Statements of injury: Prevention then and now

By Dr. Richard Stanwick

Unintentional injuries continue to be the leading cause of death, and a leading cause of hospitalization, in children and youth in Canada today. Yet a pair of CPS statements from 1984 still show just how far both the Canadian Paediatric Society and authoring ‘Accident Prevention’ Committee have evolved in the decades since.

To start, the committee name changed from “accident” to “injury” in 1991 to better reflect our enhanced understanding of unintentional injury control, and to acknowledge that these events are not the result of fate, bad luck, or a higher being’s influence. The Injury Prevention Committee remains anchored by paediatric clinicians, like-minded organizations, and government representatives, and augmented by academic injury control experts. The current committee shares a variety of interests with its counterpart at the American Academy of Pediatrics (AAP), the Committee on Injury, Violence and Poison Prevention.

The 1984 statements on “accident prevention” not only estimated hospitalizations and deaths of children and youth from unintentional injury, but their economic consequences. Their data were gleaned from a range of sources: from single Canadian hospital reports to international statistics, from detailed incident descriptions to summary statistics. Advice on how to prevent the spectrum of childhood and adolescent injuries was based on a mix of evidence-based interventions, existing programs of prevention, and prevailing expert opinion of the time.

Many recommendations and cautions from 1984 have withstood the test of time.

Nevertheless, the critical need for proper evaluation of any recommendation is illustrated by our no longer advising—but rather, actively discouraging—syrup of ipecac as a fixture in every home to prevent paediatric poisoning. (Also, concerns have arisen about its role in eating disorders.) ^[1] Over time, some programs have been found to be only marginally effective. While not doing harm, they may draw resources away from other more proven interventions ^[2].

When the 1984 statements were crafted, 3000 children from birth to 18 years were dying of unintentional injuries annually in Canada. The field of injury prevention (IP) and control was nascent. And despite a paucity of high-grade evidence, committee members boldly provided guidance based on expert opinion.

That was then, but are we doing enough today?

Since 1984, a significant reduction of unintentional injuries rates in Canada’s children and adolescents has occurred ^[3]-[5]. The reasons for improvement are many, but the CPS has been a ‘good actor’ in this story. One current committee statement, Injury Prevention: A Public Health Approach, especially captures this exemplary progress without taking sufficient credit for CPS contributions to it. Epidemiological information, much richer now than in the 1980s, provides not only detailed morbidity and mortality insights, but has expanded our repertoire of theoretical models for enhancing injury control. Vital engineering and environmental modifications that have made our homes, roads, and communities safer, such as bicycle helmet use and traffic calming measures ^[6][7], are given due credit.

The newer CPS statement also highlights a role for advocating on healthy public policies that refracts well beyond the call raised for infant and child car seats in 1984. This closer focus on advocacy has inspired a variety of CPS initiatives, including the biennial ‘report card’ Are We Doing Enough?, which ran from 2005 to 2016 and tracked how well governments in Canada were doing on evidence-based safety interventions to reduce risk for children being hurt or dying from unintentional injuries. Booster seat legislation has improved child safety during motor vehicle collisions dramatically, but efforts to ban underage recreational use of ATVs have been less successful. Statements and recommendations were also being published in Paediatrics & Child Health, the CPS journal with a broad audience of professionals and key decision-makers.

The CPS also provides opportunities for resident members to hone their advocacy skills in injury prevention. Anti-vaping initiatives at the Université de Sherbrooke and Université de Laval, and a campaign to ban underage commercial tanning in Manitoba ^[8], are recent examples of resident-driven advocacy.

Finally, and never to be forgotten, the most powerful advocates of children and youth, their parents and caregivers, can access a wealth of evidence-based information on the Caring for Kids website on how to reduce unintentional injuries at home and in everyday life. The CPS has raised family awareness around preventive public policies to consider and work toward in their home communities—from safer playground surfacing to graduated licensing.

Perhaps the most seismic change since 1984 is how the CPS communicates with our different audiences. Outreach to membership and allied professionals in 1984 involved bulletins, scholarly articles, and annual meetings. Forty years ago, the CPS worked with government departments such as Consumer and Corporate Affairs to ensure that key, if sometimes generic, safety messages reached paediatricians’ offices. We also relied on traditional media—TV, radio, and print—for public messaging. The Internet and social media have utterly transformed the landscape, making the effective communication of science and public health advocacy at once easier and more challenging. Like many organizations, the CPS has had to be nimble, and we now deploy a mix of old and new formats to get (and keep) our information before public (and professional) eyes, including short videos, podcasts, and monthly e-newsletters. Current CPS messaging on screen time, for example, is transmitted more personally through an array of social and media by technically savvy and traditionally well-spoken CPS members.

Our appreciation of the need to tailor CPS information and messaging for diverse audiences has also grown since 1984. Demographics have changed dramatically, as have child-rearing arrangements and family composition. Social determinants of health have emerged as key factors when considering our approaches to injury control. Also, summary statistics and general population trends can mask the fact that improvements realized over decades are not equally distributed. A population health approach for IP that includes gender, Indigenous identity, rural versus urban settings, and socioeconomic disadvantage is sorely needed.

As in the past, the CPS will continue to look to our partners, notably Statistics Canada, the Canadian Hospitals Injury Reporting and Prevention Program, and the Canadian Institutes of Health Research, for the quality data needed to inform novel approaches to historic problems. Additional drivers of this work would be having new, more evidence-based interventions to offer, such as building code reforms that prioritize safety (via home sprinkler systems, hot water temperature controls, and stair tread height and width) over profit. Also, better ways to evaluate safety program uptake, success, and failure are needed. Finally, more focused IP research is needed. In 2007, injury control research was fifteenth in a list of paediatric conditions requiring funding support in Canada ^[9], with no clear signals of re-priority since. We must advocate for more such research and prioritize funding accordingly.

Today’s most pressing challenge is that we already know how to reduce risk and prevent many injuries, but we still aren’t doing enough. The CPS must stay the course and take a leading role in the field of paediatric injury control.

Dr. Richard Stanwick is the very recently retired Chief Medical Officer of Health for Island Health, B.C., past president of the CPS, and former chair of the CPS Injury Prevention Committee and CPSP Steering Committee.

References

1. Benzoni T, Gibson J. Ipecac. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 2021 Oct 31.

2. Kardamanidis K, Martiniuk A, Ivers RQ, Stevenson MR, Thistlewatie K. Motorcycle rider training for the prevention of road traffic crashes. Cochrane Database Syst Rev 2010;(10):CD005240.

3. Pan SY, Ugnat A-M, Senenciw R, Desmeules M, Mao Y, Macleod M. Trends in childhood injury mortality in Canada, 1979-2002. Inj Prev 2006;12(3):155-60.

4. Fridman L, Fraser-Thomas J, Pike I, Macpherson AK. An interprovincial comparison of unintentional childhood injury rates in Canada for the period 2006-2012. Can J Public Health 2018;109(4):573-80.

5. Parachute. Unintentional Injury Trends for Canadian Children. June 2016 (Accessed April 11, 2022).

6. Olivier J, Creighton P. Bicycle injuries and helmet use: A systematic review and meta-analysis. Rev Int J Epidemiol 2017;46(1):278-92.

7. Bunn F, Collier T, Frost C, Ker K, Roberts I, Wentz R. Area-wide traffic calming for preventing traffic related injuries. Cochrane Database Syst Rev 2003;2003(1):CD003110.

8. Brulé V, Alsarran R, Percy V, et al. 190: Banning tanning. Paediatr Child Health 2015;20(5):e101.

9. Canadian Health Services Research Foundation and Canadian Institutes of Health Research, Institute of Health Services and Policy Research, 2007. Listening for Direction: Final report to Health Canada (Accessed April 11, 2022).

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