local co-ordinator, help to implement injury prevention initiatives tailored to local need
  • Child Death Review Panels can help inform and recommend injury prevention initiatives, tailored to local need.
  • Workforce development & Capacity Building helps to increase skills, confidence and knowledge of practitioners on injury prevention.
  • Injury surveillance using national data sets, helps to identify potential injury risk factors that can inform targeted injury prevention initiatives.
  • Partnership working
  • Home safety prevention initiatives including home safety equipment schemes (with fitting), smoke alarms and fire escape plans, thermostatic controlled hot water valves
  • Continued maintenance of safety standards in outdoor play and leisure
  • Swimming lessons may reduce drowning risk in young children
  • Road safety programmes – 20 mph around schools and playgrounds, partnership working and consulting with at risk communities

User views (on need, services / assets and gaps)

As a result of the ‘hotspot’ analysis described above in 2014 a pilot project was undertaken using a community development approach to reduce unintentional injury in children under five years old in this ‘hotspot’. The project involved working with the local community and service providers to plan an interactive, health focused ‘Summer Fun’ family day. During the event 41 questionnaires about injuries were completed by families who attended. Whilst this is a small sample the data provide some helpful information about community perceptions of injury risk to inform prevention programmes.

The results showed that parents have a perception of their and their family’s homes as being safe places for their children, whereas the data suggests that most unintentional injuries take place within the home environment.

chart showing where children are thought to be safest

The questionnaire asked about what families thought were the most likely hazards or dangers facing their children. Over 60% thought that crossing the road was the most likely hazard with choking and stranger danger identified by 46%. 34% of respondents thought that slips, trips and falls outside the home was a most likely hazard whereas poisoning, sunburn, drowning were considered a hazard by a quarter of respondents. Burn and scalds and riding a bike were thought by just over 12% of those responding to be a likely hazard.

The survey results showed that relatively few families had installed home safety equipment to prevent injuries.

chart showing what measures parents have taken to keep their children safe

When asked what might help to prevent accidents in the home and out and about 64% of those who responded referred to a range of road safety measures as the key means to reduce or prevent accidents and injuries outside of the home including road safety, road awareness and a reduced speed limit or safer crossings. 32% suggested increased or better supervision of children whilst they are playing out.18% referred to changes in the local environment such as cleaner communal areas and safer paths.

In the home 37% of those who responded suggesting making changes to the home such as a fire plan, smoke detectors, window locks and stair-gates and 26% of people highlighted either better education or talking to children about hazards as the best means to prevent harm.

Equalities

The information presented within this chapter provides evidence of needs in respect of diverse groups. Consideration of these needs has resulted in the identification of priority issues to be addressed within South Gloucestershire as follows:-

The data show that there are clear inequalities in the number of children and young people affected by unintentional injury. Children who live in more deprived areas are at greater risk of all types of injury. The children most likely to suffer unintentional injury are those who have a disability or impairment, belong to certain minority ethnic groups, come from low-income families, or live in poorer quality housing. Addressing these inequalities through targeted prevention work is a key priority.

Unmet needs and service gaps

The human and financial cost of childhood injuries is significant and there is a strong health and economic case for preventing childhood injuries.

South Gloucestershire has generally lower unintentional injury hospital admission rates among children than regional and national averages, but local rates have risen in recent years. Data on inequalities highlights a clear need to target injury prevention to areas of high need to reduce the gap between those in the more affluent and poorest areas of South Gloucestershire.

Recommendations for consideration by commissioners

Preventing unintentional injuries does not require major new investment; much can be achieved by mobilising existing services, building on strengths and developing capacity and incorporating unintentional injury prevention within local and national plans and strategies for children and young people’s health and wellbeing.

Broader partnership working across the public, private and voluntary and community sectors is essential, bringing together a wide range of services from diverse settings including health, education, social care, housing and homelessness and fire and rescue.

Reducing injuries in and around the home in children under 5 years and reducing road related injuries in all children and young people should be the priority.

The Child Injury Prevention Group (CHIPS) action plan sets out evidence based recommendations for agencies to work together to reduce the number of unintentional injuries in children and young people in South Gloucestershire.

Commissioners should support the implementation of this action plan and ensure that sufficient resources are available to achieve objectives.

In order to achieve this:

  • South Gloucestershire should continue to ensure sufficient resource to identify the causes and locations of unintentional injuries and to undertake appropriate interventions with target groups, or in identified neighbourhoods.
  • To continue to expand the capacity for injury prevention training for all staff who regularly work with children
  • It is recommended, in line with NICE guidance, that funding continues to be found to ensure the delivery of the successful free safety equipment scheme to the most vulnerable South Gloucestershire families, and thereby help reduce the risk of injuries in the home to the children most at risk of injury.

Recommendations for needs assessment work

Further analysis of local data may be useful to support targeted injury prevention work however no further detailed needs assessment is required at this time.

References

Keeping Children Safe at Home, 2014. Injury Prevention Briefing: preventing unintentional injuries to under fives, s.l.: s.n.

Public Health England, 2014. Reducing unintentional injuries on the road among children & young people under 25 years, s.l.: s.n.

Public Health England, 2015. Public Health Outcomes Framework [Accessed September 2015].

Royal Society for the Prevention of Accidents (ROSPA), 2013. Delivering Accident Prevention at local level in the new public health system Part 1: Context, s.l.: s.n.