Based on global data published by the World Health Organization (WHO) in 2008, injuries are among the leading causes of mortality in the paediatric population worldwide, accounting for approximately 950 000 deaths in children and adolescents aged less than 18 years.1 Unintentional injuries (UIs) amount to 90% of these deaths.1 Although mortality in the paediatric population is substantially lower in developed countries, injuries continue to be a leading cause of death, accounting for approximately 40% of all child deaths.1

According to the EuroSafe 2017 study, each year an estimated 38 million patients receive care for injuries in emergency departments in Europe, of who 52% became injured at home or in the context of sports or leisure activities.2 Nearly 5 million hospital admissions in the European Union are due to injuries each year, and 33 million require outpatient treatment in emergency care settings.

In Spain, one study has analysed unintentional injuries managed at the primary care level3 and another has analysed the cases of children admitted to hospital following an accident,4 but there are no global data of the management of UIs in the paediatric population.

Unintentional injury is one of the leading causes of hospital admission and disability worldwide,5 and one indicator that can approximate the frequency of severe injury is the percentage of cases requiring hospital admission.

Factors have been identified that predict the risk of UI. Thus, the risk of injury and their severity vary based on individual characteristics (age, sex, behaviour), the family environment (socioeconomic status, family structure, siblings, parental characteristics) and certain factors related to the community.6 In the paediatric population, there is evidence that the under-1 population is at lower risk of injury, while children and young adults aged 1–4 years and 10–24 years are at higher risk of injury.2 Previous studies have also demonstrated that the children at highest risk of injury are those who are second in the sibling order, those who are alone in the house and those that receive chronic medication.3

The primary objective of our study was to describe the management of UIs in paediatric emergency departments (PEDs) in Spain, and the secondary objective was to analyse the risk factors associated with the occurrence of UIs.

In the dates included in the study, there were a total of 10 175 visits to the 11 PEDs, of which 1941 corresponded to children with UIs (19.1%; 95% CI, 18.3–19.8), of which we finally included 1673 cases (86.2%) in the study: 1416 (84.6%) were not serious, and 257 (15.4%) were serious (Fig. 1).

Figure 1.

Flow chart of the sample selection process. Data expressed as absolute frequencies, percentages and 95% confidence intervals.

CI, confidence interval; UI, unintentional injury.

(0.12MB).

Injuries are a frequent reason for PED visits in Spain, and 90% of UIs could be prevented.10 In addition, injuries are the leading cause of death in the paediatric population in the European Union (9100 deaths a year in individuals aged less than 20 years), and 2/3 of these injuries are unintentional.10

In 2012, the European Child Safety Alliance published a study of the measures proposed and implemented by different European countries (Europa 31) to reduce child and adolescent mortality due to UIs. Spain is among the countries with the best outcomes (ranking 10th out of the 31 countries included) in nearly all areas except fall prevention.10

In our study, nearly 20% of emergency visits were due to UIs, which was consistent with other studies that have shown an increase in the number of visits to PEDs for this reason.11 This is the first study conducted in the PED setting that describes the diagnostic tests used and the rate of hospital admission due to UI and analysing the circumstances that may lead to poorer outcomes. These parameters can be good indicators of the social cost of UIs, which have been estimated to result in the cumulative loss of 40 938 life years of children and adolescents that will not grow, learn or contribute to society.12

We found that slightly more than 15% were serious injuries, in agreement with previous case series in Spain.13 In developing countries, the proportion of admission nears 50%,14 but it is lower in other countries, such as the United States (30%),15 Argentina (22.9%),16 Brazil (8.5%)17 and other Spanish studies (13.7%),18 although it was still much higher compared to our study, which found a proportion of 1.6%. Possible explanations for this difference would be that studies in those countries may not have included milder injuries or may not have included all patients managed in the PED, or that the true proportion of severe injuries was actually greater. On the other hand, the low proportion of severe injuries found in our study stood in contrast with the high number of x-rays performed in our series (nearly 60% of cases), which may reflect a certain degree of defensive medicine. This finding reveals exposure to a significant amount of radiation and the associated risk of developing malignancies later in life. We did not analyse the appropriateness of these examinations, but the study reflects the usual clinical practice in PEDs at different levels of care. The use of ultrasound for diagnosis of long bone fractures would reduce the use of x-rays in the evaluation of these patients.19

A finding worth highlighting in our study was the low proportion of patients with UIs that received sedation and analgesia in the PED (15.5% of the total and 29.2% of the group with severe injuries). Although paediatricians are increasingly aware of this issue, there are many factors that contribute to the lag in the use of sedation and analgesia in the paediatric population at the emergency care level. Some of these factors are the diversity of specialists that manage these patients (orthopaedists, paediatric emergency physicians, family physicians, etc.), as was the case in our study, or that appropriate scales for pain assessment are not routinely used.

As had been previously described,17 a previous history of fractures was associated with an increased risk of severe injury, which could reflect a more “restless” behaviour on the part of these patients. A study conducted in the primary care setting in Spain found that 25% of families believed their children exhibited sensation-seeking behaviours and that fractures were the most common type of injury in this group of children.3

In Europe, 3.6 million sports-related injuries are managed each year at the hospital level, with a peak in incidence in the group aged 10–19 years.20 There is evidence of a decrease in mortality associated with the implementation of safety programmes and campaigns for extreme sports, but on the other hand the practice of sports has increased and with it sports-related injuries.20 Our study found that sports-related and playground activities were risk factors for serious injury. Thus, it may be useful to develop programmes for the prevention of UIs in sports activities in schools and for adequate training in UI prevention of staff overseeing outdoor activities. We carried out our study in public hospitals, so we may have underestimated the incidence of sports-related injuries, as in many instances the health insurance policies covering this type of injury refer patients to private health care facilities.

Spain is still underperforming in certain aspects related to sports and physical activity.10 According to the 2012 Child Safety Report Card,12 although there are national policies and legislation requiring the use of bicycle helmets when cycling, they are only partially enforced; there is no law requiring fencing around any form of private pool (current Spanish law on the subject is at the autonomous community level and varies based on the regulations of each of these regions) and there is no national strategy for the prevention of injuries involving water safety.21

Accidental falls were the most frequent mechanism of injury in our sample4 and in most other published case series14,15,18,22,23 and carry a higher risk of serious injury, but there is no law banning the distribution and sale of walkers (associated with a higher incidence of falls),24 regulating the use of window guards or locks or guardrails in balconies and stairs, and no policy has been implemented to facilitate access to childcare equipment for disadvantaged families. A national strategy with specific targets and timelines needs to be devised for the prevention of falls in children and adolescents. All these improvements refer to the home setting as, as our study evinced, the family home was the most frequent setting of UIs.

While motor vehicles corresponded to a low frequency of UIs in our case series, they constituted a risk. Royal Decree 667/2015, of 17 July25 that amended the General Regulation on Traffic (approved in Royal Decree 1428/2003, of 21 November), regulates the use of safety belts, approved child restraint systems and the facing of these restraint systems relative to the normal direction of travel of the vehicle. The actual enactment of these safety regulations is in different stages when it comes to manufacturers and retailers. All the regulations currently in place are far from adhering to European recommendations to enact laws requiring children aged less than 13 years to ride in the back seats of vehicles, or children aged less than 4 years to be placed in restraint systems facing backward,10 although evaluating the actual degree of adherence to current law would require a specific study.

There are limitations to our study. On one hand, while 11 hospitals in different regions participated, the sample did not include PEDs from every health area in Spain, and therefore the results should be extrapolated with caution to regions that were not represented in the study. Furthermore, there were differences in the age range served by participating PEDs, as some hospitals served children up to the 14th birthday, others up to the 15th birthday and others up to the 16th birthday, which means that the incidence of injuries in the upper range of age was probably underestimated. We did not use validated severity scales because currently available scales (such as the Pediatric Trauma Score [PTS]) do not include UIs other than traumatic injury that were included in our analysis. Lastly, the study was conducted in PEDs, which presumably are the setting where patients with the most serious or concerning injuries are managed. When it comes to the development of preventive strategies, UIs managed in other settings, especially primary care, should also be taken into account. Nevertheless, we believe that the information obtained from PEDs is essential for the development of appropriate preventive measures.

In conclusion, UIs continue to be a frequent reason for visits to PEDs in Spain, although in most cases these injuries are not serious. The use of x-rays for diagnosis and immobilization for management of injuries was frequent in the paediatric emergency care setting. The risk of serious UI in children was mainly associated with patient-related factors (individual behaviours or characteristics), such as age greater than 5 years or a previous history of fracture, as well as factors related to the social environment of the child (leisure and physical activities). Thus, it is essential that nationwide policies and strategies are implemented to improve the prevention of UIs at home or in means of transport and the skills of caregivers and health care providers by means of educational interventions.

There were no external sources of funding for this article or the preceding research.

The authors have no conflicts of interest to declare.