Research In Action

Moderator's note: This post is part of our ongoing series highlighting articles from the "Preventing Unintentional Injuries Among Children and Youth" issue of Pediatric Clinics of North America. Today’s entry, written by Dr. Sadiqa Kendi, features the article “Applications of the Injury Equity Framework to Address Pediatric Injury Inequities". Dr. Sadiqa Kendi is a pediatric emergency medicine physician at Children’s National Hospital, Associate Division Chief of Academic Affairs and Research for the Division of Emergency Medicine, and Chief Medical Officer of Safe Kids Worldwide.

In our recent article in Pediatric Clinics of North America, my co-authors, Dr. Samaa Kemal and Dr. Michelle L. Macy of Ann & Robert H. Lurie Children's Hospital of Chicago, and I move the Injury Equity Framework from theory into practice.

Injuries remain the leading cause of death for children and youth ages 1 to 24. Decades of progress have stalled, and for several mechanisms the gaps are widening. Death from injury occurs disproportionately in children who identify as Black, American Indian/Alaska Native, rural, or low-income. Black youth ages 5 to 19 drown in swimming pools at 5.5 times the rate of their White peers - a legacy of pool segregation and disinvestment, not of ability. Non-Hispanic Black and American Indian/Alaska Native infants die of SUID at roughly nine times the rate of non-Hispanic Asian infants. Injury death rates are 25% higher among rural children than urban children, and the burden compounds at the intersection of rurality, race, and poverty.

To make those intersections visible, we pair the Injury Equity Framework with James Reason's Swiss Cheese Model. Each slice represents one of the framework's five contributor and countermeasure domains: built and natural environment; legislation and policy; education; equipment and technology; and treatment and recovery. The holes are social drivers of health, shaped by historical and current societal factors. In communities harmed by poverty, racism, and xenophobia, the holes are larger and more numerous, and there are fewer slices standing between a child and a preventable death.

We apply the model to five composite clinical scenarios drawn from our own emergency departments. A toddler sustains fatal injuries after being incorrectly restrained in a car seat with a label in a language that her parents do not read. A 4-year-old is shot by his brother in rural Louisiana, one of 15 states without a child access prevention law in 2025, and dies before he can reach a trauma center more than an hour away. A 3-year-old ingests a cannabis edible packaged to look like candy, and her mother shares that she turned to cannabis as support for chronic pain after losing her job and being unable to afford her prescription pain medication. A 4-month-old dies in a makeshift sleep space after her family is evicted.

Each story is a story about systems, not about parenting. Equity in childhood injury prevention will not be achieved through better caregiver education. It requires shrinking the holes and adding layers, through infrastructure investment, protective legislation, affordable housing and safety equipment, better health care coverage and accessibility, and pediatric readiness across EMS and general emergency departments.

The holes in these systems are not accidents. Neither are the children who fall through them. Our job in addressing inequities is not to teach children (or caregivers) to dodge the holes. It is to close them, layer by layer, until no child can fall through.