Background

Children are exposed to many hazards and risks as they grow and develop into adulthood, and unintentional injuries are the leading cause of death and disability for children and teenagers in the United States. The physical, social, cultural, political and economic environments in which they live can significantly increase or decrease their injury risks.

What is the Definition of a Child?

Although the definition of child is culturally determined and variable, this plan uses the definition adopted by the World Health Organization (WHO) and defined in the United Nations’ Convention on the Rights of the Child, Article 1, “A child means every human being below the age of 18 years.”5 Therefore, in general, this plan defines a child as a person younger than 18 years of age. Because some data cannot be separated to fit this age group, however, the plan sometimes uses the age cutoff of younger than 20 years. WHO and CDC also define child in this way in their 2008 reports on child injury.1, 2

What is an Unintentional Injury?

Because of their size, growth and development, inexperience, and natural curiosity, children and teenagers are particularly vulnerable to injury. This plan defines injury as “the physical damage that results when a human body is suddenly subjected to energy in amounts that exceed the threshold of physiologic tolerance—or else the result of a lack of one or more vital elements, such as oxygen.”6

Addressing all causes of child injury is important. However, for practical purposes, this plan is limited to unintentional injuries. Unintentional injuries are predictable and preventable when proper safety precautions are taken – they are not “accidents.” The plan does not cover injuries that result from harm being inflicted on purpose, such as those sustained in a suicide attempt, by child maltreatment, or among children with special needs who may require a different set of injury prevention strategies.

Unintentional injuries in this action plan refer to the following causes or mechanisms of injury:

1. Motor vehicle
2. Suffocation
3. Drowning
4. Poisoning
5. Fire/Burns
6. Falls
7. Sports and recreation

We chose these seven types on the basis of several factors:

• Burden of injury
• Cost to society
• Existence of evidence-based prevention programs and policies
• Feasibility of action
• Potential for prevention that is demonstrable and measurable
• Stakeholder/partner support for prevention efforts

The seven types of injuries do not represent all causes of unintentional injury-related disability and death to children. However, they are some of the most common types found among children in the United States. For specific steps to prevent some of these leading causes of child injury, please see CDC’s Protect the Ones You Love website at www.cdc.gov/safechild. 

What is the Overall Burden of Child Injury?       

Both fatal and nonfatal child injuries are costly in many ways. In addition to the profound burden of death and disability, injuries to children can also result in substantial economic costs, including medical care for the injured child and lost productivity for his or her caregivers.

What is the Burden of Fatal Child Injuries?

The number of children dying from unintentional injuries is staggering. In the United States, more than 9,000 children die each year—about 25 deaths a day—from such injuries.4 In 2009 alone, 9,143 U.S. children died from unintentional injuries.

Unintentional injuries are the leading cause of death among children 1–19 years of age (Figure 1). They account for nearly 37 percent of all deaths to children after infancy.4  

Figure 1. The five leading causes and number of child deaths, by age group, United States, 2007

Note: Percentage totals may not equal 100% due to rounding.

Source: National Vital Statistics System from the National Center for Health Statistics, Centers for Disease Control and Prevention; accessed through WISQARS.4

The most common causes of unintentional injuries leading to death among children include motor vehicle crashes, suffocation, drowning, poisoning, and fire- and burn-related injuries (Table 1).

Table 1. The five leading causes and number of unintentional injury deaths among children, by age group, United States, 2009

Rank*	Age <1	Ages 1–4	Ages 5–9	Ages 10–14	Ages 15–19
1	Suffocation 907 (77%)	Drowning 450 (31%)	Motor Vehicle (MV) Traffic 378 (49%)	MV Traffic 491 (68%)	MV Traffic 3,242 (67%)
2	MV Traffic 91 (8%)	MV Traffic 363 (25%)	Drowning 119 (15%)	Transportation – Other 117 (15%)	Poisoning 715 (15%)
3	Drowning 45 (4%)	Fire/Burns 169 (12%)	Fire/Burns 88 (11%)	Drowning 90 (10%)	Drowning 279 (6%)
4	Fire/Burns 25 (2%)	Transportation – Other 147 (10%)	Transportation – Other 68 (9%)	Fire/Burns 53 (6%)	Transportation – Other 203 (4%)
5	Poisoning 22 (2%)	Suffocation 125 (9%)	Suffocation 26 (3%)	Suffocation 41 (5%)	Fall 58 (1%)

Source: National Vital Statistics System from the National Center for Health Statistics, Centers for Disease Control and Prevention; accessed through WISQARS.4 *Percent of all age-specific deaths in parentheses

Years of Potential Life Lost (YPLL) is an estimate of the average number of years a person would have lived if he or she had not died prematurely. In the United States between 2000–2009, unintentional injuries among children aged 1–19 years accounted for 42 percent of all YPLL. The YPLL rate due to unintentional injuries among children was five times higher than the rate for cancer, 13 times higher than the rate for heart disease, and 31 times higher than the rate for influenza and pneumonia.2 

During the past 90 years, the rate of unintentional injury-related death among young people in the United States has decreased. However, the magnitude of this reduction has significantly lagged behind death due to other preventable causes, such as influenza, tuberculosis, and other infectious diseases over the same time period (Figure 2). 

Figure 2. Reduction in death rates for persons 1–24 years of age, by cause and year, United States, 1910–2000

Source: National Vital Statistics System from the National Center for Health Statistics, Centers for Disease Control and Prevention.8

What is the Burden of Nonfatal Child Injuries?

Injury deaths tell only part of the tragic story. Each year, millions of children are injured and live with the consequences of those injuries. In 2009, more than 8.7 million children and teenagers were treated for an injury in U.S. Emergency Departments (ED), and more than 225,000 of these children had injuries severe enough to require hospitalization or transfer to another hospital for a higher level of care.4

The most common reasons for a child injury-related ED visit are falling, being struck by or against a person or object, overexertion, a motor vehicle, and being cut or pierced (Table 2).4 For some children, injury causes temporary pain and functional limitation, but for others, injury can lead to one or more of the following: permanent disability, traumatic stress, depression, chronic pain, and a profound change in lifestyle or decreased ability to perform age-appropriate activities.

Table 2. The five leading causes and number of nonfatal unintentional injuries among children treated in emergency departments, by age group, United States, 2009

Rank*	Age <1	Ages 1–4	Ages 5–9	Ages 10–14	Ages 15–19
1	Fall 147,280 (59%)	Fall 955,381 (45%)	Fall 631,381 (37%)	Fall 615,145 (29%)	Struck by/against 617,631 (24%)
2	Struck by/against 31,360 (13%)	Struck by/against 372,402 (18%)	Struck by/against 406,045 (24%)	Struck by/against 574,267 (27%)	Fall 468,967 (18%)
3	Bite/sting 10,922 (4%)	Bite/sting 137,352 (7%)	Cut/pierce 104,940 (6%)	Overexertion 276,076 (13%)	Overexertion 372,035 (14%)
4	Foreign Body 8,860 (4%)	Foreign Body 126,060 (6%)	Bite/sting 92,590 (5%)	Cut/pierce 118,440 (6%)	Motor Vehicle Occupant 341,257 (13%)
5	Fire/Burns 7,846 (3%)	Cut/pierce 84,095 (4%)	Pedal Cyclist 84,590 (5%)	Pedal Cyclist 118,095 (6%)	Cut/pierce 184,972 (7%)

Source: National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP) from the Consumer Product Safety Commission; accessed through WISQARS.4 *Percent of all age-specific deaths in in parentheses.

What are the Financial Costs of Child Injury?

In 2000, the United States paid more than $87 billion in medical and other costs, including work loss by family members who cared for injured children. When the reduced quality of life of injured children and their families is added in, unintentional injuries cost more than $200 billion each year.9

Table 3 summarizes the estimated total medical and work loss costs for the five leading causes of child deaths, and Table 4 summarizes the estimated total medical and work loss costs for the five leading causes of nonfatal unintentional injuries resulting in an ED visit in 2005, the latest year that cost data were available.4

Table 3. Number of deaths and estimated lifetime medical and work loss costs for the five leading causes of fatal unintentional injury, both sexes, ages 0–19, United States, 2005

Mechanism of Injury, Number of Deaths, and Costs
Mechanism	Number of Deaths	Total Medical Cost	Total Work Loss Cost
Motor Vehicle - Traffic	6,781	$56 million	$8.2 billion
Drowning	1,120	$5.7 million	$1.2 billion
Suffocation	1,047	$5.4 million	$987 million
Poisoning	729	$3.4 million	$924 million
Fire/Burn	529	$7.1 million	$547 million
TOTAL	10,206	$77.6 million	$11.9 billion

NOTE: Estimated unit (per injury) of lifetime medical cost (e.g., treatment and rehabilitation) and lifetime work loss cost (e.g., lost wages, benefits, and self-provided household services) associated with injury-related deaths were developed for CDC by  the Pacific Institute for Research and Evaluation (PIRE).10 For more information, go to http://www.cdc.gov/injury/wisqars.4

Table 4. Number of emergency department visits and preliminary estimated lifetime medical and work loss costs for the five leading causes of nonfatal unintentional injury, both sexes, ages 0–19, United States, 2005

Mechanism of Injury, ED Visits, and Costs
Mechanism	Number of ED Visits	Total Medical Cost	Total Work Loss Cost
Falls	2,624,153	$5.0 billion	$10 billion
Struck By/Against	1,875,890	$2.6 billion	$5.2 billion
Overexertion	799,129	$787 million	$1.6 billion
Motor Vehicle – Occupant	588,689	$496 million	$991 million
Cut/Pierce	571,269	$361 million	$722 million
TOTAL	6,459,130	$9.2 billion	$18.5 billion

SOURCES: NEISS All Injury Program operated by the U.S. Consumer Product Safety Commission (CPSC) for numbers of nonfatal injuries.

NOTE: Estimated unit (per injury) of lifetime medical cost (e.g., treatment and rehabilitation) and lifetime work loss cost (e.g., lost wages, benefits, and self-provided household services) associated with injury-related ED visits (treated and released) were developed for CDC  by  the Pacific Institute for Research and Evaluation (PIRE )10  .Updated costs for ED visits will be available from CDC in April, 2012. For more information, go to http://www.cdc.gov/injury/wisqars/.

What are the Other Costs?

The consequences of these fatal and nonfatal injuries to children carry a physical and emotional cost to the individual and our society. An injury affects more than just the injured child—it affects many others involved in the child’s life. With a fatal injury, family, friends, coworkers, employers, and other members of the child’s community feel the loss. With a nonfatal injury, family members must often care for the injured child, which can cause stress, time away from work, and lost income. The community also feels the cost burden of child injuries, as does the state and the nation. 

Who is Most Vulnerable?

Some children are at greater risk than others for an injury. Injury-related death and disability are more likely to occur among males, children of lower socioeconomic status, those living in specific geographic regions, and in certain racial/ethnic groups. The vulnerabilities in each category vary according to:

Gender

• In every age group across all races and for every cause of unintentional injury, death rates are higher for males.
• Male death rates are almost twice that of females.
• Males aged 15–19 years have the highest rates of ED visits, hospitalizations, and deaths.

Race/Ethnicity

• Unintentional injury death rates are highest for American Indians and Alaska Natives.
• Unintentional injury death rates are lowest for Asians or Pacific Islanders.
• Unintentional injury-related death rates for whites and African Americans are approximately the same (except for drowning).    

Age

• Children less than 1 year of age who die from an injury are predominantly victims of unintended suffocation or accidental strangulation.
• Drowning is the main cause of injury deaths among children aged 1–4 years.
• Most deaths of children aged 5–19 years are due to traffic injuries, as occupants, pedestrians, bicyclists, or motorcyclists.

Socioeconomic Status

• Children whose families have low socioeconomic status or who live in impoverished conditions and are poor have disproportionately higher rates of injury.
• A broad range of economic and social factors are associated with greater child injury including:
  • Economics: lower household income.
  • Social factors: lower maternal age, increased number of persons in household, increased number of children in household under 16 years, lower maternal education, single-parents.
  • Community: multi-family dwelling, over-crowding, and low income neighborhoods.

Geography

• States with the lowest injury rates are in the northeast.
• The number of fire and burn deaths is highest in some of the southern states.
• The number of traffic injuries is highest in some southern states and in some of the upper plains.
• The lowest traffic injury rates are found in states in the northeast region.

Figure 3 illustrates the geographic distribution of childhood (0–19) unintentional injury death rates per 100,000 population for all races and ethnicities in United States counties for the period 2000–2006. The shaded red portions of the country have the highest rates and dark blue indicates some of the lowest rates.

Figure 3. Age-adjusted unintentional injury death rate per 100,000 population - all races, all ethnicities, both sexes, ages 0–19 years, United States, 2000–2006.

SOURCES: CDC National Center for Injury Prevention and Control, Office of Statistics and Programming. Deaths from the NCHS Vital Statistics System. Population estimates from the U.S. Census Bureau.
NOTE: Rates based on 20 or fewer deaths may be unstable. These rates are suppressed for counties. The standard population age-adjustment represents the year 2000 – all races, both sexes. Rates appearing in the map have been geospatially smoothed. For more information, go to http://www.cdc.gov/injury/wisqars/.4

What is the Burden of Child Injury, by Cause of Injury?

Motor Vehicle-related Injuries

Motor vehicle-related injuries are the leading cause of death for U.S. children aged 5–19 years. These injuries account for 24 percent of deaths from all causes in this age group and for most (63%) unintentional injury-related deaths.4 In addition, 514,604 children were treated in hospital EDs in 2009 for nonfatal injuries from motor vehicle crashes.4 These children sustained injuries as motor vehicle occupants, bicyclists, motorcycle riders, and pedestrians.

Teen drivers are at particular risk for motor vehicle-related injury. Although they drive less than most others, they are involved in a disproportionately higher number of crashes. Among the biggest risk factors for a teen crash are inexperience, driving with other teen passengers, and driving at night.

In addition, motor vehicle crashes also contribute to traumatic fetal injury deaths during pregnancy. Stronger efforts to ensure that pregnant women are properly restrained in safety belts may reduce this problem.

Suffocation

Unintentional suffocation is a leading cause of fatal and nonfatal injury among infants and young children. More than three-quarters of injury deaths among those younger than 1 year old are due to suffocation.4 Differences between deaths attributed to Sudden Infant Death Syndrome and unintentional suffocation are not always clear.

The number of nonfatal suffocation and choking incidents among children is difficult to estimate because many of these events are not reported. Young children are more likely than adults or older children to choke because their airways are narrower, their chewing and swallowing coordination is not fully developed, and they often put non-food items in their mouths.11

Drowning

Drowning is a leading cause of unintentional injury death among all age groups of children, but especially among those aged 1–4 years.4 In 2009, African-American children had age-adjusted drowning rates that were 45 percent higher than whites (1.6 versus 1.1 per 100,000, respectively).4 The location of drowning varies based on the age of the child. Infants tend to drown in bathtubs, children aged 1–4 years in swimming pools, and older children in natural bodies of water (e.g., lakes, ponds, and rivers).12

Poisonings

In 2009, 824 U.S. children died and an additional 116,000 were treated in hospital EDs due to poisoning.4 In 2008, U.S. poison control centers received more than 1.6 million calls for children younger than 20 years of age. Nearly 80 percent of these calls were for children younger than 5 years old.14 Young children are especially at risk for unintentional exposure to prescription and over-the-counter medications.15

The number of poisoning deaths among children has doubled since 2000, with almost all of the additional deaths occurring among adolescents. For adolescents 15–19 years of age, poisoning was second only to motor vehicle crashes as a cause of unintentional injury death.4 The tremendous burden of poisonings among adolescents is partially driven by the recent steep rise in unintentional prescription drug overdose deaths among this age group. 

Fire and Burns

Fire- and burn-related injuries are a common cause of unintentional injury death among children of all ages.4 In 2009, almost 119,000 U.S. children were injured severely enough due to unintentional fires and burns that they had to visit an ED.4 Fire and burn injury rates are highest among young children because of their natural curiosity, impulsiveness, and lack of experience in assessing danger and risk.16 In addition, young children cannot typically escape from a residential fire on their own and must rely on others for rescue.

Falls

Falls are the leading cause of child injury-related ED visits, accounting for more than 2.8 million emergency department visits in 2009 and about 150 child deaths per year.4 Most fall-related injuries occur at home.17 Children commonly fall from many locations, including windows and structures, playground equipment, and bunk beds.18, 19, 20

Sports- and Recreation-related Injuries

In 2009, an estimated 2.6 million children aged 0–19 years were treated in U.S. EDs for sports- and recreation-related injuries. Although the health benefits of physical activity are clear, children who participate in sports and recreational activities are exposed to of various injury risks. High school athletes are at particular risk. High school students participating in nine sports (boys’ football, soccer, basketball, wrestling, and baseball, and girls’ soccer, volleyball, basketball, and softball) sustained an estimated 1.2 million injuries during the 2008–2009 school year.21

Preventing Childhood Injuries

Many injuries are predictable events that can be prevented and can be addressed in the same fashion and with the same fervor as preventing other public health problems. The public health approach includes identifying the magnitude of the problem through surveillance and data collection, identifying risk and protective factors, and, on the basis of this information, developing, implementing, and evaluating interventions, and promoting widespread adoption of evidence-based practices and policies.

As with other public health issues, injury prevention includes strategies on many levels, such as preventing the injury event in the first place (e.g., avoiding drinking and driving, removing hazards in the home), preventing or minimizing injury after an event has occurred (e.g., child safety seat in a crash, smoke alarms in a fire, soft playground surfaces in a fall, bike helmets when cycling), and reducing long-term consequences of injury (e.g., emergency medical services, trauma care, rehabilitation).

Another approach to injury prevention is a focus on the “Three Es”: education, enforcement, and engineering. The most effective injury prevention efforts use a combination of these strategies:

1. Education is the foundation of much of public health. It can inform the public about potential risks and safety options and help people behave safely. An example would be teaching expectant parents how to properly use a child safety seat when transporting their newborn.
2. Enforcement uses the legal system to influence behavior and the environment and can be very effective in preventing injuries, especially when combined with education. Examples include laws and ordinances requiring the use of child safety seats and bicycle helmets and enforcement of speeding limits and healthy housing codes. Adequately enforcing laws, ordinances, and regulations increases their effectiveness.
3. Engineering uses environmental and product design strategies to reduce the chance of an injury event or to reduce the amount of energy to which someone is exposed. The best engineering solutions are passive: those that do not require any effort from the person being protected.  Examples include flame-resistant sleepwear for children, safety surfacing on playgrounds, and toys without small parts. Other technological solutions require repeated action by the user, for example, installing a child safety seat, using booster seats, and installing and maintaining a working smoke alarm.  

What Costs can be Saved by Preventing Child Injury?

Besides the enormous benefit of saving children from injury-related death and disability, preventing child injury also results in cost savings to society. The cost effectiveness of interventions that prevent childhood injury compares favorably to that of many widely used public health interventions, such as immunization and water fluoridation programs.

Child injury prevention strategies such as  child occupant protection laws, smoke alarm distribution programs, and standards for child-resistant cigarette lighters are not only effective, but can be cost saving as well. Significant financial savings are associated with the use of safety products, such as smoke alarms, bicycle helmets, and child passenger restraints, as described in Table 5.

This Table shows the significant savings realized in health care and other costs for every U.S. dollar spent on a proven injury intervention.

Table 5. Estimated cost savings by select child injury intervention, 200922

Every Dollar Spent On	Saves Society
Childproof Cigarette Lighter	$72
Booster Seat	$71
Bicycle Helmet	$48
Child Safety Seat	$42
Zero Alcohol Tolerance, Driver Under 21*	$25
Smoke Alarm	$17
Pediatrician Counseling	$9
Poison Control Center	$7

*A Zero Tolerance law applies to a person under age 21 who operates a motor vehicle with a blood alcohol concentration (BAC) of .02% or more, but not more than .07%.