Childhood Injury and Death
Statement for the Record on Unintentional Childhood Injury and Death by Mark L. Rosenberg, M.D.
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
Before the Senate Committee on Labor and Human Resources
May 5, 1998 8
Mr. Chairman and Members of the Committee, I am pleased to submit this statement for the
record on behalf of the Centers for Disease Control and Prevention.
As the Nation's prevention agency, CDC's mission is to promote health and quality of life by
preventing and controlling disease, injury, and disability. In the area of injury prevention and
control, CDC strives to reduce the incidence, severity, and adverse outcomes of injury. CDC
accomplishes this through research, surveillance, program implementation and evaluation, and
communications. CDC works closely with other federal agencies; national, state, and local
organizations; state and local health departments; and research institutions across the country.
For example, we are proud of our collaboration with the National SAFE KIDS Campaign, the
National Highway Traffic Safety Administration, the Consumer Product Safety Commission,
which testified at this important hearing.
My statement summarizes CDC's injury prevention efforts, particularly those focusing on
children, and describes some of the intervention strategies known to be effective.
Injury In the United States
Unintentional and intentional injuries combine to be the leading cause of death for Americans
aged 1 to 44 years. In the United States, more than 400 people die of injuries every day; at least
58 of the daily death toll are children. In addition to these deaths, thousands more are non-fatally
injured, many of whom suffer permanent disabilities. Injuries also claim more years of potential
life lost before age 65 (YPLL-65) than any other cause of death. YPLL-65, which is a way of
calculating the magnitude of the loss from injury and disease, measures the difference between a
person's age at death and age 65. By calculating loss of life this way, the measurement weighs
more heavily those conditions that kill children, teenagers, and young adults.
More children die or become seriously hurt from injuries than from all childhood diseases
combined. Each year, more than 21,000 children aged 1 to 19 are killed; an estimated 600,000
are hospitalized; 12 million are seen in emergency departments because of injuries; and more
than 50,000 are permanently disabled. The number of children who have serious lasting
impairments as a result of brain injury is estimated to be even greater than the number who die
from this cause. CDC estimates that, each year, there are more than 10,000 children who become
disabled from brain injury. The lifetime cost of injury for 0-14 year olds is estimated to be well
over $13.8 billion annually.
It is at these younger ages where severe injuries that may require many years or a lifetime of
medical care or rehabilitation create the greatest social and financial burdens. Investments made
in preventing these deaths and injuries have the potential to save billions of dollars.
Although the greatest cost of injury is in human suffering and loss, the financial cost is
staggering. Including direct medical care and rehabilitation as well as lost income and
productivity, injury costs are estimated at more than $224 billion. This represents an increase of
42% over the last decade. The savings from preventing injury, as compared with treating it and
its consequences, are dramatic. Every dollar spent on:
- bicycle helmets saves $29
- child safety seats saves $29
- smoke detectors saves $65
- counseling by pediatricians to prevent injuries saves $10
- poison control center services saves $7 in medical costs
CDC Leadership in Prevention
Whereas other agencies have regulatory or enforcement roles, CDC is a scientific
organization concerned with public health. CDC uses science to understand the causes of injury
and how it occurs; applies the findings from scientific studies to design and evaluate strategies to
prevent injury; and works to bring together into a successful partnership the varied groups
dedicated to addressing and solving the problem of injury in America. CDC scientists study
prevention of unintentional and intentional injuries, and the disabilities caused by injury, as well
as ways to improve acute care systems and rehabilitation.
CDC administers a grants program of more than $20 million for extramural research in the
three phases of injury control (prevention of injury, acute care for the injured, and rehabilitation),
and the two major disciplines of injury control research (epidemiology which looks at the risks
for injury, and biomechanics which studies how the human body reacts to impact). CDC funds
Injury Control Research Centers, which work in all three phases of injury control, and also serve
as training centers for public health professionals and information centers for the public. In
addition, CDC funds individual studies, and small projects of two or more related studies.
CDC also funds state and community injury prevention programs, including surveillance and
intervention design in a number of injury areas.
In its efforts to prevent injury, CDC works extensively with numerous partners, including
Federal agencies, state and local governments and organizations, and voluntary and professional
organizations. CDC and its partners are demonstrating the efficacy of a science-based, public
health approach in several areas of unintentional and intentional injury, including residential
fires, drownings, poison control, recreational activities, youth violence, family and intimate
partner violence, sexual assault, suicide, and traumatic brain injury.
Childhood Injury Prevention
CDC and its partners are working to prevent childhood injuries: to make children safe at
home, safe at school, safe in communities, and safe on the move. In this section of my statement,
I will focus on our work in childhood unintentional injury.
A. Child Restraints
What is the problem?: Motor vehicle crashes are the leading cause of unintentional
injury-related death among children ages 14 and under. According to the National Highway
Traffic Safety Administration, 2,761 child occupants ages 14 and under died in motor vehicle
crashes in 1996. Children ages 4 and under accounted for 35 percent of these childhood motor
vehicle occupant deaths. The majority of these deaths result from fatal head injuries, especially
among the youngest children. Children are particularly at risk from death and injury as
occupants in motor vehicles.
What are the causes? Riding unrestrained is the greatest risk factor for death and injury among
children as occupants in motor vehicles. In 1996, it is estimated that 85 percent of infants
(children under age 1) were restrained while riding in motor vehicles. However, usage rates
sharply declined as a child's age increased. Only 60 percent of children ages 1 to 4 and 65
percent of children ages 5 to 14 were restrained by child safety seats or safety belts. Unrestrained
children are more likely to be injured, to suffer more severe injuries, and to die in motor vehicle
crashes than children who are restrained.
What works to prevent the problem? Child safety seats are extremely effective when correctly
installed and used, reducing the risk of death by 71 percent for infants (under age 1) and by 54
percent for toddlers (ages 1 to 4), and reducing the need for hospitalization by 69 percent for
children ages 4 and under. From 1982 through 1995, it is estimated that 2,934 lives were saved
by child restraint use. Nearly 280 children ages 4 and under were saved as a result of child
restraint use in 1995 alone. Child safety seats and safety belts not only reduce health care costs
by preventing injury, but among children hospitalized for motor vehicle-related injuries, those
unrestrained are more severely injured and incur 60 to 70 percent greater hospital costs. Every
child safety seat saves this country $85 in direct medical costs and an additional $1,275 in other
costs to society (Childhood Injury: Cost and Prevention Facts, Ted Miller, CSN Economics and
Insurance Resource Center).
CDC Leadership: Child occupant protection and safety belt use laws are proven effective at
increasing the rate of restraint use. All 50 states, the District of Columbia and all U.S. territories
have child occupant protection laws, which allow police to stop vehicles solely for violations of
child restraint laws. These laws vary widely in their age requirements, exemptions, enforcement
procedures and penalties. In 1996 and 1997 CDC published recommendations for preventing
injuries associated with air bags to infants and children in child restraints. These included the
recommendations that infants in rear-facing child safety seats should never ride in the front seat
of a vehicle equipped with a passenger air bag and that infants in rear-facing child safety seats
always must ride in the back seat facing the rear of the car (CDC's Morbidity and Mortality
Weekly Report (MMWR) 1996; 45:1073-6, MMWR 1997;46:1098-9).
B. Bicycle-related Head Injuries
What is the problem? Head injury accounts for 44% of all deaths resulting from injuries in the
U.S. Head injuries account for 62% of bicycle-related deaths, for 33% of those admitted to
emergency departments, and 67% of bicycle-related hospital admissions. Each year about
153,000 children receive treatment in hospital emergency departments for bicycle-related head
What are the causes? 96% of bicyclists killed in 1996 were not wearing helmets. Perhaps the
most important reason people don't wear helmets is a failure to appreciate the risk of head injury
from bicycling and the effectiveness of helmets in preventing these injuries. Many riders feel
they need not worry about being injured if they aren't riding in traffic. However, statistics show
that many bicycle-related head injuries do not involve traffic collisions, rather, they are caused
by falls, crashing into fixed objects, equipment failures, being chased by dogs, and colliding with
other cyclists. Among children, fear of peer ridicule is a key factor in not wearing helmets.
Other reasons for not wearing a helmet include cost, appearance, and ventilation. A very small
percentage of youth report wearing helmets all or most of the time.
What works to prevent the problem? Bicycle helmets have been shown to reduce the risk for
head injury by as much as 85% and the risk for brain injury by as much as 88%. It is estimated
that 75% of bicycle-related fatalities among children could be prevented if all children on
bicycles wore helmets. Universal use of bicycle helmets by children ages 4 through 15 years old
would prevent between 135 and 155 deaths, between 39,000 and 45,000 head injuries, and
between 18,000 and 55,000 scalp and face injuries annually. Intensive intervention efforts in the
Pittsburgh community in California (through funding from CDC) resulted in an increase in
bicycle helmet usage among elementary students from 21.5% to 32.9%.
CDC Leadership: In 1995, CDC published recommendations for bicycle helmet use that
included a review of the research concerning helmet use, a discussion of standards, and strategies
that should be implemented to increase helmet use. These recommendations were disseminated
throughout the public health community, to public safety organizations, and to individuals and
organizations that work with youth. In addition, to better understand how to increase helmet
usage rates and increase program effectiveness, CDC currently funds 5 states to implement and
assess programs promoting the use of bicycle helmets.
C. Playground Injuries
What is the problem? The United States Consumer Product Safety Commission has reported a
dramatic increase in childhood playground related injuries over the past two decades. In 1977,
93,000 injuries were reported as contrasted to more than 200,000 in 1996. Children ages 5 to 14
account for 70 percent of these playground-related injuries.
What are the causes? It is estimated that one-third of playground-related fatalities and 70 percent
of injuries occur on public playgrounds. More than 70 percent of playground-related injuries
involve falls to the surface and 9 percent involve falls onto equipment. Yet, more than 90
percent of public playgrounds lack adequate protective surfacing. Falls account for 90 percent of
the most severe playground-related injuries (mostly head injuries and fractures) and one-third of
fatalities. Head injuries are involved in 75 percent of all fall-related deaths associated with
playground equipment. Lack of supervision is associated with 40 percent of playground injuries.
What works to prevent the problem? More resilient playground surfaces, and greater attention to
the role of supervision, training, and hazard identification in risk management and injury
reduction on playgrounds. Despite prior research and the magnitude of the playground injury
problem, most communities do not promote, mandate, or enforce standards based on published
guidelines for playground surfaces and playground equipment. Few teachers, parents, or
students have been properly trained in the appropriate use of playground equipment or the
importance of supervision during play. While some measures to address these problems have
been initiated, until 1995, there was no coordinated national effort at promoting the prevention
of playground injuries.
CDC Leadership: In October 1995, CDC funded the University of Northern Iowa to establish a
National Program for Playground Safety (NPPS). The NPPS developed the National Action Plan
for the Prevention of Playground Injuries through a consensus process with an advisory board.
The national plan recommends a number of actions centering around four issues: age appropriate
playgrounds, maintenance of playgrounds, supervision of children, and proper playground under
surfacing. Implementation of the plan will involve six broad actions: a) leadership in galvanizing
implementation of the plan; b) partnering with others to implement the plan; c) training those
involved in playground safety; d) performing clearinghouse and information dissemination
functions to support the plan; e) conducting national surveillance on playground hazards and
playground injuries; and, f) conducting research on playground surfacing and defining a research
agenda. The plan calls for actions at the national, state and local levels to help prevent the annual
200,000 emergency department-treated playground injuries incurred by America's children.
D. In-line Skating Injuries
What is the problem? In-line skating is the fastest growing recreational sport in the U.S. In 1993,
there were about 12.6 million in-line skaters in the U.S., an increase of 37% from the previous
year. An estimated 17.7 million people younger than 18 years participated in this sport in 1996,
a 24% increase over the previous year. As the sport has grown, so has the number of
In 1996, an estimated 76,000 children and teenagers younger than 21 years were injured
sufficiently while in-line skating to require emergency department care. Most in-line skating
injuries are to wrists, arms, and legs. Approximately 5% of all injured in-line skaters suffered
head injury and 3.5% of the injured in-line skaters required hospitalization.
What are the causes? Risk factors associated with injury and the likelihood of injury are
presently under study. It seems that speed, obstacles, lack of protective gear, and the hard impact
surface all contribute to the risk of injury. Many of those injured were first-time skaters who lost
control and fell.
What works to prevent the problem? The importance of wearing safety equipment must be more
heavily promoted. Instructions should be readily available on how to stop safely by using brake
pads at the heel of most in-line skates. Avoid skating on streets, driveways, or surfaces with
water, sand, gravel, or dirt.
CDC Leadership: CDC collaborated with CPSC to recommend and promote the use of 1)
helmets; 2) wrist guards; and, 3) knee and elbow pads to help prevent injuries among in-line
skaters. It is also important to ensure a safe skating environment for all users of facilities where
in-line skating is to be allowed. The in-line skate industry plays a role in educating the consumer
public about in-line skate products and safety awareness through posters and advertisements that
promote safe skating.
F. Deaths from Residential Fires
What is the problem? In 1996, there were an estimated 417,000 residential fires in the United
States, which killed 4,035 individuals and injured an additional 18,875 people. Fires are the
second leading cause of unintentional injury death among children. In comparison with the total
population, children aged four years and younger have a fire death rate more than twice the
national average. About 800 children ages 14 and under die by fire each year, and 55% of these
children are under the age of five. The leading reason for this excess is that children react less
effectively to fire than adults, but it is also true that they generally sustain more severe burns at
lower temperatures than adults. Losses to society from childhood burn deaths and injuries total
approximately $5.5 billion annually. Two-thirds of fire-related deaths and injuries among
children under age 5 occur in homes without working smoke alarms. Black, Hispanic, and
Native American children are at higher risk than white children for home fire deaths.
What are the causes? About 8% of US households do not have at least one smoke alarm
installed. A large percentage of these households have incomes below $15,000 per year. Among
households that are equipped with smoke alarms, a large proportion of the alarms are not
properly maintained (e.g., batteries are dead, batteries removed because of nuisance alarms, or
the unit is disconnected). An observational study by CPSC found that 27% of households with
alarms had inoperable alarms.
What works to prevent the problem? One of CDC's first injury control programs was conducted
by the Oklahoma Department of Public Health. This CDC-sponsored project in Oklahoma City
demonstrated the effectiveness of targeting parts of the city with the highest fire-related death
rates with a program that delivered and installed smoke alarms, and ensured that the alarms
remained operable. This project reduced burn-related deaths by 83% during the study period
while the rate in the rest of the city rose 33%. Data from the project show that each dollar spent
on smoke alarms saves $20 in injury-related costs in the state.
CDC Leadership: Through its Residential Fire Injury Prevention Initiative, CDC is working with
a number of other public and private organizations to conduct a fire-related injury prevention on
program in three states and two cities which have some of the highest fire-related death rates in
the country: Mississippi, Arkansas, Alaska, Cleveland, and Atlanta. The program will develop,
implement, and evaluate an educational tool targeting high risk residents and will conduct
targeted smoke alarm distribution programs. CDC also is working with 5 state health
departments to evaluate the most effective method of distributing smoke alarms in high risk
Last year, CDC provided one time funding to support a Mississippi State Department of Health
effort to prevent fire-related deaths in Benton County. With these funds, 912 smoke alarms were
purchased and distributed to Benton County homes in an attempt to address a long-standing fire
death problem in that region. CDC staff worked with staff in the Mississippi Department of
Health to develop a residential fire injury prevention program that utilizes community volunteers
to distribute the smoke detectors and provide community education and support. A year after
this program was instituted, Benton County reportedly went from having the highest residential
fire death rate in Mississippi to no fire-related deaths.
CDC has also enumerated and described key elements of 50 smoke detector project of various
types from across the U.S. and compiled these findings in an inventory for use by those intending
to conduct smoke detector promotion programs. The inventory has been widely distributed.
Opportunities for Prevention
A Safe America means putting appropriate and effective strategies in place in our
communities. For example, many important interventions are in place: seat belts, child restraint
seats, bicycle helmets, educational programs in schools, smoke detectors, and many more. The
success of many of these programs is due in part to the determination of people to prevent or
control injuries in their communities. We also must raise public awareness.
To achieve the greatest success for the Nation, we must identify the populations most at risk
and overcome the barriers to injury prevention, including attitudes, environment, and behavior.
We must identify effective strategies and model programs, and replicate effective efforts
nationwide. We must conduct research in injury prevention, coordinate work being done in the
field, and promote professional education and training in injury prevention.
In sum, we must strengthen the science base for injury prevention, and implement effective
interventions in communities throughout our Nation. And importantly, we must make a firm
commitment to assure a safe future for our children.