The numbers are stark: in 1996, more than 13,000 children and adolescents in the United States died from unintentional injuries, most of them resulting from car crashes, drownings and residential fires. That's about 37 deaths a day. According to "Unintentional Injuries in Childhood," the newest issue of The Future of Children published three times yearly by the Packard Foundation, commonplace safety measures —child car seats, bicycle helmets, smoke detectors and traffic-law changes—could have reduced that number by 4,000 if regulations governing their use were uniform and well-enforced. Additional safety efforts based on strategies that have proven effective in other countries could save many more.

Among the key recommendations: pediatricians and other health care providers should make education about safety practices part of routine visits, and insurers should reimburse doctors for spending this extra time with patients. Certain successful models for community-based education programs should be copied in every community. Efforts to make children's environments safer—changing traffic patters and enclosing swimming pools on all four sides, for example—should be widely implemented and required by law. Car and booster seat use should be regulated and enforced across all states. State should require and enforce bicycle helmet use and the installation of smoke detectors that are either hardwired or dependent on long-lasting lithium batteries. Finally, comprehensive information should be gathered on the cost effectiveness of various safety measures.

The issue includes eight articles, all looking at different aspects of the same problem: how best to go about the difficult job of keeping children out of harm's way. The authors identify three main approaches: education, modification of products or the environment, and legislation or regulation. The bottom line? Legislation and regulation are the big guns of injury prevention, as dramatically demonstrated by the success of car seat laws. Such laws, now in effect in all 50 states, have reduced crash-related deaths of infants and young children by about 70 percent, according to the report. One example of a missed opportunity: though studies indicate bicycle helmets can reduce head injuries by 85 percent, 35 states still lack bicycle helmet laws.

Legislation and Education Both Needed
In an analysis of the findings contained in this issue, the authors recognize that regulation and legislation work best in conjunction with educational efforts; and that not all of the unintentional injury risks faced by children can be addressed through legislation, which often becomes "embroiled in arguments about restriction of personal freedom, on the one hand, and a contribution to societal health and welfare, on the other."

A review of the research on educational efforts shows that some have been fairly successful, increasing car seat use, smoke detector ownership, and parents' awareness of the dangers of too-hot tap water temperatures. However, over time, individual behavior often reverts to old patterns. The reviewers also find that health professionals, such as pediatricians, are rarely trained in the best ways to encourage people to change their behavior. A time-honored practice, using scary or negative messages to try and frighten people into new ways, has been proven ineffective. But doctors often don't know how to use positive approaches to encourage and motivate people to change—and in this day of HMOs, they often don't have the time.

As the authors note, poor and minority children are at greater risk of suffering unintentional injuries, for a range of reasons: they may live in neighborhoods where heavy traffic makes it dangerous to play outside; or bicycle helmets, car seats and smoke detectors may be unaffordable. The issue includes articles on the history of public health efforts to control injuries; a systematic review of 22 controlled trials examining whether counseling and other interventions delivered in a clinical setting can convince more parents to adopt safety practices such as car seat use, smoke alarm installation, and lowering hot water heater temperatures to a safe level; an analysis of 32 studies of community-based campaigns to promote safety measures; a review of how six legislative efforts have worked to reduce childhood injuries; an analysis of national and state data on the social, medical, and resource costs, as well as quality-of-life costs, of childhood injuries; a discussion of how Oklahoma City officials used evaluation tools to improve their campaign to increase the use of smoke alarms; and a look at how the Indian Health Service developed effective new ways to train employees in the best way to encourage people to change their behaviors to reduce children's risk of injury.

Overall, the issue provides both a powerful argument in favor of a comprehensive effort to push communities and product manufacturers to do more to keep children safe, and a wealth of data to support such an effort.

• Visit the David and Lucille Packard Foundation's The Future of Children [1] series online.

---

Susan Phillips [2] is managing editor of Connect for Kids.