NIHR Signal Simple preventive actions by parents linked to fewer child injuries

Published on 3 October 2017

Education is promoted as a way to tackle the scale of avoidable injuries to young children. Children have two to five times the risk of an accident leading to injury if a parent leaves them on a raised surface, places hot drinks within reach, or does not put medicines away straight after use.

For example, children are also more than twice as likely to attend hospital for falling on stairs if their parent leaves stair gates open or does not use them.

In this NIHR-funded study, parental behaviours, use of safety equipment and home hazards were compared amongst similar children under five years who either had or hadn’t been injured at home and attended hospital.

The scale of the problem led researchers to recommend that all staff give safety advice to parents of children under five years old.

The researchers have produced a NICE-endorsed Injury Prevention Briefing, a commissioning guide, and online content for GPs and parents.

Simple preventive actions by parents linked to fewer child injuries

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Why was this study needed?

Children under five years are especially at risk from unintentional injuries in and around the home. On average from 2008 to 2012-2013 in England, these led to around 60 deaths, 450,000 A&E visits, and 40,000 emergency hospital admissions each year. The estimated annual cost of these emergency admissions is £36 million.

To improve sparse evidence on the effectiveness of parental safety measures and injury prevention interventions, the NIHR funded a Keeping Children Safe research programme from 2009 to 2014. This covered fire, scalds and other burns, falls and poisonings, which are among the main causes of injury-related hospital stays.

This Signal focuses on one part of this programme - the largest series of observational studies to date in UK injury prevention research. It aimed to find out whether parents’ and children’s behaviours and home safety equipment are associated with the risk of unintentional injury for children aged under five years in England.

What did this study do?

The case-control studies compared parents’ and children’s behaviours, use of home safety equipment and home hazards for children who had attended hospital with an injury (the ‘cases’) to similar children who had not (the ‘controls’).

One multicentre study was carried out for each of five injury types: falls from furniture, falls on one level, falls on stairs, poisonings, and scalds. Each ‘case’ child was matched to ‘control’ children of the same age and sex recruited from local GP practices. Each study included at least 300 cases and 1,400 controls.

Data from parents completing questionnaires compared well with researchers’ observations in 162 homes, but the nature of such self-reporting I a limitation to this type of study. The analysis also took into account child temperament, parental characteristics and socio-economic deprivation which could all have explained some of the differences seen. On its own, this type of research cannot prove cause and effect.

What did it find?

  • Babies aged 0 to 12 months who attended hospital following a fall from furniture were five times more likely to be left on raised surfaces compared to controls (odds ratio [OR] 5.62, 95% confidence interval [CI] 3.62 to 8.72).
  • Parents of children up to five years who attended hospital after a fall on stairs were more than twice as likely as parents of controls not to use stair gates at home (OR 2.50, 95% CI 1.90 to 3.29) and three times more likely to leave gates open (OR 3.09, 95% CI 2.39 to 4.00).
  • Parents of a child attending hospital for a scald were twice as likely as parents of controls to have households where hot drinks are left in reach of children (OR 2.33, 95% CI 1.63 to 3.31).
  • Parents of a child attending hospital for a poisoning were twice as likely as the parents of controls not to put medicines away straight after use (OR 2.11, 95% CI 1.54 to 2.90).
  • A number of other and child behaviours were also linked to hospital-attended injury. These included not teaching children about safety rules, storing medicines and household products within reach, and having stairs in need of repair.

What does current guidance say on this issue?

Public Health England and the Child Accident Prevention Trust produced guidance in 2017 for all staff who work with children under five years. They recommend healthcare workers provide advice and support to families about preventing accidental injuries in the home through contact during the Healthy Child Programme. Opportunities to identify and address safety issues could occur in a range of settings.

The NICE 2016 Quality Standard on preventing unintentional injury in children under 15 years proposed that during home visits, practitioners should assess home hazards, give advice, and refer families for a structured home safety assessment if there are concerns.

What are the implications?

Health visitors, midwives, GP practices and accident treatment centres could display safety messages in leaflets and posters such as those in the PHE 2017 guidance, and advise parents during consultations and home visits.

A separate work stream in this research programme found through systematic review that it was possible to increase parents’ use of safety gates and safe storage of medicines through parental education, low-cost or free safety equipment, and home safety assessments. However, the availability of these assessments and equipment schemes may vary across the UK.

Tailored online content for commissioners, GPs, children’s centres and parents based on the Keeping Children Safe research programme’s findings can be accessed here.

Citation and Funding

Kendrick D, Ablewhite J, Achana F, et al. Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives. Programme Grants Appl Res. 2017;5(14).

This project was funded by the National Institute for Health Research (Programme Grants for Applied Research) (project number RP-PG-0407-10231).

Bibliography

Hayes M, Kendrick D, Deave T. Injury Prevention Briefing: Preventing unintentional injuries to the under fives: a guide for practitioners. Nottingham: University of Nottingham; 2014.

Hayes M, Kendrick D. A guide for commissioners of child health services on preventing unintentional injuries among the under fives. Nottingham: University of Nottingham; 2016.

NHS Choices. Baby and toddler safety. London: Department of Health; 2016.

NICE. Unintentional injuries: prevention strategies for under 15s. PH29. London: National Institute for Health and Care Excellence; 2010.

NICE. Unintentional injuries in the home: interventions for under 15s. PH30. London: National Institute for Health and Care Excellence; 2010.

NICE. Preventing unintentional injury in under 15s. QS107. London: National Institute for Health and Care Excellence; 2016.

PHE. Preventing unintentional injuries: A guide for all staff working with children under five years. London: Public Heath England; 2017.

PHE. Reducing unintentional injuries in and around the home among children under five years. London: Public Heath England; 2014.

Why was this study needed?

Children under five years are especially at risk from unintentional injuries in and around the home. On average from 2008 to 2012-2013 in England, these led to around 60 deaths, 450,000 A&E visits, and 40,000 emergency hospital admissions each year. The estimated annual cost of these emergency admissions is £36 million.

To improve sparse evidence on the effectiveness of parental safety measures and injury prevention interventions, the NIHR funded a Keeping Children Safe research programme from 2009 to 2014. This covered fire, scalds and other burns, falls and poisonings, which are among the main causes of injury-related hospital stays.

This Signal focuses on one part of this programme - the largest series of observational studies to date in UK injury prevention research. It aimed to find out whether parents’ and children’s behaviours and home safety equipment are associated with the risk of unintentional injury for children aged under five years in England.

What did this study do?

The case-control studies compared parents’ and children’s behaviours, use of home safety equipment and home hazards for children who had attended hospital with an injury (the ‘cases’) to similar children who had not (the ‘controls’).

One multicentre study was carried out for each of five injury types: falls from furniture, falls on one level, falls on stairs, poisonings, and scalds. Each ‘case’ child was matched to ‘control’ children of the same age and sex recruited from local GP practices. Each study included at least 300 cases and 1,400 controls.

Data from parents completing questionnaires compared well with researchers’ observations in 162 homes, but the nature of such self-reporting I a limitation to this type of study. The analysis also took into account child temperament, parental characteristics and socio-economic deprivation which could all have explained some of the differences seen. On its own, this type of research cannot prove cause and effect.

What did it find?

  • Babies aged 0 to 12 months who attended hospital following a fall from furniture were five times more likely to be left on raised surfaces compared to controls (odds ratio [OR] 5.62, 95% confidence interval [CI] 3.62 to 8.72).
  • Parents of children up to five years who attended hospital after a fall on stairs were more than twice as likely as parents of controls not to use stair gates at home (OR 2.50, 95% CI 1.90 to 3.29) and three times more likely to leave gates open (OR 3.09, 95% CI 2.39 to 4.00).
  • Parents of a child attending hospital for a scald were twice as likely as parents of controls to have households where hot drinks are left in reach of children (OR 2.33, 95% CI 1.63 to 3.31).
  • Parents of a child attending hospital for a poisoning were twice as likely as the parents of controls not to put medicines away straight after use (OR 2.11, 95% CI 1.54 to 2.90).
  • A number of other and child behaviours were also linked to hospital-attended injury. These included not teaching children about safety rules, storing medicines and household products within reach, and having stairs in need of repair.

What does current guidance say on this issue?

Public Health England and the Child Accident Prevention Trust produced guidance in 2017 for all staff who work with children under five years. They recommend healthcare workers provide advice and support to families about preventing accidental injuries in the home through contact during the Healthy Child Programme. Opportunities to identify and address safety issues could occur in a range of settings.

The NICE 2016 Quality Standard on preventing unintentional injury in children under 15 years proposed that during home visits, practitioners should assess home hazards, give advice, and refer families for a structured home safety assessment if there are concerns.

What are the implications?

Health visitors, midwives, GP practices and accident treatment centres could display safety messages in leaflets and posters such as those in the PHE 2017 guidance, and advise parents during consultations and home visits.

A separate work stream in this research programme found through systematic review that it was possible to increase parents’ use of safety gates and safe storage of medicines through parental education, low-cost or free safety equipment, and home safety assessments. However, the availability of these assessments and equipment schemes may vary across the UK.

Tailored online content for commissioners, GPs, children’s centres and parents based on the Keeping Children Safe research programme’s findings can be accessed here.

Citation and Funding

Kendrick D, Ablewhite J, Achana F, et al. Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives. Programme Grants Appl Res. 2017;5(14).

This project was funded by the National Institute for Health Research (Programme Grants for Applied Research) (project number RP-PG-0407-10231).

Bibliography

Hayes M, Kendrick D, Deave T. Injury Prevention Briefing: Preventing unintentional injuries to the under fives: a guide for practitioners. Nottingham: University of Nottingham; 2014.

Hayes M, Kendrick D. A guide for commissioners of child health services on preventing unintentional injuries among the under fives. Nottingham: University of Nottingham; 2016.

NHS Choices. Baby and toddler safety. London: Department of Health; 2016.

NICE. Unintentional injuries: prevention strategies for under 15s. PH29. London: National Institute for Health and Care Excellence; 2010.

NICE. Unintentional injuries in the home: interventions for under 15s. PH30. London: National Institute for Health and Care Excellence; 2010.

NICE. Preventing unintentional injury in under 15s. QS107. London: National Institute for Health and Care Excellence; 2016.

PHE. Preventing unintentional injuries: A guide for all staff working with children under five years. London: Public Heath England; 2017.

PHE. Reducing unintentional injuries in and around the home among children under five years. London: Public Heath England; 2014.

Keeping Children Safe: a multicentre programme of research to increase the evidence base for preventing unintentional injuries in the home in the under-fives

Published on 2 August 2017

Kendrick D, Ablewhite J, Achana F, Benford P, Clacy R, Coffey F, Cooper N, Coupland C, Deave T, Goodenough T, Hawkins A, Hayes M, Hindmarch P, Hubbard S, Kay B, Kumar A, Majsak-Newman G, McColl E, McDaid L, Miller P, Mulvaney C, Peel I, Pitchforth E, Reading R, Saramago P, Stewart J, Sutton A, Timblin C, Towner E, Watson M C, Wynn P, Young B & Zou K.

Programme Grants for Applied Research Volume 5 Issue 14 , 2017

Background Unintentional injuries among 0- to 4-year-olds are a major public health problem incurring substantial NHS, individual and societal costs. However, evidence on the effectiveness and cost-effectiveness of preventative interventions is lacking. Aim To increase the evidence base for thermal injury, falls and poisoning prevention for the under-fives. Methods Six work streams comprising five multicentre case–control studies assessing risk and protective factors, a study measuring quality of life and injury costs, national surveys of children’s centres, interviews with children’s centre staff and parents, a systematic review of barriers to, and facilitators of, prevention and systematic overviews, meta-analyses and decision analyses of home safety interventions. Evidence from these studies informed the design of an injury prevention briefing (IPB) for children’s centres for preventing fire-related injuries and implementation support (training and facilitation). This was evaluated by a three-arm cluster randomised controlled trial comparing IPB and support (IPB+), IPB only (no support) and usual care. The primary outcome was parent-reported possession of a fire escape plan. Evidence from all work streams subsequently informed the design of an IPB for preventing thermal injuries, falls and poisoning. Results Modifiable risk factors for falls, poisoning and scalds were found. Most injured children and their families incurred small to moderate health-care and non-health-care costs, with a few incurring more substantial costs. Meta-analyses and decision analyses found that home safety interventions increased the use of smoke alarms and stair gates, promoted safe hot tap water temperatures, fire escape planning and storage of medicines and household products, and reduced baby walker use. Generally, more intensive interventions were the most effective, but these were not always the most cost-effective interventions. Children’s centre and parental barriers to, and facilitators of, injury prevention were identified. Children’s centres were interested in preventing injuries, and believed that they could prevent them, but few had an evidence-based strategic approach and they needed support to develop this. The IPB was implemented by children’s centres in both intervention arms, with greater implementation in the IPB+ arm. Compared with usual care, more IPB+ arm families received advice on key safety messages, and more families in each intervention arm attended fire safety sessions. The intervention did not increase the prevalence of fire escape plans [adjusted odds ratio (AOR) IPB only vs. usual care 0.93, 95% confidence interval (CI) 0.58 to 1.49; AOR IPB+ vs. usual care 1.41, 95% CI 0.91 to 2.20] but did increase the proportion of families reporting more fire escape behaviours (AOR IPB only vs. usual care 2.56, 95% CI 1.38 to 4.76; AOR IPB+ vs. usual care 1.78, 95% CI 1.01 to 3.15). IPB-only families were less likely to report match play by children (AOR 0.27, 95% CI 0.08 to 0.94) and reported more bedtime fire safety routines (AOR for a 1-unit increase in the number of routines 1.59, 95% CI 1.09 to 2.31) than usual-care families. The IPB-only intervention was less costly and marginally more effective than usual care. The IPB+ intervention was more costly and marginally more effective than usual care. Limitations Our case–control studies demonstrate associations between modifiable risk factors and injuries but not causality. Some injury cost estimates are imprecise because of small numbers. Systematic reviews and meta-analyses were limited by the quality of the included studies, the small numbers of studies reporting outcomes and significant heterogeneity, partly explained by differences in interventions. Network meta-analysis (NMA) categorised interventions more finely, but some variation remained. Decision analyses are likely to underestimate cost-effectiveness for a number of reasons. IPB implementation varied between children’s centres. Greater implementation may have resulted in changes in more fire safety behaviours. Conclusions Our studies provide new evidence about the effectiveness of, as well as economic evaluation of, home safety interventions. Evidence-based resources for preventing thermal injuries, falls and scalds were developed. Providing such resources to children’s centres increases their injury prevention activity and some parental safety behaviours. Future work Further randomised controlled trials, meta-analyses and NMAs are needed to evaluate the effectiveness and cost-effectiveness of home safety interventions. Further work is required to measure NHS, family and societal costs and utility decrements for childhood home injuries and to evaluate complex multicomponent interventions such as home safety schemes using a single analytical model. Funding The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 5, No. 14. See the NIHR Journals Library website for further project information.

The term ‘unintentional injury’ rather than ‘accidental injury’ indicates that these injuries are often predictable and avoidable.

A structured home safety assessment or inspection is carried out by a trained assessor. Using a checklist, the assessor systematically identifies home hazards, provides safety advice to parents, and suggests improvements. Parents may self-assess using home safety checklists.

Expert commentary

The incidence of accidents in the UK shows a peak at either end of life, and effective prevention has been neglected in both practice and research. The concluding 16 instructions in this report offer practical preventive advice and many are simple and sensible. Depending on ‘good parenting’ may not be sustainable in vulnerable families.

A greater emphasis on simple structural home alterations, alongside better training of daycare staff, may offer alternative risk reduction. Alas, this depends on small, but out of reach resources unless accident prevention is prioritised by commissioners and internal design of homes takes injury reduction seriously.

Dr Yvonne Doyle, Director for London, Public Health England

Categories

  •   Child Health, Public Health, Social care, Trauma