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prevention of childhood ingestion injuries.pptx
- 1. Prevention of Ingestion Injuries in Children Dr Tanita van Niekerk 10/09/2020
- 2. Overview • The Burden of ingestion Injury • A clinical perspective • Agents • Presentation • complications • A public health perspective • Epidemiology of Childhood injuries • Childhood Ingestion Injuries • The aetiology of Injury • Risk factors • Prevention
- 3. Ingestion Injuries • children under- 5 have the highest risk • peak incidence at 3 years of age • A Healthcare Burden: • increased emergency room visits • long term consequences and morbidity • Preventable !
- 4. Agents • Coin ingestion • Choking on age-inappropriate food items • Caustic: sodium hydroxide and potassium permanganate, hair relaxer, swimming pool products, and toilet bowl cleaners • Corrosive: hydrochloric acid, battery acid • Button batteries • Magnets
- 5. Presentation • A history of ingestion may be absent • Ingestion is witnessed in as few as a quarter of all cases • These external signs do not reliably predict oesophageal penetration • Caustic Ingestion • volatile agents (e.g. paraffin, hydrocarbons). • Household cleaning agents
- 6. Complications • Chemical Burns: strong alkali (pH ≥11.5), strong acid (pH ≤2) • Oesophageal stricture formation • Sharp objects penetrate GIT • Blunt objects cause GIT obstruction and pressure necrosis • ≥2 magnets : entero-enteric fistula • Electric Disk cells: • focal oesophageal burns • perforation with mediastinitis • trachea-oesophageal fistula formation • oesophago-aortic fistulas due to erosion • long-term oesophageal stricture formation
- 7. Ingestion Injuries in Context of Childhood Injuries
- 8. Causes of <5 deaths
- 10. Death Disability Hospitalisation Pain and suffering The Consequence of Injury
- 11. The Aetiology of Injury
- 12. The Child • Vulnerable to different injuries at different stages of their lives • Toddlers • Infants: • Children <9years • ADHD
- 13. The Environment • The backdrop to injury patterns • Physical and Psychological • SES factors • Emotional stress • Social and cultural
- 14. Prevention • Change the environment, behaviour and societal concern • Multifacited approach: • Community • professionals of many disciplines • government. • Healthworkers: inform the public and motivate for change • Educators and media: educate, increase safety and awareness • Community participation • Identify local priorities • Find accepted and effective solutions
- 15. The 4 E’s • Education • Environmental Modification • Technological Engineering • Legislation and Enforcement
- 16. • Research • Advocacy • inform legislation • contribute to the development of state policies and programmes • submissions to new legislation • make recommendations for legislation and specifications on products designed to be used by children. • Education • Programmes: Safe travel to school, home safety, walk this way
- 17. Organisations promoting education campaigns: • Parrafin Safety Association of SA • MRC- UNISA Crime Violence and Injury Lead Programme • The Department of Transport and Emergency Services
- 20. Legislation and Enforcement in SA • Child-proof bottle tops • Limitation on pH of detergents • Toy sizing • Secure battery compartments • Package labelling requirements • warning on packaging of aspiration or swallowing risk. • Dangerous product recall
- 21. Unresolved Challenges to Primary Prevention • Ongoing household use of strong industrial-strength caustic agents • Marketing, using brightly coloured packaging
- 22. References • A. Gill, DrP Nancy R Kelly ‘Pediatric injury prevention: Epidemiology, history, and application’ `UpToDate. June 2020 • M. Kibel, H. Saloojee, T Westwood ‘Child Health for All’ Fifth Edition 2012 • M Arnold,A B van As, A Numanoglu ‘Prevention of ingestion injuries in children’ S Afr Med J 2017;107(3):183-187. • T. Friedman ‘A Framework for Public Health Action: The Health Impact Pyramid’ Am J Public Health. 2010 April; 100(4): 590–595.
Editor's Notes
- children under- 5 have the highest risk of injury from ingested foreign bodies and caustic substances with a peak incidence at 3 years of age Curiosity, exploration of the developing oral phase, the child’s inexperience and limited understanding of the environment inadequate caregiver supervision A burden to society: increased emergency room visits, long term consequences and morbidity, they are preventable
- Coin ingestion alone has been reported in as many as 4% of children, with 15% of their parents seeking healthcare. choking on age-inappropriate food items (typically hard sweets or large chunks of meat) or bones (especially fish bones, and accidental medication ingestion). Caustic ingestion affects 5 - 518/100 000 people per year, largely in less industrialised nations. Accidental ingestion of caustic agents continues to be a major concern for pediatric emergency department clinicians. Caustic ingestions can cause severe acute injury and long-term complications, especially the development of esophageal strictures Most ingestions by children are accidental and the amounts ingested tend to be small. The opposite is the case in adolescents and adults,
- Caustic Ingestion: peri-oral inflammation, dysphagia, drooling, cough, stridor, hoarseness, vomiting or signs of peritonitis. volatile agents (e.g. paraffin, hydrocarbons) cause respiratory distress, which may require temporary oxygen support. Household cleaning agents: peroxide or chloride bleach: superficial redness and mild oedema
- Foreign body perforation and/or obstruction of the gastrointestinal tract (GIT) typically occurs proximal to normal anatomical narrowing, i.e. the cricopharynx, which is the narrowest part of the child’s upper GIT the upper third of the oesophagus, where the left main bronchus and aortic arch cross anteriorly with the vertebral bodies posteriorly (iii) the oesophagogastric junction (lower oesophageal sphincter) (iv) the pylorus (v) the duodenum at the ligament of Treitz (vi) the ileocaecal valve.
- The number of under-5 deaths, as well as under-5 mortality rates in SA, have declined in the past decade. Under-5 mortality is estimated at 37 - 40 deaths per 1 000 live births for 2015 Neonatal mortality accounts for approximately one-third of all under-5 deaths. UN and VR figures both suggest that, outside of the new-born period, pneumonia, diarrhoea and non-natural deaths are the leading causes of death. Declines in the number of deaths and case fatality rates associated with diarrhoea, pneumonia and severe acute malnutrition have contributed substantially to the decline in under-5 mortality.
- Mortality statistics are only the tip of the iceberg, viewed in isolation they do not reflect the full picture. Although accurate data is not available, non-fatal injury also results in a huge short term cost, both human and financial and carries a significant risk of long term complications or permanent disability.
- Complex interacting causes of injury The Agent: Inflicts the Injury directly Some agents are inherently dangerous whilst others become dangerous in specific situations The Child The Environment
- Vulnerable to different injuries at different stages of their lives Toddlers are inquisitive and active, lack physical coordination and cannot perceive danger susceptible to ingestion injuries, poisoning, drowning and burns. Infants: vulnerable to chocking as they instinctively feed objects into their mouth Children <9years lack the physical and cognitive maturity to assess dangers in their environment, in particular traffic situation. ADHD
- The backdrop to injury patterns Physical and Psychological SES factors determine: type and quality of hazards the space available for safe play the quality of adult supervision the access to healthcare Emotional stress within the family unit: makes the child more vulnerable distracts the caregiver from providing adequate supervision Substance abuse is important in this regard Social and cultural: many people have a fatalistic attitude to life and believe that injuries are beyond their control.
- Education is more effective when targeted at specific groups, may not show immediate benefits, Can be on an individual basis or campaigns Environmental modification especially to uplift low SES Environmental modificatiom, engineering and legislation can bring about more immediate change
- A model for conceptualizing the potential impact of paediatric injury prevention interventions is the Health Impact Pyramid. In this model, the lower tier interventions (at the base of the pyramid) have greater population impact and require less individual effort; the higher tier interventions have less population impact and require more individual effort: ●Tier 1 – Socioeconomic factors (e.g., poverty reduction, improved education) ●Tier 2 – Changing the environmental context to encourage healthy decisions (e.g., improved road and vehicle safety) ●Tier 3 – Long-lasting protective interventions (e.g., car seat loaner programs, smoke detector installation programs) ●Tier 4 – Clinical interventions (e.g., clinic-based car seat or bicycle helmet inspection for proper fit and use) ●Tier 5 – Counselling and education (e.g., counselling to wear seat belts, provision of patient education handouts, such as "The Injury Prevention Program" handouts from the American Academy of Paediatrics) (see 'Injury prevention resources' below)
- Child-proof bottle tops Limitation on pH of detergents Restriction of toys marketed for children ≤3 years old to a minimum of 3 cm in diameter. Secure battery compartments Package labelling requirements LABELS: regarding content of chemicals in household use, associated health risks with ingestion, and first-aid advice, including poison centre contact details warning on packaging of any smaller object to prevent access by children <3 years because of aspiration or swallowing risk. Dangerous product recall
- Ongoing household use of strong industrial-strength caustic agents, often illegally sold or decanted and stored in nondescript containers or recycled cold-drink containers, is of great concern. Thirsty children may seek these out or be given these by unsuspecting older siblings, particularly in hot weather, with devastating consequences. Marketing, using brightly coloured packaging, has brought new risks to the fore in the past few decades, e.g. automated dishwasher detergent pods, which have caused an upsurge in associated caustic oesophageal injuries in developed countries, although fortunately significant injury occurs in <5% of cases.