trol, 10 leading causes of death, 1997). Although the total number of unintentional injury deaths has declined by more than 40 percent during the past 20 years (CDC Injury Mortality Stats), the rates of childhood injury are much higher in the United States when compared with other developed countries. In 2001, unintentional injuries consttuted 70 percent of all injury deaths to children and adolescents (0 to 20 years) in the United States (National Center for Health Statistics, 2004).

The enormous impact of injury on children’s health is manifest by the fact that approximately 18 hospitalizations and 233 emergency department visits occur for every injury death (Grossman, 2000). As injury deaths continue to decline, nonfatal injuries continue to be important causes of child morbidity and disability and substantially reduce quality of life, especially among adolescents. However, it should be noted that data collection on nonfatal injuries is incomplete.

The elements of a safe and healthy physical environment differ according to a child’s developmental stage. The American Academy of Pediatrics has conducted extensive reviews of the literature to establish the evidence-based recommendations in The Injury Prevention Program, an age-appropriate prevention education program ( for physicians and families. Recommendations include counseling parents on use of infant car seats, never leaving infants and toddlers alone in pools or bathtubs, the use of safety equipment for in-line skating and skateboarding, and firearm safety.

The use of playground equipment is the leading cause of injuries to children in school and child care environments, with 211,000 children receiving emergency department care annually for injuries sustained on playgrounds (Centers for Disease Control and Prevention, 1999a). Factors influencing playground injury prevention include supervision, age-appropriateness of equipment, suitable fall surfaces, and equipment maintenance. Supervision has been shown to be inconsistent, age appropriateness is infrequently indicated, and many playgrounds have had equipment with significant safety issues (Sibbald, 2002).

Automobile crashes are the leading cause of death among children over a year old. In 2000, 2,343 children under age 15 were killed in traffic crashes, including 1,668 who were passengers, 469 who were pedestrians, and 175 who were on bicycles. That same year, 291,000 children under 15 years of age were injured in traffic crashes, including 248,000 who were passengers and 22,000 who were pedestrians. On an average day, 6 children are killed and 797 are injured in motor vehicle crashes.

The determinants of motor-vehicle-related injuries and fatalities are well recognized. Some relate to behavioral issues, such as speeding, failing to yield to pedestrians at crossings, and driving while intoxicated; others relate to automobile design and features, including impact absorption, seat belts, air bags, and similar features. Still others relate to roadway features. Public health interventions addressing these factors, from seat belts to traffic signals and from law enforcement to public education and the development of bike paths, have achieved dramatic reductions in injury and fatality rates (Rivara, 1999).

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