burden of child injury with special reference to developing countries

5. I am
Handle
me
with
care!

6. ChildhoodChildhood
IInjurynjury
((ACCIDENTS IN CHILDRENACCIDENTS IN CHILDREN))Dr mohammad nurul huq
Bdangladesh Medical College

7. In HICs

8. At the end of this you will learnAt the end of this you will learn
 Impact of injury isImpact of injury is devastatingdevastating
 95% child injuries95% child injuries (CI)(CI) occur in L&MICsoccur in L&MICs
 DrowningDrowning is a great killeris a great killer
 Control of CI is essential to achieve MDG4Control of CI is essential to achieve MDG4
 ID and Mn. are controlled, but CI is clearly a big problemID and Mn. are controlled, but CI is clearly a big problem
 Most CI are preventable!Most CI are preventable! Px program must be integratedPx program must be integrated
into all child health initiativesinto all child health initiatives
CI: child injuries.CI: child injuries. Px: preventionPx: prevention
L&MIC:L&MIC: low-income -, MIC: middle-income countrieslow-income -, MIC: middle-income countries

9. InjuryInjury
Definition:Definition: is the intentional/un- damage to body from ac.is the intentional/un- damage to body from ac.
exposure to thermal, mechanical, electrical, or chemicalexposure to thermal, mechanical, electrical, or chemical
energy or from the absence of such essentials as heat/O2energy or from the absence of such essentials as heat/O2
90% are unintentional90% are unintentional

10.  >2k/d or 9,30,000 U-18y die/y9,30,000 U-18y die/y fromfrom unintentionalunintentional CICI:: (=(=toto
death from DPT, measles, poliodeath from DPT, measles, polio.. >50% from>50% from RTA ,RTA , drowningdrowning
 Tens of millions are admitted/y for non-fatal CITens of millions are admitted/y for non-fatal CI
 CI isCI is a significant MM since 1y age anda significant MM since 1y age and the leading c/ofthe leading c/of
death for >9y agedeath for >9y age
 Impact of CI is hidden by other c/of U-5MImpact of CI is hidden by other c/of U-5M
MM: morbidity and mortalityMM: morbidity and mortality
World Figure of CI:World Figure of CI: >12% of disease burden>12% of disease burden

11. Common CIs:Common CIs: drowning, RTA, burns, falls, homicide,drowning, RTA, burns, falls, homicide,
poisoning.poisoning. Drowning is number 1 killer among 1-Drowning is number 1 killer among 1-
4y age in Bangladesh4y age in Bangladesh
 In HICs: CIs account for 40% of all child deaths;In HICs: CIs account for 40% of all child deaths; but manybut many
countries have reduced it by 50%countries have reduced it by 50%
World Figure of CI …World Figure of CI …

15. CIs are strongly related to social determinantsCIs are strongly related to social determinants

17. Children are at greater riskChildren are at greater risk
 Children live in a world built for adults: strong associationChildren live in a world built for adults: strong association
between injuries andbetween injuries and
– his age, developmental stagehis age, developmental stage
– his interactions and activities with/in the worldhis interactions and activities with/in the world
– lack of supervision, access to protective materialslack of supervision, access to protective materials
 Simply reproducing injury Px. strategies for adults maySimply reproducing injury Px. strategies for adults may
not be effective for childrennot be effective for children
 World becomes dangerous for them: cleaning chemicals,World becomes dangerous for them: cleaning chemicals,
outlets, ovens, sharp corners, kerosene lamps, bodies ofoutlets, ovens, sharp corners, kerosene lamps, bodies of
water, traffic, etc.water, traffic, etc.

19. Impact of CIImpact of CI
• Losing a child unexpectedly has a huge impactLosing a child unexpectedly has a huge impact
on families and communitieson families and communities
• DisabledDisabled children may have poor social dev.,children may have poor social dev.,
education, work, etc.education, work, etc.
• CIs place significant strain on overstretchedCIs place significant strain on overstretched
health care systems in L&MICshealth care systems in L&MICs
Injury Px is a v. cost-effective!Injury Px is a v. cost-effective!

20. RTA: leading c/of death in 10-19yRTA: leading c/of death in 10-19y
• 720 children720 children die/d. 10million non-fatally injured/ydie/d. 10million non-fatally injured/y
• The biggest killer in 15-19y and the 2The biggest killer in 15-19y and the 2ndnd
in 10-14yin 10-14y
• RTA and falls are main c/of disabilitiesRTA and falls are main c/of disabilities
• HICs:HICs: most victims are occupants of vehiclesmost victims are occupants of vehicles
• L&MICs:L&MICs: they are usually pedestrians or cycliststhey are usually pedestrians or cyclists
• The most common injuries: head injuries and fractureThe most common injuries: head injuries and fracture
RTI: road traffic injury. RTA: - - accidentsRTI: road traffic injury. RTA: - - accidents

21. RTI: What works?RTI: What works? Road safetyRoad safety
 Helmets. Minimum drinking-age lawsHelmets. Minimum drinking-age laws
 Lower BAC for novice drivers and zero toleranceLower BAC for novice drivers and zero tolerance
 Graduated driver licensing systemsGraduated driver licensing systems
 Seat-belts, child-restraints. Speed reduction (Seat-belts, child-restraints. Speed reduction (school,school,
residence, play areas)residence, play areas)
 Separating road users:Separating road users: bicycle and pedestrian lanesbicycle and pedestrian lanes
 Daytime running lightsDaytime running lights
 Enforce traffic law, straighten roadsEnforce traffic law, straighten roads

24. 11

26. Falls:Falls: the leading c/of ED visitthe leading c/of ED visit
• 47,000 children die /y47,000 children die /y
• For every fatal fall 690For every fatal fall 690
children miss schoolchildren miss school
• Falls are the leading c/ofFalls are the leading c/of
long term disabilitylong term disability
c/of: cause of. ED: emergencyc/of: cause of. ED: emergency
departmentdepartment

27. Falls: World FactsFalls: World Facts
 130 die/d: 60% from a height130 die/d: 60% from a height
 In some countries: 50% children ED visits are for fallIn some countries: 50% children ED visits are for fall
 Non-fatal falls:Non-fatal falls: significant Disability Adjusted Life Years lostsignificant Disability Adjusted Life Years lost
 Commonest falls:Commonest falls:
– prams, baby walkers, changing tablesprams, baby walkers, changing tables
– cots, beds, bunk bedscots, beds, bunk beds
– rooftops, windows, stairsrooftops, windows, stairs
– playground equipmentplayground equipment
– Trees; sportsTrees; sports

28. Children playing on roofs is a common sight inChildren playing on roofs is a common sight in
many Asian countriesmany Asian countries

31. FallsFalls are leading c/of CI inare leading c/of CI in BangladeshBangladesh and 1 of theand 1 of the
major c/of permanent disabilitymajor c/of permanent disability
 770 children are injured/d and770 children are injured/d and 5 die5 die
 10 are disabled/d10 are disabled/d
 MajorMajor categories: from trees, cliffs, buildings, windows,categories: from trees, cliffs, buildings, windows,
roofs, furniture, jumping/diving into waterroofs, furniture, jumping/diving into water
 Infants have the highest rates ofInfants have the highest rates of
fatal fallsfatal falls

32. Common causes of falls in BangladeshCommon causes of falls in Bangladesh
 The roads in rural areas become slippery when wetThe roads in rural areas become slippery when wet
 The concrete slabs around tube-wells also becomeThe concrete slabs around tube-wells also become
slippery when wetslippery when wet
 Children fall from their beds or cots, or slip from the lap ofChildren fall from their beds or cots, or slip from the lap of
another childanother child
 Young children also fall when they learn how to walkYoung children also fall when they learn how to walk

33. Falls: What works?Falls: What works?
 Redesigning nursery furniture and other productsRedesigning nursery furniture and other products
 Safe playground: appropriate surface, material, height ofSafe playground: appropriate surface, material, height of
equipment and maintenanceequipment and maintenance
 Legislating for window/roof guards, rLegislating for window/roof guards, railingailing
 Multifaceted community programs:Multifaceted community programs: ‘Children can't fly’‘Children can't fly’
 All should be careful about childrenAll should be careful about children
 Prevent them from climbing and slippery surfacesPrevent them from climbing and slippery surfaces
 Hold children on rickshawsHold children on rickshaws
 Ensure children’s shoes are not slipperyEnsure children’s shoes are not slippery

34. Burns:Burns: only CI more common in girlsonly CI more common in girls

35. Burns: World FactsBurns: World Facts
 260 die from burn/d260 die from burn/d
 The death is x11 in L&MICsThe death is x11 in L&MICs
 Infants are at highest riskInfants are at highest risk
 Smoke inhalation alone can be fatalSmoke inhalation alone can be fatal
 25% from fire, 75% from hot liquids, steam, electricity, etc25% from fire, 75% from hot liquids, steam, electricity, etc
 Many children are disfiguredMany children are disfigured

36. Burns in Bangladesh

37. Risk factors for burn in BangladeshRisk factors for burn in Bangladesh
 Young children are the most vulnerableYoung children are the most vulnerable
 Rural children: >4 times at riskRural children: >4 times at risk
 Homes are the most common placeHomes are the most common place
 The kitchen is the most hazardousThe kitchen is the most hazardous
 KupiBatiKupiBati (kerosene lamp): 10% of the total flame burns(kerosene lamp): 10% of the total flame burns
 46% of burns occur between breakfast to lunch46% of burns occur between breakfast to lunch

38. Burns: What works?Burns: What works?
 Laws for smoke alarmsLaws for smoke alarms
 Child-resistant lightersChild-resistant lighters
 Laws for tap water temp.Laws for tap water temp.
 Educating the publicEducating the public
 Caution in transporting hot water, drinksCaution in transporting hot water, drinks
 Rx at a dedicated burns centreRx at a dedicated burns centre

39. Poisoning:Poisoning: World FactsWorld Facts
 >45,000 die/y
 Highest for U-1y, but peaks again at 15y and older as theyHighest for U-1y, but peaks again at 15y and older as they
experiment with substancesexperiment with substances
 Fatal poisoning is x4 in L&MICs than HICsFatal poisoning is x4 in L&MICs than HICs
 The most common poisons in L&MICs are paraffin,The most common poisons in L&MICs are paraffin,
household products and drugshousehold products and drugs
 In HICs these are OTC drugs, household products,In HICs these are OTC drugs, household products,
prescription drugsprescription drugs

40. Substances found in and around the home are mostSubstances found in and around the home are most
commonly involved in childhood poisoningcommonly involved in childhood poisoning
• Many millions of calls are made to poison control centres,
most of which are resolved over the phone
• Children <1y of one are at greatest risk of fatal poisoning.

41. Poisoning: What works?Poisoning: What works?
 Toxin free home. Removing the toxic agent
 Child-resistant packaging of drugs and poisons
 Packaging drugs in non-lethal quantities
 Store out of reach of children
 Air pollution, smoking, arsenic mitigation
 Establishing poison control centres

42. World Child Health ProjectsWorld Child Health Projects
Convention on Rights of a Child:Convention on Rights of a Child: 19891989
 Protect childrenProtect children. They have the right to the best health. They have the right to the best health
care and a safe environ., free from injury and violencecare and a safe environ., free from injury and violence
WHA resolutionsWHA resolutions
 Children are frequently mentioned in allChildren are frequently mentioned in all resolutionsresolutions
8 MDGs: 48 MDGs: 4thth
 to cut 2/3to cut 2/3rdsrds
U-5MR; not attainable if CI is not controlledU-5MR; not attainable if CI is not controlled

43. UNGA:UNGA: A world fit for childrenA world fit for children (including(including CI)CI)
Child SurvivalChild Survival is an important issue globally. It is “theis an important issue globally. It is “the
most pressing moral dilemma”most pressing moral dilemma”
The Bellagio PapersThe Bellagio Papers
 CI Px should be integrated into all child health initiativesCI Px should be integrated into all child health initiatives
 2/32/3rdsrds
of 11million U-5MR can be reduced by adding 23of 11million U-5MR can be reduced by adding 23
proven cost-effective interventions for CIproven cost-effective interventions for CI

44.  U-5MR from ID is now low:U-5MR from ID is now low: CI is aCI is a major killermajor killer
 14% of all death: 50/100,00014% of all death: 50/100,000
 53% death in 5-17y-age53% death in 5-17y-age
(increasing with age)(increasing with age)
 U-18y MRU-18y MR
 CI mortality:CI mortality: 30,000/y30,000/y (drowning(drowning
17,000/y)17,000/y)
– injury morbidity:injury morbidity: 9,55,500/y (9,55,500/y (permanentpermanent
disabilities13,134/y)disabilities13,134/y) contdcontd
Bangladesh ScenarioBangladesh Scenario

45. U-18y CI mortality: 30,000/y
– Drowning: 17,000 (46 /d)
– RTA 3,400
– Animal bite 2,600
– Suicide 2,200
(15-17y; 6/d)
– Others 4,800
U-18y CI morbidity
9,55,500: 30% of all morbidity:
16/1000 (13000 permanent disability)
– Fall 2,81,500
– Burn 1,73,000
– Cut 1,22,500
– RTA 1,11,500
– Near drowning 68,800
– Others 1,98,200

46.  Every 2 min a child is injured. Lack of care and supervisionEvery 2 min a child is injured. Lack of care and supervision
are main reasonsare main reasons
 Caregivers are often preoccupied (poor, both parentsCaregivers are often preoccupied (poor, both parents
working, living in cities)working, living in cities)
 Low awareness of or indifference to risksLow awareness of or indifference to risks
 Harmful practices often make situations worse withHarmful practices often make situations worse with
absence of first-aid knowledgeabsence of first-aid knowledge
Bangladesh …Bangladesh …

49. Impact of Injury (BD)Impact of Injury (BD)
 38,000 are orphaned/y38,000 are orphaned/y
 36/d are disabled36/d are disabled (bleak future, trapped in poverty, denied(bleak future, trapped in poverty, denied
for Rx, education, protection; can’t cope with environ.)for Rx, education, protection; can’t cope with environ.)
 It brings devastation for the poorIt brings devastation for the poor
 Many families are pushed to poverty or even familyMany families are pushed to poverty or even family
dissolution due to Rx and rehab. costdissolution due to Rx and rehab. cost
 RTA loses 2% GDPRTA loses 2% GDP

50. Why must we act now?Why must we act now?
 If not, the burden of CI will riseIf not, the burden of CI will rise
 We can now prevent better by more resources, goodWe can now prevent better by more resources, good
health knowledge and culturehealth knowledge and culture
 ... make our roads safe for children; plan cities, caution... make our roads safe for children; plan cities, caution
against flood or mud flows, droughts, desertification oragainst flood or mud flows, droughts, desertification or
rises in sea levelrises in sea level

51. Child injuries are preventableChild injuries are preventable
 12 Proven interventions could12 Proven interventions could
save >1000 children/dsave >1000 children/d
 Many HICs have been able toMany HICs have been able to
reduce CI deaths by 50% over the past 3Dsreduce CI deaths by 50% over the past 3Ds

52. CI prevention is cost effectiveCI prevention is cost effective

56. Challenges in CI Px in BangladeshChallenges in CI Px in Bangladesh
 Lack ofLack of datadata
 Lack ofLack of political willpolitical will
 LackLack of fundof fund, human, human resourcesresources
 AppropriateAppropriate technologytechnology for DCsfor DCs
 Perception that CI is a chancePerception that CI is a chance
 Poor collaboration and cooperation between agenciesPoor collaboration and cooperation between agencies

57. Overall RecommendationsOverall Recommendations
 Integrate CI into aIntegrate CI into a comprehensive approachcomprehensive approach to childto child
health and developmenthealth and development
 DevelopDevelop CI prevention policy and implement actionsCI prevention policy and implement actions
 StrengthenStrengthen health systemshealth systems to address CIto address CI
 EnhanceEnhance datadata for CI preventionfor CI prevention
 Priorities forPriorities for researchresearch
 InvestInvest for CI preventionfor CI prevention

58. WHO
“The cost of doing nothing for CI is
unacceptable”
It would be tragic to achieve significant gains
in child survival only to lose to CI
Make CI top PH policy and practice
PH: public health

61. DrowningDrowning
andand
Near DrowningNear Drowning

62.  Drowning: death within 24 hrs of
submersion
 Near drowning: survival after 24 hrs
of submersion (may die later)

63. Drowning: World FactsDrowning: World Facts
 480 children die/d.480 children die/d. >98% in L&MICs, usually in open>98% in L&MICs, usually in open
bodies of water. Most happen in and around the homebodies of water. Most happen in and around the home
 1111thth
U-5MR. 4U-5MR. 4thth
c/of death among 4-14y-age. 1c/of death among 4-14y-age. 1stst
in 1-4yin 1-4y
 2-3million/y get into trouble in water (close to drowning)2-3million/y get into trouble in water (close to drowning)
 U-5 children are at greatest risk – infants can drown in aU-5 children are at greatest risk – infants can drown in a
few CM of waterfew CM of water
 In HICs: most drowning happen in swimming poolsIn HICs: most drowning happen in swimming pools

66. Bangladesh ScenarioBangladesh Scenario
 Drowning is number 1 killer in 1-4y ageDrowning is number 1 killer in 1-4y age
 2007 flood: 87% of U-5MR was from drowning2007 flood: 87% of U-5MR was from drowning
 In pre-vax. era, it was equal to measles as killer (9% ofIn pre-vax. era, it was equal to measles as killer (9% of
deaths in 1-4y in 1983); now 53% in 2000deaths in 1-4y in 1983); now 53% in 2000
Most Drowning OccurMost Drowning Occur
 in pools. (>75% within 20m of house), in the monsoonin pools. (>75% within 20m of house), in the monsoon
(April – Sept),(April – Sept), during flood; between 9 am-noon:during flood; between 9 am-noon: mother ismother is
busy!busy!
 46% were <4y:46% were <4y: cant swimcant swim

67. Male Female RatioMale Female Ratio
overalloverall 3:13:1
TeenagersTeenagers 10:110:1
Age of drowningAge of drowning

<1 y<1 y 5%5%
 1-4y1-4y 37%37%
 5-9y5-9y 15%15%
10-14y10-14y 15%15%
15-19y15-19y 28%28%
Age 1-4 y: most D occur in residential poolsAge 1-4 y: most D occur in residential pools

68. PlacesPlaces
 PondsPonds
 Bath tubsBath tubs
 BucketsBuckets
 Swimming poolsSwimming pools
 LakesLakes
 StreamsStreams
 FloodFlood
 RiverRiver
 Ocean beachesOcean beaches
Infants mostly drown in bathtubs, buckets, or toiletsInfants mostly drown in bathtubs, buckets, or toilets
Bucket drowning is 24% of all toddler drowningBucket drowning is 24% of all toddler drowning

69. Risks Factors of DrowningRisks Factors of Drowning
 Lack of supervision:Lack of supervision: most drowned childrenmost drowned children
– were last seen in home in care of parents!were last seen in home in care of parents!
– had been out of sight forhad been out of sight for <5 min!<5 min!
 Water recreation, alcohol, illicit drugsWater recreation, alcohol, illicit drugs
 Epilepsy (x13 rise)Epilepsy (x13 rise)
 Child abuseChild abuse
Most pediatric drowning victims drown silentlyMost pediatric drowning victims drown silently

70. Recreation waters:Recreation waters: majority >15y. Recreationalmajority >15y. Recreational
boating: hypothermia, trauma, CO poisoning, etcboating: hypothermia, trauma, CO poisoning, etc..
Alcohol:Alcohol: in 25-50% of teenager and adult drowningin 25-50% of teenager and adult drowning
 affects balance, coordination, judgmentaffects balance, coordination, judgment
 effect iseffect is ⇑⇑ by sun and heatby sun and heat
Epilepsy:Epilepsy: drowning is the greatest c/of death (bathtubdrowning is the greatest c/of death (bathtub
highest risk)highest risk)

71. PathophysiologyPathophysiology
Immediate hypoxiaImmediate hypoxia
– cardiac arrest (? catechol. induced fatal arrhythmia):cardiac arrest (? catechol. induced fatal arrhythmia):
ischemia to all tissuesischemia to all tissues
LaryngospasmLaryngospasm
Pulmonary aspirationPulmonary aspiration (absent in 15%)(absent in 15%)
HypothermiaHypothermia
ComaComa
Terminal apneaTerminal apnea (medullary depression)(medullary depression)

72. HeartHeart
– Cardiac arrestCardiac arrest
– Initial tachycardia, severe hypertensionInitial tachycardia, severe hypertension⇒⇒
bradycardia and arrhythmiasbradycardia and arrhythmias
CNSCNS:: fails in 3min of hypoxiafails in 3min of hypoxia
– Cerebral edemaCerebral edema
– Increased ICPIncreased ICP
LiverLiver:: raised transaminasesraised transaminases

73. LungsLungs
– ARDS; aspiration pn. (gastric, caustic, fluid)ARDS; aspiration pn. (gastric, caustic, fluid)
– Pulmonary edemaPulmonary edema
Kidneys:Kidneys: ATN, cortical necrosisATN, cortical necrosis
CirculationCirculation:: DIC, hemolysis, low plateletDIC, hemolysis, low platelet
GITGIT:: abrasions, bloody stools, infxabrasions, bloody stools, infx..
PancreasPancreas:: raised serum enzymesraised serum enzymes

74. FEBFEB (derangement not common)(derangement not common)
– Sea waterSea water: hemoconcentration,: hemoconcentration, hypernatremiahypernatremia
– Fresh waterFresh water: water intoxication: water intoxication
 hemodilution, hyponatremiahemodilution, hyponatremia
 hemolysis: ARF, hyperkalemiahemolysis: ARF, hyperkalemia
– SIADHSIADH
Temperature:Temperature: commonly hypothermiacommonly hypothermia
Bradycardia,Bradycardia, ⇓⇓ myocardial contractionmyocardial contraction
loss of vasomotor tone, hypotension, shockloss of vasomotor tone, hypotension, shock

75. ResuscitationResuscitation
 Clear airwaysClear airways
 Don’t press abdomen!Don’t press abdomen! Vomits commonlyVomits commonly
 M2M/M2N breathingM2M/M2N breathing
 IntubationIntubation
 Temp. maintenanceTemp. maintenance
 Venous catheterVenous catheter
 ECGECG
 Correction ofCorrection of hypoglycemiahypoglycemia

79. Prognosis: depends onepends on
– Circumstances of the incidentCircumstances of the incident
– Duration of submersionDuration of submersion
– Speed of rescueSpeed of rescue
– Effectiveness of resuscitationEffectiveness of resuscitation
Cardiac arrest requires aggressive prolongedCardiac arrest requires aggressive prolonged
resuscitationresuscitation

80. A: adult supervisionA: adult supervision
 Must watch children with a distance of an arm’s lengthMust watch children with a distance of an arm’s length
 Look in the pool first if a child is missingLook in the pool first if a child is missing
 Get a lifeguard for social gatheringsGet a lifeguard for social gatherings
Prevention: ABCDPrevention: ABCD

82.  Adult supervision is critical!Adult supervision is critical!
 A lapse of <5min is seen in most drowningA lapse of <5min is seen in most drowning
 May drown in 1-2in. of waterMay drown in 1-2in. of water
 Frequently occurs in bath tubs, buckets, toilets, diaper pailsFrequently occurs in bath tubs, buckets, toilets, diaper pails
and wading poolsand wading pools
 Taking an eye off aTaking an eye off a
child in water forchild in water for
2 sec puts a child at risk!2 sec puts a child at risk!

83. A swimming teacher teaches children to swim

84. B means BarriersB means Barriers
 A non-climbable (4F) fence for pool/spa. No items usableA non-climbable (4F) fence for pool/spa. No items usable
for climbing near fencefor climbing near fence
 Self-closing, -latching gates to pool/spa,Self-closing, -latching gates to pool/spa, (latches above a(latches above a
child's reach)child's reach)
 Power operated pool safety coversPower operated pool safety covers
 Secure locks for all openings to pool/spa when not in useSecure locks for all openings to pool/spa when not in use
 Doors and windows could be alarmed when openedDoors and windows could be alarmed when opened

87. Fence keeps
children
away from
water
Use of waist
bells

88. C means ClassesC means Classes (swimming, CPR)(swimming, CPR)
 Swimming by an instructorSwimming by an instructor
 Teach children toTeach children to
– leave the water if adult leavesleave the water if adult leaves
– enter the water only with a swim suitenter the water only with a swim suit
– first enter the water in the shallow endfirst enter the water in the shallow end
 Teach adults CPR, rescue techniques,Teach adults CPR, rescue techniques, risks ofrisks of
– Bath tubs, buckets, commodes, washing machineBath tubs, buckets, commodes, washing machine
– Close toilet and bath doorsClose toilet and bath doors
– Cover commodeCover commode

90. D means DevicesD means Devices
 Poolside emergency phonePoolside emergency phone
 Install a life saving ring, shepherd's hook and CPR posterInstall a life saving ring, shepherd's hook and CPR poster
by the poolby the pool
 Children must wear Personal Flotation Device (PFD)Children must wear Personal Flotation Device (PFD)
when at water siteswhen at water sites
 Wear PFD while in a boatWear PFD while in a boat

91. Also, never…Also, never…
 leave full bucket/tubs, norleave full bucket/tubs, nor leave a child alone nearleave a child alone near
water or let swim alone, nor use "floaties" or inflatablewater or let swim alone, nor use "floaties" or inflatable
toys as life jackets or substitutes for supervisiontoys as life jackets or substitutes for supervision
 leave toys in or around the pool/spaleave toys in or around the pool/spa
 consider a child asconsider a child as ''drown-proofdrown-proof'' despitedespite
swimming skills, or experienceswimming skills, or experience
 use alcohol or drugsuse alcohol or drugs
 swim in thunder or lightningswim in thunder or lightning
 dive into unfamiliar or shallow bodies of waterdive into unfamiliar or shallow bodies of water

92. MDG 4 and drowning
 To achieve MDG4 we must reduce drowning by 50%
 GoB has included CI as 1 of 5 PH prioritiesGoB has included CI as 1 of 5 PH priorities
 Make homes, schools, communities safe for children;Make homes, schools, communities safe for children;
students will learn CI prevention, 1students will learn CI prevention, 1stst
AidAid
 Importance of learning swimming and supervisionImportance of learning swimming and supervision
 Awareness: mass media, educn., P2P communicationAwareness: mass media, educn., P2P communication
 Develop teachers’ manuals for CIDevelop teachers’ manuals for CI
 For working children make workplace safeFor working children make workplace safe

93. MCQMCQ
 Drowning is the greatest injury-death among childrenDrowning is the greatest injury-death among children
 Near drowning means there is no aspiration in the lungsNear drowning means there is no aspiration in the lungs
 Drowning in sea water causes water intoxicationDrowning in sea water causes water intoxication
 The brain can tolerate hypoxia up to 9 minThe brain can tolerate hypoxia up to 9 min
 Most children in this country drown in out door poolsMost children in this country drown in out door pools
 Preventing drowning can achieve MDG4Preventing drowning can achieve MDG4

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