Each year, nearly 37 million people in the European Union seek care for injuries in emergency departments; of all these injuries, 14.1% require hospital admission and 0.6% result in death.1 In the paediatric population, more than two thirds of these deaths are due to unintentional injuries (UIs), which are injuries in which the harmful outcome was not sought or results from the physical energy in the environment. These UIs generate millions of visits per year to European hospitals.2 Thus, every year 1 in 10 children in the European Union experiences an injury that requires urgent medical attention.2

The most frequent mechanisms of death due to UIs in children are road traffic accidents, followed by drowning, poisoning, thermal injuries and falls.3 Although most injuries can be treated, recent studies suggest that the impairment that may result from even mild injuries can affect the quality of life of a child for 2 to 3 years.4

More importantly, many of these UIs are preventable,3 while the costs associated with their treatment are high.4

In order to develop effective preventive measures and improve care efficiency, we need to learn the circumstances that surround UIs in our country.

While there is a register of UIs managed at the primary care level,5 there is very little data on the characteristics of paediatric patients that seek emergency care for UIs in Spain.

The aim of the study was to analyse the clinical and epidemiological characteristics of children that seek emergency care for UIs in Spain.

Unintentional injuries are a frequent reason for consultation in Spanish PEDs. The mechanisms involved differ between age groups, although injuries related to falls, blunt trauma and athletic activity amount to 80% of overall visits related to UIs. Although the most frequent diagnosis is contusion of the limb, a fracture was found in more than 20% of cases of trauma to the extremities.

Despite a decline in their incidence in recent years, UIs continue to be the main cause of death in children in the European Union, accounting for 28% of all deaths in children aged 1 to 14 years. The decline is attributed, at least in part, to the impact of child safety programmes implemented in every country of the European Union aimed at preventing potentially fatal accidents (promotion of use of harnessing systems, smoke alarms, fences, window locks, etc.). Nevertheless, visits to emergency departments continue to increase.1 In fact, in our study, nearly 20% of the overall visits to PEDs corresponded to UIs, and while none of the patients died in the first 24h following the event, these injuries caused substantial morbidity. The importance of this problem in our study is consistent with reports from other countries. Thus, it is estimated that 9.2 million children visit emergency departments in the United States due to UIs.9 Taking into account that health professionals employed in PEDs must be prepared to manage any patient seeking emergency care,10 training on the management of patients with UIs should be a priority in the education of paediatricians, with particular emphasis on traumatic injury of the extremities. This is even more important if we consider the high percentage of children that receive outpatient care before arriving to the hospital for this type of traumatic injury.

Several studies have analysed different mechanisms of UI in Spain, such as bicycle accidents, poisonings, road traffic injuries or falls in infants aged less than 1 year.11,12 Our study is the first one to collect comprehensive data on the UIs managed in Spanish PEDs. Its prospective and multicentric design allowed us to obtain information on a large scale with the purpose of identifying opportunities for improvement in the prevention and management of these injuries in Spain. In fact, the design and setting of the study, which allowed us to study the UIs that most worry parents, caregivers and the patients themselves, helped identify epidemiological factors associated with these injuries and compare these findings with other studies. Thus, we found that more than half the patients were injured at home or in school, although the proportion of children injured at home was lower compared to the proportion in the European Injury Database1 and the findings of other studies.13,14 This underscores the need for adequate training not only of parents, but also of the collectives that are commonly in contact with children, such as teachers. We ought to highlight that nearly half of the UIs in our study were not witnessed by an adult, which is consistent with the findings of previous studies, which have shown a frequent lack of supervision of young children and, even more frequently, inadequate adult supervision.11,15 We must emphasise the importance of making adults more aware of the need to closely monitor children and take the necessary precautions, especially at home and in school.

On the other hand, we found a higher frequency of UIs in spring, contrary to a study conducted in primary care that found the peak in autumn, although its authors highlighted the possibility of recall bias in their series.5 These findings may be related to the weather in Spain, which is generally mild. In the United States, for instance, there is a higher incidence of unintentional fractures in the summer.16 In our series, we found a lower frequency of UIs in summer, probably because most of the participating hospitals were in densely populated urban areas, from which families and children are often away during the summer holidays.

We found several incidence peaks involving different mechanisms of injury similar to those found in a study conducted in Spain at the primary care level,5 in which the peak incidence occurred between ages 8 and 11 years, unlike the United States, where the incidence peaks between ages 15 and 19 years.9 However, it is important to remember that not all the PEDs in our study managed patients past the age of 14 years, so that injuries in this age group are probably underrepresented. On the other hand, the percentage of children injured during the weekend was similar to the percentage reported in studies conducted in Spain that analysed falls in infants aged less than 1 year,11 UIs in children managed in primary care5 and UIs in children that required hospital admission.17 This could be due to the weekend being when children spend the most time out of doors, even if it is also the time when they are most likely to be supervised by parents or caregivers.

Falls, and low-energy falls in particular, were the most frequent mechanism of injury overall, as is the case in the European Injury Database1,2 and in the United States.13 This mechanism of injury is particularly important in children aged less than 10 years. However, we must emphasise that there is a broad variety of mechanisms of injury as well as the importance of sports-related injuries in older children.

These patients tended to visit the emergency department early, and a significant number received outpatient care before going to the hospital, especially in the afternoon. Consistently with the existing literature,18 the proportion of children with UIs admitted to hospital was very low and below the proportion of children admitted to hospital for emergencies overall in Spain.

It is particularly alarming that two thirds of children injured in bicycle accidents reported not having worn a helmet, a finding that confirmed the results of a previous multicentre study in Spain.12 It seems obvious that the measures adopted to date are not as effective as expected, despite finding that the percentage of children that were correctly harnessed during road traffic accidents was high.

There are several limitations to our study. On one hand, while it was conducted in 11 hospitals from different regions, it did not include PEDs from every region in Spain, so caution must be exercised in generalising its results to regions that were not included. Also, the hospitals that participated in the study belonged to a research network, although we do not believe that this had an impact on the conclusions of the study, as this is probably not an aspect considered by parents when choosing a facility to seek care for their children. Last of all, the study was conducted in PEDs, which are likely to manage the patients with the most severe or alarming UIs. To develop adequate preventive measures, it is also important to take into account UIs managed in other settings, especially primary care. However, we believe that the information obtained from PEDs is essential to improve these measures.

In conclusion, UIs that occur in different settings account for a significant proportion of the reasons why children seek care in PEDs in Spain. The mechanisms of injury vary based on age. An awareness of the circumstances under which these injuries tend to occur would help develop adequate preventive measures and improve the skills of the individuals in and out of health care that are involved in the management of these children.

The authors have no conflicts of interest to declare.