Accident Prevention Health Gap (That Is, Health Inequalities) Within England

LEADING ARTICLE 275

Trauma prevention public health strategy for England ...... (www.ohn.gov.uk). It was published in Arch Dis Child: first published as 10.1136/adc.88.4.277 on 1 April 2003. Downloaded from July 1999 with the two laudable aims of improving health and reducing the Accident prevention health gap (that is, health inequalities) within England. Four disease processes I Maconochie have been targeted: cancer, coronary ...... heart disease, mental health, and accidents. The target for accidents is: “the A priority for paediatricians reduction in death rates by at least one fifth and to reduce the rate of serious rauma prevention is a neglected area The aim of this leading article is to injury by at least one tenth by 2010”, so from the point of view of coordi- examine the scale of the problem, to saving up to 12 000 lives. nated input by paediatricians at local show what government strategies have The Department of Health set up the T Accidents and Accidental Injury Task level and to an extent at the Royal been developed, what resources are College of Paediatrics and Child Health available, and how paediatricians at local Force. Its terms of reference were to (RCPCH) level. This oversight is surpris- and at RCPCH level help reduce the mor- advise the Chief Medical Officer on: ing given that injury to children is asso- bidity and mortality associated with (1) The most important priorities for ciated with considerable morbidity and injury. immediate action in order to meet mortality. Part of the difficulty generat- the (White Paper) target ing interest in trauma prevention may lie THE SCALE OF THE PROBLEM (2) The development of an implementa- in the relatively intangible benefits of Trauma is overall the leading cause of tion plan, consulting with other death in childhood in the developed reducing injury, but nonetheless every stakeholders where necessary paediatrician should consider it within world as shown in table 1. their remit to take any opportunity to The morbidity associated with injury (3) Whether the necessary delivery reduce accidents which account for over is indicated by HASS (home accident structures are in place to forward the one third of all deaths up to19 years of surveillance system) or LASS (leisure implementation plan age. Injury prevention schemes can be accident surveillance system, not includ- (4) How progress on the implementa- cost effective provided they are well ing road traffic accidents). These are two tion plan should be monitored 1 directed with achievable goals. surveillance databases of the attend- (5) How to develop and publicise a more ances to 18 accident and emergency Effective injury prevention depends unified approach to accident preven- (A&E) departments and their data are on a combination of three areas of tion across the government and the implementation: education, alteration of extrapolated to represent the picture NHS. environmental hazard, and the enforce- throughout England and Wales.8 They ment of safety legislation. Paediatricians estimate that annually nearly 2 million It had been expected to report its find- can be involved in improving all the ele- children attend A&E departments be- ings in December 2001. ments of injury prevention: primary pre- cause of injury. The true figure for child- The OHN paper has launched a raft of hood morbidity associated with acci- iniatives aimed at reducing accidents vention (prevention of the accident; for http://adc.bmj.com/ example, using safe materials in play- dents is probably much higher, as for involving other departments of govern- grounds2); secondary prevention (reduc- example, up to 30% of cycling injuries ment; these include “Safe routes to ing the effects from the accident; for are treated at home and so do not enter schools and healthy citizens pro- example, promoting the wearing of bicy- any system of injury surveillance. The gramme” (directed at minimising the cle helmets3); and tertiary prevention financial cost to the NHS of trauma in all effects of accidents though the skills (diminishing the consequences of the ages is put at £12 billion per year, and the programme for 14–16 year olds), event by the effectiveness of the emer- average cost of dealing with a childhood “Hedgehogs—child road safety” (aimed

gency services provided after the acci- injury is £1300; about 10 000 patients are at 7–12 year olds), “THINK! Road on September 30, 2021 by guest. Protected copyright. dent). The latter aim can be achieved by believed to be permanently affected by safety”, and also “Fire kills—you can improving resuscitation training for injury each year.9 prevent it”. The latter three campaign dealing with critically ill children by This burden of trauma on the health- details are located on the Department for teaching courses such as Paediatric care services and on society as a whole Transport, Local Government and the Advanced Life Support (PALS),4 Ad- has been recognised by the government. Regions Safety pages (www.dltr.gov.uk). vanced Paediatric Life Support (APLS),5 Other governmental departments pro- the Advanced Trauma Life Support GOVERNMENT STRATEGIES vide useful information on their user course (ATLS),6 and Prehospital Paediat- The Saving Lives: Our Healthier Nation friendly websites (see the appendix). ric Life Support Courses.7 (OHN) White Paper is the government These sites provide useful points of reference to local initiatives that can be undertaken in conjunction with commu- Table 1 Causes of deaths in boys and girls in 1999 (published by the nity health bodies, police, health promo- Office for National Statistics, www.statistics.gov.uk) tion bodies, and other organisations such Age of boys/girls as the Royal Society of Prevention of Accidents, the Child Accident Prevention 1–4 5–9 10–14 15–19 Trust, and the National Community Fire All causes 306/241 141/111 176/117 555/267 Safety Centre (www.community-ﬁre- Trauma (includes poisoning) 61/47 30/22 67/28 329/114 safety.org.uk), as well as local authori- Infection 31/26 7/5 5/5 18/20 ties. Neoplasms 42/30 46/30 39/17 53/34 CNS disease 44/31 20/20 21/23 38/23 Respiratory disease 29/17 9/11 9/11 15/13 THE ROLE OF LOCAL AUTHORITIES Circulatory disease 15/20 2/7 10/6 16/13 IN INJURY PREVENTION Local authorities have statutory duties regarding injury prevention and can be a

www.archdischild.com 276 LEADING ARTICLE valuable source of information. They consequences of trauma, from those who Another hospital based scheme is the have a legal requirement to reduce traffic work in the prehospital phase of trauma, Gloucestershire Home Safety Check and Arch Dis Child: first published as 10.1136/adc.88.4.277 on 1 April 2003. Downloaded from accidents and have duties regarding to those who are hospital based, and Herefordshire Home Check (www. trading standards, environmental those involved in the rehabilitation of homesafety.co.uk). This is based at the health, and educational roles in accident the injured patient. The central tenet is Health Promotion Unit at Gloucester- prevention. the seamless transition of care from the shire Royal Hospital and represents a There is a great deal of expertise arrival of the first professional in contact collaboration with local health authori- within local authorities: environmental with the injured patient to the last ties, Health Trusts, voluntary and non- health officers, road safety officers, trad- healthcare worker. Traumacare UK fo- statutory groups, and neighbourhood ing standards officers, community fire cuses on improving tertiary prevention and community groups. It offers home and police officers, youth workers, and and has produced a manual of trauma safety visits, repairs and rectifications, workers in childcare and community management in the UK. This organis- smoke detector fitting, and child safety development sectors all have an impact ation holds biannual conferences cover- services. on decreasing the burden of trauma. ing all aspects of trauma and acts as a forum for professionals from different WHAT PAEDIATRICIANS CAN DO THE ROLE OF THE VOLUNTARY backgrounds to meet and discuss prob- AT A LOCAL LEVEL SECTOR IN INJURY PREVENTION lems that they face in looking after the Paediatricians may wish to form local There are many voluntary national bod- injured patient. networks with their other hospital based ies that can assist in the three areas of colleagues, and with the local authorities injury prevention. These include the EDUCATION and community services. Healthcare pro- Child Accident Prevention Trust, the Education combined with directed envi- fessionals such as general practitioners, Royal Society for the Prevention of Acci- ronmental change comprises the key- health visitors, school nurses, commu- dents, and Trauma Care; their websites stones of injury prevention. The import- nity nurses, and managers, combined provide links to other key players in ance of the educational aspects of injury with heads of schools, playgroup leaders, these areas. These three bodies can prevention has been illustrated by the and local media can form a powerful provide information and support for Department for Education and Skills alliance to launch injury prevention paediatricians and other healthcare pro- which published good practice guidance schemes. fessionals interested in primary, second- in December 2001 with the aim of An example of a local prevention ary, or tertiary prevention strategies. increasing the amount of safety educa- initiative, in conjunction with A&E tion taught within schools colleagues, is the routine collection of Child Accident Prevention Trust (www.teachernet.gov.uk/bank/Safety data relating to injuries attending A&E. (www.capt.org.uk) Guidance leaflet2.pdf). These data can, for example, identify Two paediatricians, Dr Hugh Jackson Attitudes to safe behaviour can be areas frequently associated with injury and Professor Donald Court, formed a taught as part of the National and lead to effective safety changes in committee in the late 1970s to focus on Curriculum. The Injury Minimisation road design in “accident blackspots” by child accident prevention, which became Programme for Schools (IMPS) (www. liaising with local police and the local the Child Accident Prevention Trust impsweb.co.uk) includes an education authority. Similarly, types of frequently (CAPT) in 1981.This charity is commit- pack with accident prevention lessons occurring domestic injuries can lead to http://adc.bmj.com/ ted to reducing childhood injury and based on the National Curriculum, and a targeted local campaigns. supports local coalitions of families, hospital visit including first aid training Any such campaign which has an health professionals, and organisations and a tour of the local A&E department. educational element needs to be de- in making communities safer for chil- Five months after the programme, chil- signed with its audience in mind. Teen- dren under their “SAFEKIDS” cam- dren are more likely to identify subtle agers can very effectively teach one paign. dangers, are more likely to seek help, and another; the same message from an “old Every year CAPT holds a Child Safety to tell others that their behaviour is fogey” (that is, anyone over the age of 20 16 on September 30, 2021 by guest. Protected copyright. Week (in 2003 it commences on 23 dangerous.10 Paediatricians can actively years!) may not be assimilated as well. June). This week has a number of aims, support this programme by contacting The RCPCH can also be supportive in including providing clear safety infor- IMPS. Currently this programme is local initiatives. mation to the public, persuading local active in 13 centres in England and is communities to take part in child safety actively seeking more locations through- WHAT CAN THE RCPCH DO? activities, and encouraging the media to out the UK. The RCPCH can be more active in give positive coverage to child injury pre- supporting injury prevention by the vention and safety issues. CAPT has pro- following: duced a planning kit to help organise HOSPITAL BASED WORK IN (1) Establishing Trauma Fellowships activities around the theme of accident INJURY PREVENTION which would allow trainees and prevention. This can be directly down- The home, roads, playgrounds, and seniors to develop the necessary loaded from the website. sporting arenas have risks which can be reduced by environmental and behav- skills to research the causes of injury Royal Society for the Prevention of ioural changes; wearing bicycle helmets, and establish effective interventions, Accidents (www.rospa.co.uk) for example, reduces by 63–88% the risk and help in develop prevention This charitable organisation provides of head, brain, and severe brain injury for strategies on a local or national information, advice, resources, and all ages of cyclists.11 scale. training, and promotes safety in all areas Local initiatives involving hospital (2) Showing more overt support of of life. based paediatricians in the UK have had CAPT activities; yearly initiatives an impact in these areas—for example, with CAPT could be developed and Traumacare UK the work on bicycle helmet use12 13 and the membership of the RCPCH be (www.traumacare.org.uk) on playground safety14 15 has led to a bet- encouraged to take part. Such activi- This is a multidisciplinary charitable ter understanding of the effects of alter- ties could count towards continuous organisation. It includes healthcare pro- ing the environment and on implement- professional development (CPD) fessionals who have contact with the ing advances in the design. and awards be given to examples of

www.archdischild.com LEADING ARTICLE 277

particularly good working partner- APPENDIX 4 PALS. Paediatric Advanced Life Support.

Course material. American Heart Association, Arch Dis Child: first published as 10.1136/adc.88.4.277 on 1 April 2003. Downloaded from ships, so encouraging prevention The Department of Trade and Industry web- c/o UK Resuscitation Council, UK. work. site (www.dti.gov.uk) provides advice on 5 APLS. Advanced Paediatric Life Support. regulatory guidance, consumer protection, Course material. Advanced Life Support (3) Providing a database of injury pre- environmental issues, and product safety, as Group, 2nd edn. London: BMJ Books, 2002. vention activities involving mem- well as containing the home safety network. 6 ATLS. Advanced Trauma Life Support course. Course material. Advanced Trauma Life bers; they could brieﬂy describe Other helpful government websites include Support Instructor Manual, 6th edn. American their work on the BPSU monthly the Health and Safety Executive (www. College of Surgeons, 1997. return card, along with their contact hse.gov.uk) and the Health Development 7 Advanced Life Support Group. Pre-hospital Agency (www.had-online.org.uk) which Paediatric Life Support. Course material. details. London: BMJ Books, 2001. comes under the Department of Health 8 Department of Trade and Industry. Home (4) Currently the BPSU does collect (www.doh.gov.uk). and leisure accident report: summary of 1998 information regarding non- The Scottish Executive and National As- data. London: DTI Publications, 1998. accidental abdominal injuries; its sembly also have a wealth of informative sites 9 Children Accident Prevention Trust. which can be accessed via www.scotland.go- Website. http//www.capt.org.uk. remit could be widened to study a 10 Frederick K,BixbyE,OrzelMN,et al.An particular form of injury and then, v.uk and www.wales.gov.uk. evaluation of the effectiveness of the Injury Minimization Programme for Schools (IMPS). with the support of other agencies, Arch Dis Child 2003;88:275–277 Injury Prevention 2000;6:92–5. study the effect of injury prevention 11 Thompson DC, Rivara FP, Thompson R. strategies on a national basis...... Helmets for preventing head and facial Authors’ affiliations injuries in bicyclists (Cochrane Review). In: The last RCPCH based meeting on The Cochrane Library, Issue 2. Oxford: I Maconochie, Department of Paediatric Update Software, 2002. paediatric accidents was in 1991; one of Emergency Medicine, St Mary’s Hospital, 12 Lee AJ, Mann NP, Takriti R. A hospital led the authors of the publication of the London, UK promotion campaign aimed to increase cycle meeting held under the auspices of the helmet wearing amongst 11–15 year olds in Correspondence to: Dr I Maconochie, West Berkshire. Injury Prevention Royal College of Physicians was the cur- Department of Paediatric Emergency Medicine, 2000;6:151–3. rent President Elect of the RCPCH, St Mary’s Hospital, South Wharf Road, London 13 Takriti R, Lee AJ, Mann NP. Teenage W2 1NY, UK; [email protected] attitudes to cycle helmets. Health Educ Professor Alan Craft. He wrote in the 2000;101:169–75. opening chapter “Improvements in acci- 14 Mott A, Evans, Rolfe K, et al. Patterns of dent rates will be slow and will come REFERENCES injuries to children on public playgrounds. Arch Dis Child 1994;71:328–30. about as a result of environmental 1 Miller TR, Levy DT. Cost-outcome analysis in injury prevention and control: eighty-four 15 Mott A, Rolfe K, James R, et al. Safety of change by education. Both are needed, recent estimates for the United States. Medical surfaces and equipment for children in 14 Care 2000;38:562–82. playgrounds. Lancet 1997; :316–20. but the education needs to be correctly 16 Harden A, Weston R, Oakley A. A review of 2 Norton C, Morris S, Jones MD, et al. Have targeted. The doctor undoubtedly has a the effectiveness and appropriateness of modern safety changes to playgrounds role to play in this change.”17 peer-led promotions interventions for young reduced head injury and fracture to children? people. London: Evaluation of Health Accident prevention needs paediatri- [G69 abstract]. RCPCH meeting, York, April Promotion and Social Interventions, cians being involved at local level and for 2002. 1999:1–180. 3 Mann NP, Lee AJ. Bicycle helmets: their role 17 Sibert J, ed. Accidents and emergencies in the RCPCH to appear more active in in injury prevention. Curr Paediatr childhood. London: Royal College of injury prevention. 1999;9:173–6. Physicians, 1992. http://adc.bmj.com/

IMAGES IN PAEDIATRICS...... Cloacal exstrophy

his newborn baby was referred to us for malformed lower

abdomen since birth. On examination the umbilical cord on September 30, 2021 by guest. Protected copyright. Twas displaced downward and the lower abdominal wall was replaced by a large red coloured mass. The mass had a thin, red, protruding tubular structure in the middle resembling an elephant trunk, and five visible orifices. Exter- nal genitalia could not be identified (fig). A diagnosis of cloacal exstrophy was made. Cloacal exstrophy is the rarest and most extreme form of the exstrophy–epispadias complex that occurs once in 200 000 to 400 000 births.1 Embryologically four separate folds— cephalic, caudal, and right and left lateral—each of which has a splanchnic and somatic aspect, form the anterior abdominal wall. Failure of the caudal fold to close results in cloacal 2 exstrophy. Classically it consists of an exstrophic central R A Reddy, B Bharti, S C Singhi bowel field flanked by two hemi-bladders. Omphalocoele is Dept of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, V., present in 90% of cases. There are 3–4 orifices in the central India; [email protected] bowel field, which is an ileocaecal region. The proximal orifice leads to the terminal ileum, which often prolapses, producing References an elephant trunk deformity. The distal orifice leads to a short, 1 Manzoni GM, Hurwitz RS. Cloacal exstrophy. In: Freeman NV, Burge blind ending colon segment. One or more appendiceal DM, Griffiths M, Malone PSJ, eds. Surgery of the newborn. Edinburgh: orificesmay be present. The anus is imperforate, and external Churchill Livingstone, 1998:767–80. 2 Davis CF, Young DG. Congenital defects and surgical problems. In: genitalia have a wide range of anomalies, including absent Rennie JM, Roberton NRC, eds. Textbook of neonatology, 3rd edn. 1 penis/clitoris, absent scrotum, epispadias, hemiscrota, etc. Edinburgh: Churchill Livingstone, 765–93.