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EDITORIAL Table of Contents   
Year : 2010  |  Volume : 7  |  Issue : 2  |  Page : 61-65
Childhood trauma: The neglected childhood killer disease


Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110 029, India

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Date of Web Publication29-Apr-2010
 

How to cite this article:
Gupta DK. Childhood trauma: The neglected childhood killer disease. Afr J Paediatr Surg 2010;7:61-5

How to cite this URL:
Gupta DK. Childhood trauma: The neglected childhood killer disease. Afr J Paediatr Surg [serial online] 2010 [cited 2019 Dec 6];7:61-5. Available from: http://www.afrjpaedsurg.org/text.asp?2010/7/2/61/62842
Trauma is rightly called as the "The Neglected disease of Modern Developing Nations". Trauma causes significant morbidity and mortality both in the developed and the developing world. Over the decades, not much attention has been given to develop this as a specialty. As the economy is improving, we see the decline in the diseases such as diarrhoea, malnutrition, and infectious diseases amongst the developing nations. However, paediatric trauma which was not so common in the developing world, is now taking its toll as one of the main killers of children in the 21 st century. Children are at disadvantage as their heads are large, the vital organs are not well protected by the bony cage and also their small body bears the whole impact of the energy. As polytrauma is common (50% cases), a multidisciplinary approach is required. Peripheral injuries occur in approximately 20% of the children. However, these are the major liver, chest, and head injuries (15%), which are responsible for the high mortality in this age group.

Trauma is still the neglected and the killer disease especially in the developing world; the facilities are limited and the education is lacking. The traditional practices (streets sports with sharp objects, flying kites from rooftops with no protection, enjoying unsafe fire crackers, etc.), and various myths contribute to this problem. The mode of transport is still slow and variable. In the developing world, with the growing road traffic the incidences of trauma are also increasing. It is the mode of transport (and not the distance) that is more important for the children to reach the hospital in time and avoid the initial delay in providing care during the first golden hour.


   Magnitude of Problem Top


Traumatic injuries represent the major cause of death among children above the age of one year across the globe. It forms approximately 12% of the global burden of disease, the third most important cause of overall mortality in the developed world. [1] The available figures for the paediatric trauma from the developing world are very scant. The infrastructural facilities for treating the children suffering from various types of trauma differ a lot from country to country and city to city; air lifting the patients on one hand to the use of bullock cart on the other hand.

Trauma has been found to be the second major cause of hospitalisation among individuals below the age of 15. [2] In the US, trauma is the leading cause of death in children after the first year of life, accounting for 50% of mortality, with an injury occurring every 4 minutes and death every 6 minutes. [3]

In Europe, injury is the leading cause of death between the age group of 1-14 years, with a death occurring twice as often as a death due to cancer and eight times as often as a respiratory related death in the similar age group. [4] However, in the developing countries, congenital anomalies, infectious diseases, and malnutrition are still more common causes of morbidity and mortality in paediatric age group. In the recent past, there has been a 42% decline in the death rate due to paediatric trauma between the age group of 1-14 years during 1987-2000. [5] However, the loss of man power and the economic burden to the society are quite massive as more than 16% of the children admitted for trauma develop some kind of permanent disability. [6]

In the US, motor vehicle and traffic-related incidents are responsible for 63% of the deaths in children under 18 years, followed distantly by homicide, suicide, and drowning. The leading cause of nonfatal injuries was falling, more than 8 million nonfatal injuries receiving medical attention, whereas more than 151,000 required hospitalisation. [7]

Injuries were responsible for the largest number of admissions (46.9%), the greatest number of inpatient days (49.1%), and were the leading cause of surgical deaths (48%). The most common injury diagnosis was burns (18.1%). [8] without an appropriate action, by 2020; the road traffic injuries are predicted to become the third leading contributor to the global burden of disease worldwide and the second leading determinant of disability-adjusted life years (DALYs) in the developing countries. [9]

The risk of death following disaster like tsunami is substantially increased in children. It is due to the dependant nature of the child and lack of physical inability to escape danger. In the recent Asian tsunami, the relative lack of infrastructure, staff and equipment, the paediatric expertise in critical care and the tertiary paediatric facilities add to the mortality. [10]

In hurricane Andrew in Florida and Louisiana, 22% of the casualties were in children. Moreover, children were exposed to toxic ingestions including hydrocarbons and bleach used for power, lighting, and cleaning. [11]


   Causes and Mechanism of Injury Top


According to the geographical and social variation, blunt trauma is the most common. Mostly the trauma is accidental in children. Rarely, it could be homicidal and suicidal. Gunshot and penetrating injuries are uncommon but are seen occasionally, especially in the developed world. The data from the developing world is lacking as the trauma registry system is poor or nonexistent. In the European Union, road traffic accidents (RTAs) were the leading cause of paediatric trauma in the age group of 1-14 years, accounting for 34% of all injury-related deaths. [12]

The common causes of childhood trauma are: RTAs, falling from height, drowning in the well or the pond, homicidal injury, firearm injury, suicidal tendencies; child abuse is also becoming a common cause these days. Children also get involved in violence during the terrorist attacks, gun fires, and natural calamities such as earth quakes, failing to cry or escape. The agriculture dominated nations present a different spectrum of the trauma as the children are exposed to outwardly life with their parents at work and home. Injuries due to agricultural tools, bullock carts, animal horn injuries, dog bites, snake bites, fall from unprotected roof tops while flying kites, fall in the unprotected wells, injury due to collapse of the weak walls during the rainy season, hand and facial burns due to use of fire crackers on festival seasons are quite common.

In India, the trauma data primarily emanates out of road traffic injury estimates; the road traffic accidents are increasing at an annual rate of 3%. In 1997, 10.1% of all deaths in India were due to accidents and injuries. A vehicular accident is reported every 2 minutes and a death every 8 minutes on Indian roads, and a trauma related death every 1.9 minutes. But the exact figure of paediatric trauma is lacking in India. India losses approximately 2-2.5% of its GDP due to only road traffic injuries. [13]

In a study at the Department of Forensic Medicine, Kasturba Medical College, Manipal, during the 13 year period (1992-2004), the paediatric fatalities formed 8.5% of the total deaths due to trauma, of which road traffic accident accounted for 44.6%. [14] Following the Gujarat earthquake in 2001, more than 250,000 individuals were injured with an estimated 30,000 deaths. Also, 25% of the causalities admitted were younger than 17 years of age. Of the children needing surgery, 42% required orthopaedic attention, 42% had soft tissue trauma, 10% had burns, and 6% had miscellaneous injuries. [15] Traumatic brain injury (TBI) is the most common cause of death, following paediatric trauma accounting for more than 50%. [16]

Cost to the society

In US, the cost estimated is as following: 347 billion dollar annual cost in unintentional childhood injury, 17 billion dollar in medical cost, 72 billion dollar in future work lost, and 257 billion dollar in loss of quality of life. This is based upon the estimation that 1 in 4 children sustain an unintentional injury requiring medical care each year. [17] However, in the developing countries the cost estimate is not available but it can only be imagined with a mammoth work load due to over 1 billion children below the age of 14 years.

Management

Prehospital trauma care ideally involves a fast response transport system, where an emergency medical technician (paramedic), trained in resuscitation, and stabilisation of the injured child goes to the scene of the accident, and carries out the task of ongoing trauma care until arrival to the emergency department. [18]

In the developed nations, there are dedicated Paediatric Trauma Centers to take care of the injured children. The response is quick and patient-friendly, including air lifting the victim needed. Communication is necessary and utilised fully to coordinate the delivery of the medical care. The public and private partnership brings together the unique expertise of a paediatric hospital's staff and services to treat a wide variety of childhood injuries. Within the Center, the care of an injured child is led by a paediatric surgeon working together with the multispecialty hospital team. Children may enter the hospital system via the Paediatric Emergency Department or by transfer from their local hospital. The hospital provides the necessary education on the prevention of the trauma, psychological support as well as rehabilitation of the victim.

The Advanced Trauma Life Support (ATLS) protocol can be still followed as in the adults with the primary survey in the initial process of identifying and temporising the potentially life threatening injuries and follows the ABCDE sequence: airway, breathing, circulation, disability, and exposure. As the traumatic children have multiple traumas of varying magnitudes, a multidisciplinary approach is warranted.


   The Indian Scenario Top


Many new trauma centers are being established, especially in the metro cities. These usually handle not only the adults but also the paediatric patients. The staff is also getting slowly geared up to manage the paediatric major polytrauma as otherwise would have been managed in the tertiary care level centers. Role of media is also being highlighted. The Government agencies are also being approached to formulate necessary legislation and issue warnings wherever needed. For example, compulsory use of helmets and the seat belts in cars, declaring sale of strong acids and alkalis as poisonous items in child proof and amber color bottles, effectively covering the manholes and wells. The parents have also a major role in preventing the childhood trauma; by a close supervision of the children during kite flying, using fire crackers, crossing the roads, etc.

The Delhi centralised accident and trauma service (CATS) has been in place to transport trauma victims to the nearest tertiary care center. Even the air services are also available but only in a few centers and for a heavy cost. Many nongovernmental organisations are now coming forward to assist the hospitals and the government efforts to provide necessary support at a reasonable cost. Unfortunately due to heavy demand and insufficient number of ambulances, lack of trained personal available and so also due to the traffic congestion to transport a trauma victim, there is lot of scope for improvement. Private ambulance companies as well as private hospitals are able to provide somewhat more efficient dispatch system as well as trained personnel; however, the problem of traffic congestion and lack of uniform standards of many such private transport systems are still there. Most of the time a trauma victim is brought to the emergency room (ER)/Casualty by private vehicle by the relatives, the police, or by-standers in the event of an ambulance delay, which is a frequent occurrence. [18]

Prevention

Improvement in trauma care in Africa and other developing parts of the world will ultimately depend on the establishment of functioning trauma care systems, of which a trauma registry is a key infrastructural component. [19] The correct use of appropriate restraints for children has a significant effect on reducing the risk of motor vehicle-related injuries and death. Implementation of road safety measures are of paramount importance.

For balconies, adherence to the currently recommended spacing of 4 inches (10 cm) or less could prevent almost every child from slipping between rails. For windows, since most of the falls were through low lying windows, either window guards or modification of the window to limit its opening or keep it closed, could prevent most of these falls. Alternatively, ''child safety'' window screens may provide protection against these falls. [20]

The menace of mixing drinking and driving is being projected through public media and checked by effective policing. Highway police patrolling is ensuring safe limit of the vehicular traffic as well as transporting the victims to the nearby hospitals. Mobile phone technology has improved the communications to help faster information to the police regarding the site of the accident. Even in cases requiring completion of medico legal services, the instructions are issued not to delay the treatment.

For instance, the government of India is also quite active to take steps in checking and preventing the abuse of narcotic drugs especially among the students in the schools and colleges, banning smoking at all public places, and preventing the use of alcohol in public places including schools and the religious places. Sexual abuse in slums is being tackled by improving the social awareness and offering education. The child labour is being treated as an offense. There is a free facility for the compulsory education for the entire children up to 12 th standard. There is also a law for the minimal age and wage for work. Child rights are being protected and monitored by Child Rights national commissions. Dangerous toys and arms are made out of bounds to the children. National disaster management centers have also been opened for an immediate response in case of natural major calamity.

Registry system

Establishing a trauma registry is a step forward. This allows for the registration and continuous monitoring of the process of injury care. [21] A trauma registry provides a means of collecting and analysing pertinent epidemiologic data that can be used for the purposes of quality improvement, research, and planning. [22] It also allows the Government to get convinced in formulating the national policy and allocating appropriate funds on priority to establish the medical facilities.

Proposals

There is a need to create awareness of the problem and the availability of the facilities at the district level. The selected patients requiring higher level of services should then be referred to the regional and tertiary care level centers. There should be regional and national level centers for teaching and training this subject. The country should have some centers of national importance in the field to provide state of the art facilities including organ transplantation in case of emergencies. This cannot be achieved without the help and support from the government, philanthropists, and the nongovernment organisations, with zeal to establish and excel in this field.

Even in the developed countries, there are few paediatric emergency department skilled personal in large metros. A paediatric mass casualty event can saturate even the largest and the most capable of paediatric emergency departments. Despite this fact, paediatric disaster preparedness has received little attention worldwide. [23] The value of the expertise and capability of dedicated paediatric emergency facility and their staff must be recognised and integrated into community, regional, and national disaster response plans. There will never be sufficient highly-skilled emergency paediatric practitioners to cover all the areas of a nation for all potential paediatric disasters. As such, the expertise of the existing experts must be made available through educational outreach programs, planning groups, response teams, and other methods such as telemedicine. [24] Child beating at home and in school is a punishable offense. [25] There is a recent interest in initiating trauma research in immunobiology in the selected centers, and utilise the same to improve the outcome of the trauma patients.

Message

Paediatric trauma still remains a neglected field, more so in the developing nations. Lack of education, funds, trained staffs, and dedicated hospital, make them vulnerable to man-hours loss. Prevention is possible to a great extent in most of the cases; however, it requires an awareness, commitment and enforcement through the public, media, health workers, policy makers and other agencies. Medical and paramedical staff also needs to be trained regularly through seminars, CME programs, and workshops to manage the trauma victims with efficiency. In most of the cases, a conservative approach is effective. However, in children requiring surgical intervention for major trauma to chest, head, liver, and spleen due to haemodynamic instability, the morbidity and mortality remains a concern.

"We should not expect anything from 21 st century. It is the 21 st century that expects everything from us". (Gabriel C. Marquez)

 
   References Top

1.The World Health Report. Available from: http://www.who.int/whr/2001/en/index.html,2001. [accessed on 2006 Dec 10].   Back to cited text no. 1      
2.Irwin CE Jr, Cataldo MF, Matheny AP Jr, Peterson L. Health consequences of behaviors: Injury as a model. Paediatrics 1992;90:798-807.  Back to cited text no. 2      
3.Rockwood CA, Wilkins KE, King RE, editors. Fractures in children. Philadelphia: JB Lippincott; 1984.  Back to cited text no. 3      
4.WHO Mortality Database. Available from: http://www.who.int/whosis, 2003. [accessed on 2006 Dec 10].  Back to cited text no. 4      
5.Wallace AL,Cody BE, Mickalide AD. Report to the nation: Trends in unintentional childhood injury mortality, 1987-2000. Washington, DC: National Safe Kids Campaign; May 2003.  Back to cited text no. 5      
6.Children's Safety Network, Economics and Insurance Resource Center: Special run: Hospitalised unintentional injury among children 15 and under. Feb 2003.  Back to cited text no. 6      
7.Mendelson KG, Fallat ME. Paediatric injuries: Prevention to resolution. Surg Clin North Am 2007;87:207-28 Viii.  Back to cited text no. 7      
8.Bickler SW, Sanno-Duanda B. Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bull World Health Organ 2000;78:1330-6.  Back to cited text no. 8      
9.Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet 1997;349:1498-504. World Health Organisation. Available from: http://www.who.int/hac/events/tsunamiconf/presentations/2-10-reproductive-maternal-child-health-malnutri-senanayake.doc.pdf. [accessed on 2005 Sep 30].  Back to cited text no. 9      
10.Alson R, Alenxender D, Leonard RB. Analysis of medical treatment at a field hospital following Hurricane Andrew, 1992. Ann Emerg Med 1993;22:1721-8.  Back to cited text no. 10      
11.The World Health Report. Available from: http://www.who.int/whr/2001/en/index.html, 2001. [accessed 2006 Dec 10].  Back to cited text no. 11      
12.Indian Society for Trauma and Acute Care. Available from: http://www.traumaindia.org. [accessed on 2009 May].  Back to cited text no. 12      
13.Vikram P, Arun M, Prashantha B. Paediatric fatalities due to trauma. Medicolegal Update 2006;6:4.  Back to cited text no. 13      
14.Jain V, Noponen R, Smith BM. Paediatric surgical emergencies in the setting of a natural disaster: Experiences from the 2001 earthquake in Gujarat, India. J Pediatr Surg 2003;38:663-7.  Back to cited text no. 14      
15.Meyer T, walker ML, Johnson D. Causes of morbidity and mortality in severe paediatric trauma. JAMA 1981;245:719.  Back to cited text no. 15      
16.Tuggle DW, Garza J: Paediatric trauma. McGraw Hill Professional. Trauma 2007, chapter 46: p. 987-1001.  Back to cited text no. 16      
17.Khilani P. Management of a child with multiple trauma. Indian J Crit Care Med 2004;8:78-84.  Back to cited text no. 17      
18.Nwomeh BC, Lowell W, Kable R, Haley K, Ameh EA. History and development of trauma registry: Lessons from developed to developing countries. World J Emerg Surg 2006;1:32   Back to cited text no. 18      
19.Istre GR, McCoy MA, Stowe M, Davies K, Zane D, Anderson RJ, et al. Childhood injuries due to falls from apartment balconies and windows. Injury Prevention 2003;9:349-52.  Back to cited text no. 19      
20.Rutledge R. The goals, development, and use of trauma registries and trauma data sources in decision making in injury. Surg Clin North Am 1995;75:305-26.  Back to cited text no. 20      
21.Nwomeh BC, Lowell W, Kable R, Haley K, Ameh EA. History and development of trauma registry: Lessons from developed to developing countries. World J Emerg Surg 2006;1:32.  Back to cited text no. 21      
22.Markenson D, Redlener I. Paediatric disaster preparedness national guidelines and recommendations: Findings of an evidence based consensus process. Biosecur Bioterror 2004;2:301-14.  Back to cited text no. 22      
23.Brandenburg MA. Paediatric considerations in disasters. Disaster medicine. Lippincott Williams and Wilkins, 2nd ed. 2007. Chapter 3. p. 29-38.  Back to cited text no. 23      
24.Gupta DK. Child abuse: An ongoing stigma for the civilised society. J Indian Assoc Pediatr Surg 2007;12:79-80.  Back to cited text no. 24    Medknow Journal  
25.Gupta DK, Charles AR, Srinivas M. Paediatric Surgery in India: A specialty come of age. Pediatr Surg Int 2002;18:649-52.  Back to cited text no. 25      

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Correspondence Address:
Devendra K Gupta
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.62842

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    The Indian Scenario
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