Why Preventing Pediatric Injury Death Is Only Part of the Puzzle

April 2, 2014

In a letter published today in the Australian & New Zealand Journal of Public Health, I commend the work being done by my pediatric injury prevention research colleagues in New Zealand to help reduce child injury mortality in their country. They developed injury prevention recommendations that were published late last year in the Australian & New Zealand Journal of Public Health using a well-developed European Child Safety Report Card model as a metric for comparison. These include a number of evidence-based injury prevention policy and legislative actions that they believe will have the greatest impact on reducing childhood injury mortality in New Zealand.[1]

It is important to further adapt these Report Card metrics and also measure reduction in non-fatal morbidity from injuries in children. Injury-related functional disability is far more common than death; 95 percent of children and young adults survive moderate to severe trauma, and often have significant long-term physical and cognitive impairment.[2,3] These disabled patients face challenges with reintegration into society and adapting to their ‘new normal’ after a serious but non-fatal injury.

In addition to the aftermath of these disabling injuries, all survivors – even those with minor injuries or no injuries – are at high risk for post traumatic stress and may meet criteria for the recently revised Diagnostic and Statistical Manual (DSM-5) diagnosis for post traumatic stress (Criterion A: Traumatic Stressor of exposure to real or threatened death, injury, or sexual violence) from the American Psychiatric Association.[4]

According to a recent review in JAMA Pediatrics by my colleague, Nancy Kassam-Adams, PhD, a substantial body of research shows that posttraumatic stress (PTS) symptoms are common after pediatric injury and that these symptoms can affect a child’s physical and functional recovery. Although many children have a few traumatic stress reactions (such as re-experiencing, avoidance, or hyper-arousal) in the first few weeks after an injury, for most these reactions improve with time and with support from family and friends. Unfortunately, a significant sub-group (about 1 in 6 injured children) has more severe and persistent PTS symptoms, lasting more than a month and impeding return to normal functioning. Patients should be screened for traumatic stress reactions following injuries of any mechanism or severity.[5,6]

Healthcare providers should be trained in tertiary prevention to improve outcomes for injured children and their families. Tertiary prevention aims to minimize the ongoing damage of existing injury through pre-hospital, acute, critical, rehabilitation, and ambulatory care. Disabling trauma is life changing for children and their families. With continued research into the patterns of injury-related disability and best practices for care, including screening for post traumatic stress, we can maximize prevention, treatment, and recovery of these injuries.

References:

  1. Shepherd M, Kool B, Ameratunga S, Bland V, Hassall I, Chambers J, Carter W, Dalziel S. Preventing child unintentional injury deaths: prioritising the response to the New Zealand Child and Adolescent Injury Report Card. Aust N Z J Public Health. 2013 Oct;37(5):470-4.
  2. Zonfrillo MR, Durbin DR, Winston FK, Zhao H, Stineman MG. Physical disability after injury-related inpatient rehabilitation in children. Pediatrics 2013 Jan;131:e206-13.
  3. Zonfrillo MR, Durbin DR, Winston FK, Zhang X, Stineman MG. Residual cognitive disability after completion of inpatient rehabilitation among injured children. J Pediatr. 2013 Oct 15. [Epub ahead of print]
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Publishing, 2013.
  5. Kassam-Adams NK, Marsac ML, Hildenbrand A, Winston FK. Posttraumatic stress following pediatric injury:  Update on diagnosis, risk factors, and intervention. JAMA Pediatr. 2013 Oct 7.
  6. The Center for Pediatric Traumatic Stress. Health Care Toolbox. (Accessed July 9, 2013, at http://www.healthcaretoolbox.org.)