| Abstract|| |
Background: Little attention is generally paid to paediatric injuries, especially in low income settings. The aim of this study is to provide an overview of the epidemiology of hospital-based paediatric injuries in a semi-urban area in Cameroon prior to the initiation of a formal registration system. Patients and Methods: A sixteen items data collection sheet derived from a newly instituted trauma registry is used to retrospectively gather hospital-based basic information about epidemiology of injuries in patients aged 15 years or below in a low income setting. Results: Two hundred and seventy seven cases representing 16% of all injury cases could be analysed. The frequency of injuries significantly increased with age with a peak between 11 and 15 years (P < 0.001). Children in school playgrounds carried a significantly higher risk of sustaining an injury (P < 0.001). Falls and interpersonal violence were the most frequent mechanisms. The face and locomotor systems were the most commonly involved. More than 60% of patients were discharged back home. Conclusions: The data from the present registration system seem to indicate a higher injury rate in pre-adolescent children and in the school playground. The institution of a formal registration system is likely to improve the quality of data recording system.
Keywords: e0 pidemiology, hospital-based, low income setting, paediatric injury, registration system
|How to cite this article:|
Chichom-Mefire A, Fokou M. Epidemiology of paediatric injury in low income environment: Value of hospital based data prior to the institution of a formal registration system. Afr J Paediatr Surg 2013;10:265-70
|How to cite this URL:|
Chichom-Mefire A, Fokou M. Epidemiology of paediatric injury in low income environment: Value of hospital based data prior to the institution of a formal registration system. Afr J Paediatr Surg [serial online] 2013 [cited 2021 Oct 27];10:265-70. Available from: https://www.afrjpaedsurg.org/text.asp?2013/10/3/265/120909
| Introduction|| |
Injury is now a major cause of death and disability in low income countries. Sub-Saharan Africa seems to be disproportionately affected. , The management of injury cases in such an environment is a special challenge because of sub-standard technical capabilities and complex socio-cultural environment. The problem is more acute in paediatric populations as little or no special attention is usually paid to this particularly vulnerable group of the population. ,,,, It has been estimated that as many as 95% of all childhood injury-related deaths occur in low income settings. 
Basic data on the epidemiology and impact of injuries in paediatric population are available in very few African countries. ,,,, To our knowledge, no such information is available in Cameroon. In the absence of such data, no efficient policy of prevention and management of paediatric injuries can be implemented.
Community-based surveys are difficult to implement in our environment as police reports are usually not available and post-mortem investigation are made difficult by the hostile socio-cultural background. Hospital-based surveys, though not the best tool, remain a valuable source of collection of basic data on the epidemiology of paediatric injuries. Unfortunately, the data sources available in hospitals are usually administrative records with little relevant information which could help improve on the outcome of injuries. The best known approach for a more accurate collection of hospital data on injuries is the institution of formal trauma registries which have been shown to improve injury surveillance and to be a fundamental tool for trauma quality care improvement. ,,,
We instituted a 16-item trauma registry in our hospital since September 2008, both for adults and children. We hoped to compare of basic trauma data obtained from the previous registration system with the input of the new trauma registry in describing injury cases.
The aim of this study was to provide an overview of the epidemiology of paediatric injuries in the Emergency Department of a level III institution in a low income environment. We also intended to analyse the present registration system of paediatric injury cases prior to the institution of a formal trauma registration system. This will allow us estimate the utility of a trauma registry as an injury surveillance tool.
| Patients and methods|| |
This retrospective study was conducted over a period of 1 year (between July 1 st 2007 and June 30 th 2008) at the Regional Hospital, Limbe, a level III institution located in the South West region of Cameroon. This is a hospital with a capacity of 200 beds, an emergency department functioning 24 h/day and a surgical ward with 26 beds capacity. All emergencies arriving in Limbe Hospital are managed in the casualty department for a maximum period of 24 h. They are then either admitted in the surgical ward, discharged back home or referred to the major city of Douala where two large reference hospitals with all the specialized services are located. There is no pre-hospital care system in Limbe: Patients are usually rushed to the hospital by relatives or bystanders who witnessed the accident or injury.
Over the study period, registers of the Emergency Department and call duty reports were checked for all cases of patients aged 15 years or below admitted for initial treatment of an injury belonging to one of the following predefined categories: Road traffic accident, assault (defined as intentional inter-personal injuries, including family violence), unintentional interpersonal violence, falls, domestic accidents, burns, orificial foreign body, drowning or near drowning and self-inflicted injuries.
For the purposes of exploring patterns of injury, patients who did not have age, sex, or mechanism of injury were excluded from the analysis. These exclusion criteria have been used previously in large surveys related to injuries.  Patients who attended another institution prior to consultation in the emergency department of our hospital and babies with birth injuries were excluded as well.
A 16-item one page data collection form derived from our registry of trauma was used to retrospectively collect data. These items included age, sex, profession, place of residence, mechanism of injury, type of collision and position of patient (either driver or rider, passenger or pedestrian) in cases of road traffic accident, delay before arrival to hospital, systolic blood pressure and respiratory rate on arrival, location of injury, Glasgow coma scale, description of lesions and outcome of patient's care in the Emergency Department. Whenever possible, the data were used to estimate the severity of injury using the paediatric trauma score (PTS) and the paediatric injury severity score (PISS).
Data were analysed using Epi-info 2003 and comparisons were made using the Chi-square tests with Yates correction for small samples. Results were considered significant for P values <0.05.
| Results|| |
A total of 1713 injury cases were recorded over the 1 year study period, representing 27.26% of the total number of emergency consultations in our institution. Two hundred seventy nine (16%) of these patients were aged 15 years or below. Thirty eight (13%) were excluded for lack of one or more basic information. Fourteen (5%) had attended other institutions prior to consultation. A total of 227 patients could finally be analysed.
As shown on [Figure 1], there was a peak of incidence towards the end of the year, especially in the month of September, the periodduring which children returned to school.
|Figure 1: Monthly distribution of paediatric injury cases in Limbe, 2007|
Click here to view
There were more males than females with a sex ratio of 1.25/1. For the purpose of age groups analysis, our patients were divided into three groups: Group 1 (aged 0-5 years), Group 2 (aged 6-10 years) and Group 3 (aged 11-15 years). As shown on [Figure 2], the frequency of injuries significantly increased with age groups (P = 0.004).
[Table 1] reviewed the items of our trauma registry, which were available in the data recording system prior to the institution of our trauma registry. According to this table, basic data such as blood pressure and respiratory rate were not available for a large majority of patients. Glasgow Coma Scale was never available. In cases of road traffic injuries, the type of collision was rarely indicated. For 83% of cases there was an attempt to describe the lesions, but the description available did not usually permit estimation of the PISS. This score could be estimated only in 32 (14%) cases. PTS could never be estimated.
The place where the accident occurred was specified as part of description of the mechanism in 169 patients (74%). This indicated that a significantly higher rate of accidents (40%) occurred at school (P = 0.0002). Other frequent locations included road or street (26% of cases) and home (10% of cases).
[Figure 3] displays the overall distribution of our patients according to the mechanism of injury. Falls appear to be the most frequent mechanism (n = 52), most often in school playground (n = 29). Violence included both intentional (9% of cases) and unintentional injuries (12% of cases). As shown in [Table 2], age group analysis indicates that 11-15-year old patients were significantly more exposed to RTA and to unintentional interpersonal injuries (P < 0.001).
|Figure 3: Frequency distribution of paediatric injuries according to the mechanism|
Click here to view
The location of injury was specified in 163 patients (72%) who all sustained a total of 265 injuries (mean of 1.63 injuries per patient). As shown on [Table 3], the face, soft-tissue and the locomotor systems were the most frequently involved.
|Table 3: Distribution of paediatric injuries according to their location|
Click here to view
The outcome and destination of patient after the emergency department was specified in 182 patients (80%): 112 patients (62%) were discharged back home, 11 (6%) were referred to another institution and 53 (29%) were admitted in the surgical ward. Six patients (3%) were reported dead in the Emergency Department. The specific cause of death could never be traced.
| Discussion|| |
Injury has become a leading cause of death and long term disability, especially in low income settings. ,, Generally, little specific attention is paid to the problem of the injured child and adolescent. , Most data relating to the problem of paediatric injury are from Western countries. Few data has been recorded in low income environment, especially in Africa. ,,,,
As community-based studies are difficult to implement in low income countries, the option of obtaining hospital data, based mainly on the institution of formal trauma registries, though less accurate in providing an overview of the importance of trauma in a community, remains a reasonable approach. ,,, Our choice for a 16-item register as compared to the 108 items used by Navascués et al.  or the 291 items registry of Van de Voorde et al.  is motivated by the fact that it is preferable in low income environment to use registers with the least possible number of items to make analysis possible. A similar model has been previously used and validated as an accurate predictor of outcome of injury in the adult.  There is an increasing concern about the need for developing separate registries for paediatric injuries to answer the specific concerns of this group of the population. ,
The present registration system does not permit us to assess the severity of injuries. Most basic data such as blood pressure, respiratory rate and Glasgow Coma Scale are generally not available. We need to improve on this as Engum et al.  described these data to be amongst the most accurate in predicting outcome of injury.
However, a number of useful features of paediatric injuries are clearly outlined by this study. Children are involved in more than 16% of injury cases attending the ED, similar to what have been described previously. ,, This is influenced by the age cut-off which varies widely in different studies as some authors wish to include adolescents up to 19-21 years. ,,,,, Many of the authors believe that differential age groups analysis is of interest as the incidence of injury-related death and disability has been shown to gradually increase with age. , The mechanisms seem to be correlated to age groups. ,,,
It is also clear that males are usually more affected than females, sometimes at a greater rate than what we found. ,,,, Furthermore, it appears that schools in our city are not safe as a significantly higher number of injuries occur there as compared to the road or homes. This is different from other findings pointing mainly at homes or streets. ,, This finding will need to be confirmed by the formal registration system and could serve as a base for a strong recommendation towards security in schools.
Generally, falls, road traffic accidents and domestic accidents are predominant overall mechanisms of injuries in children. ,,,,,,,,, Differential age groups analysis performed by other studies indicates little difference in the age-related incidence of falls while road traffic injuries and intentional violence seem to reach a peak towards adolescence.  This picture is confirmed by our study. If the age cut-off is increased to 19 years, the incidence of firearms injuries becomes a leading cause of injuries in older children in areas where these weapons can be reached by adolescents. 
The mean number of injuries per child in our study seems to indicate that many children are received in a situation of polytrauma. This is the only indicator of severity of injury that the present registration system could propose. The global incidence of severe injuries is usually less than four per cent. ,
In most studies published so far, systems most frequently involved in paediatric include head, face, neck and locomotor systems, though their relative contributions vary widely from one study to another. ,,,,, Differential analysis seems to indicate that head injuries, often isolated, seem to occur more frequently in infants. 
The analysis of outcome in our patients is very similar to those of Snodgrass and Ang.  who discharged 67.5 per cent of their cases. The majority of injured children who reach hospital usually survive. , The overall mortality seems to be positively influenced if management is done in a trauma centre specifically dedicated to paediatric cases. ,
| Conclusion|| |
This study is the first to propose an overview of the epidemiology of paediatric injuries in Limbe and in Cameroon. According to the present data collection system, unintentional injuries (especially falls), traffic injuries and domestic accidents are the most prominent mechanisms of paediatric injury. Traffic injuries seem to represent a special threat towards adolescence. School playgrounds also seem to be significantly associated to a higher risk of sustaining an injury. This deserves the attention of decision makers in Limbe.
However, the current registration system displays a number of limitations. It is not possible to assess the overall severity of the injury in the present situation. Furthermore, the absence of information about the exact type of vehicle involved in road traffic related injuries and about the type of collision would make any analysis of this specific mechanism meaningless.
It is likely that the institution of a formal registration system will help improve on these weak points. It is also likely to improve the capture of paediatric injury cases and permit a better appraisal of the problem of paediatric injuries in Limbe Hospital.
| References|| |
|1.||Nordberg E. Injuries as a public health problem in sub-Saharan Africa: Epidemiology and prospects for control. East Afr Med J 2000;77:S1-43. |
|2.||Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 1997;349:1269-76. |
|3.||Mock C, Abantanga F, Goosen J, Joshipura M, Juillard C. Strengthening care of injured children globally. Bull World Health Organ 2009;87:382-9. |
|4.||Holland AJ. Paediatric trauma. J Paediatr Child Health 2005;41:623-4. |
|5.||Gernaat HB, Dechering WH, Voorhoeve HW. Clinical epidemiology of paediatric disease at Nchelenge, north-east Zambia. Ann Trop Paediatr 1998;18:129-38. |
|6.||Sebastian van As AB. Paediatric trauma care. Afr J Paediatr Surg 2010;7:129-33. |
|7.||Pearson J, Stone DH. Pattern of injury mortality by age-group in children aged 0-14 years in Scotland, 2002-2006, and its implications for prevention. BMC Pediatr 2009;9:26. |
|8.||Krug E. Injury: A Leading Cause of The Global Burden Of Disease. Geneva: World Health Organization; 1999. (WHO/HSC/PVI/99.11). |
|9.||Hulme P. Mechanisms of paediatric trauma at a rural hospital in Uganda. Rural Remote Health 2010;10:1376. |
|10.||Ekenze SO, Anyanwu KK, Chukwumam DO. Childhood trauma in Owerri (south eastern) Nigeria. Niger J Med 2009;18:79-83. |
|11.||Etebu EN, Ekere AU. Paediatric accidental deaths in Port Harcourt, Nigeria: A 10-year retrospective study. Niger J Med 2004;13:140-3. |
|12.||Krabbe CA, Rutten JP, Phiri Y, Heiji HA. Prevalence and outcome of paediatric and adolescent limb fractures in rural Zambia. S Afr J Surg 2003;41:89-91. |
|13.||Abantanga FA, Mock CN. Childhood injuries in an urban area of Ghana a hospital-based study of 677 cases. Pediatr Surg Int 1998;13:515-8. |
|14.||Engum SA, Mitchell MK, Scherer LR, Gomez G, Jacobson L, Solotkin K, et al. Prehospital triage in the injured pediatric patient. J Pediatr Surg 2000;35:82-7. |
|15.||Navascués JA, Matute J, Soleto J, García Casillas MA, Hernández E, Sánchez-París O, et al. Paediatric trauma in Spain: A report from the HUGM Trauma Registry. Eur J Pediatr Surg 2005;15:30-7. |
|16.||Owor G, Kobusingye O. Trauma registries as a toll for improved clinical assessment of trauma patients in an urban African hospital. East Cent Afr J Surg 2001;6:57-63. |
|17.||Oprescu F, Peek-Asa C, Young T, Figan I, Nour D. Emergency department visits for nonfatal childhood injuries in Romania. Eur J Emerg Med 2008;15:268-75. |
|18.||American College of Surgeons Committee on Trauma. National Trauma Data Bank Report 2005. Chicago, IL: American College of Surgeons; 2005. |
|19.||Van de Voorde P, Sabbe M, Calle P, Lesaffre E, Rizopoulos D, Tsonaka R, et al. Paediatric trauma and trauma care in Flanders (Belgium). Methodology and first descriptive results of the PENTA registry. Eur J Pediatr 2008;167:1239-49. |
|20.||Kobusingye OC, Lett RR. Hospital-based trauma registries in Uganda. J Trauma 2000;48:498-502. |
|21.||O'Toole P, Callender O, O'Hare B, Walsh S, Orr D, Fogarty E. Epidemiology of major paediatric trauma. Ir Med J 2008;101:251-3. |
|22.||Agran PF, Anderson C, Winn D, Trent R, Walton-Haynes L, Thayer S. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics 2003;111:e683-92. |
|23.||DiMaggio C, Durkin M. Child pedestrian injury in an urban setting: Descriptive epidemiology. Acad Emerg Med 2002;9:54-62. |
|24.||Peng RY, Bongard FS. Pedestrian versus motor vehicle accidents: An analysis of 5,000 patients. J Am Coll Surg 1999;189:343-8. |
|25.||Danseco ER, Miller TR, Spicer RS. Incidence and costs of 1987-1994 childhood injuries: Demographic breakdowns. Pediatrics 2000;105:E27. |
|26.||Zuckerbraun NS, Powell EC, Sheehan KM, Uyeda A, Rehm KP, Barlow B. Community childhood injury surveillance: An emergency department-based model. Pediatr Emerg Care 2004;20:361-6. |
|27.||Snodgrass AM, Ang A. Unintentional injuries in infants in Singapore. Singapore Med J 2006;47:376-82. |
|28.||Zwi KJ, Zwi AB, Smettanikov E, Söderlund N, Logan S. Patterns of injury in children and adolescents presenting to a South African township health centre. Inj Prev 1995;1:26-30. |
|29.||Sznajder M, Chevallier B, Leroux G, Bruneau C, Yacoubovitch J, Auvert B. Frequency of childhood injuries: First results of the Boulogne-Billancourt registry. Rev Epidemiol Sante Publique 2001;49:125-34. |
|30.||Durkin MS, Laraque D, Lubman I, Barlow B. Epidemiology and prevention of traffic injuries to urban children and adolescents. Pediatrics 1999;103:e74. |
|31.||Engström K, Diderichsen F, Laflamme L. Socioeconomic differences in injury risks in childhood and adolescence: A nation-wide study of intentional and unintentional injuries in Sweden. Inj Prev 2002;8:137-42. |
|32.||Shabbir J, Shah MA, Nissar A, Clarke-Moloney M, Kavanagh EG, Drumm J, et al. Non-orthopaedic paediatric trauma in a regional hospital. Ir J Med Sci 2005;174:23-7. |
|33.||Tepas JJ 3 rd , Frykberg ER, Schinco MA, Pieper P, DiScala C. Pediatric trauma is very much a surgical disease. Ann Surg 2003;237:775-80. |
|34.||Bayreuther J, Wagener S, Woodford M, Edwards A, Lecky F, Bouamra O, et al. Paediatric trauma: Injury pattern and mortality in the UK. Arch Dis Child Educ Pract Ed 2009;94:37-41. |
|35.||Holland AJ, Jackson AM, Joseph AP. Paediatric trauma at an adult trauma centre. ANZ J Surg 2005;75:878-81. |
|36.||Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000;49:237-45. |
Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, P.O. 25526, Yaounde
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]