Introduction

There are three main categories of environmental hazard for a growing child: Accidents, poisoning and abuse.

The parents and other family members are mostly responsible for minimizing the risk of hazard, but social and healthcare workers also have a role, usually when the family are failing in, or abusing theirs.
Factors that increase the risk of hazards for children include:
  • Low socioeconomic status
  • Overcrowding at home
  • Lack of a safe environment for play
  • Poor parenting skills. Could be due to:
    • Psychiatric illness
    • Substance abuse
    • Poor education
    • Lack of social support
    • Violence

Accidents

aka ‘Unintentional Injuries
Accidents are the 2nd highest cause of death in children aged 1-14, behind malignant disease

Epidemiology

¼ children will attend A&E each year

  • ½ of these will be as a result of accidents

Most accidents only cause minor injury
More common in boys
More common n the summer

  • The above two are particularly true in nursery age children

Number of children killed in accidents has declined sharply in the last 20 years.

  • This is due to new safety measures (essentially common sense measures!) for example, proving child-proof containers around the home, putting fences around swimming pools, encouraging the use of cycle helmets etc etc.

Two organisations that have lobbied for change in this areas are:

  • Royal Society for the prevention of Accidents
  • Child Accident Prevention Trust

Typical scenarios

  • Baby – left unsupervised, they are unable to sit up if they fall over. Thus a common accident is drowning in the bath
  • Toddlers –like to explore, and to put things in their mouths. Have little sense of the consequences of their actions. Typically might ingest poisons, or pull scalding pots/pans off kitchen surfaces. May wander off and drown in large water sources.
  • Older children –accidents usually result from RTA’s, sports injury, or other outdoor activities (e.g. falling when climbing).

Complications

Death
  • About 200 cases per year in the UK, over half of which are RTA’s.

Disability

  • The most common cause of acquired disability is via head inury.

Psychological effects, e.g.:

  • PTSD
  •  Other psychological effects, e.g. after disfiguring burns injury

Specific Examples

Road Traffic Accidents (RTA’s)

The Most common cause of accidental death
As pedestrians
  • Boys ages 5-9 most likely to be affected (particularly after 3pm)
  • Children are poor ad judging speeds of objects
  • Education of children has had little effect. Thus primary measures have been taken (e.g. lolly pop ladies, zebra crossings)

As Passengers

  • Seat belts!

Bicycle accidents

  • Helmets reduce the severity of head injury
  • Head injury is the main cause of death

Head Injury

  • Its normal for children to get head injuries
  • Only 1 in 800 cases will have serious consequences
  • Aim of children is to identify children at risk of secondary brain injury and treat accordingly
  • In children who skulls have not yet fused, a raised ICP may not present with neurological symptoms, due to the elastic nature of the skull.
  • Retinal damage (often with associated bruising) is a common presentation of child abuse

Internal Injury

Abdominal        
  • Ruptured Spleen
  • Ruptured Liver
  • Ruptured kidney
  • Ruptured bowel
  • X-ray and CT is useful for diagnosis
  • Any of the above should be suspected in abdominal trauma
  • Often require surgery, but may be treated conservatively with close monitoring

Chest

Burns and Scalds

  • Very common cause of injury
  • Not often a cause of death. Although house fires are a common cause of death, death usually results from smoke inhalation, rather than from the burn itself.

Management

Assess ABC’s

Any smoke inhalation?

Depth of the burn

  • Superficial – the skin can heal without significant permanent damage. Regeneration occurs from the margin of the wound and works inwards.
  • Partial Thickness – there is blistering, and the skin is usually pink and mottled. Skin is probably able to regenerate in a similar manner to a superficial burn, but more scarring is likely. Skin may also regenerate from around hair follicles, which are deep in the dermis.
  • Full thickness (deep) – the dermis and epidermis are completely destroyed. The skin may look white and scarred, but is usually painless. Requires grafting.

Prognosis and surface area

  • The palm and fingers accound for 1% of surface area
  • 5% full thickness or 10% partial thickness require special burns unit treatment
  • >70% burns has a poor chance of survival

Location

  • Hands – might cause functional loss
  • Face – disfiguring. Can cause psychological trauma
  • Mouth –can affect the patency of the airway, due to oedema.

Treatment

  • Assess pain, and treat accordingly. May require IV opiods
  • Treat shock – usually with IV fluids, typically plasma expanders. Monitor haematocrit and urinary output.
  • Children with >10% burns will need IV fluids

Wound care

  • Cover with plastic wrapping. This reduces pain from contact and also reduced the risk of infection.
  • Don’t touch blisters
  • Get Tetanus status and give booster if required
  • Irrigation – not usually advisable, as it can cause rapid cooling. Acceptable in cases of <10% superficial or partial thickness.

Drowning

  • 3x more common in boys
  • 30% of cases can be prevented by trained resuscitators.
  • Children with fixed dilate pupils and who are unconscious can still be saved, particularly if the water is cold, as hypothermia is protective.
  • No difference between fresh and salty water

Management

  • Chest compressions and mouth to mouth breaths
  • Keep child covered / warm

Complications

  • Water Aspirationmay cause pneumonia
  • Pulmonary oedema – occurs between 1-72 hours after the original incident. Thought to be due to surfactant deficiency.

Inhaled foreign body

Management

  1. Encourage Coughing
  2. If child still conscious:
    1. Do 5 back blows
    2. Try Heimlich manoeuvre. Whiost standing behind the child; Make a fist with one hand, and place this between the xiphisternum and umbilicus. Place your other hand on top, and then pull back into the abdomen. Not suitable for babies and toddlers as you can cause abdominal injury instead, tilt the child forwards so that their head is lower that their chest, and repeat the back blows
  3. If child is unconscious – open the airway, then give 5 breaths. Then begin normal CPR routine.

Accidental Poisoning

  • Peak age of presentation : 30 months
  • Very few deaths
  • Incidence declining due to :
    • Child proof containers
    • Reduced size of packets of drugs
    • Reduced prescribing of dangerous drugs (e.g. iron and aspirin)
  • Dont forget to assess the social circumstances. Usually accidental poisoning occurs due to inadequate supervision (although this rarely qualifies as abuse!)

Child Abuse

Not recognised as an entity until after WWII
Can be divided into roughly 6 categories:
  • Physical Abuse
  • Emotional Abuse
  • Neglect
  • Sexual Abuse
  • Non-accidental poisoning
  • Fabricated / induced illness
  • Avoid the use of the term ‘Munchausen’s By Proxy’ – as this is a psychiatric diagnosis, and as a paediatrician you are not qualified to state this.

Often more than one category of abuse is apparent in an individual case

All types of abuse are emotionally damaging to a child. Sexual abuse in particular can have long term implications for the sexual behaviour of the child.

Treatment for the abuse should not only seek to prevent further abuse but should involve direct treatment of psychological issues.

  • Adults who abuse children do not normally suffer from a psychiatric diagnosis. Alcohol and drugs, and sometimes postnatal depression may however be factors.

Differentiating Child Abuse from innocent Injury

 
Innocent Injury
Child Abuse
History from parent
Clear, specific, details do not change from one telling to the next
Vague. Details may change as story is retold several times
Injury Severity
May be severe or minor
Severe events often occur after the child has presented several times before with mild injuries

 

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