Abstract
Background. Road traffic accidents are a significant public health problem and a major cause of economic loss globally.
Objectives. The aim of the study was to describe the epidemiological profile of child victims of traffic accidents and the prevalence of craniofacial trauma in a municipality in the northeastern region of Brazil.
Material and methods. A documentary study was carried out through the analysis of the medical records of the traffic accident victims hospitalized in emergency wards in the municipality of Campina Grande, Paraíba, Brazil, from January to December 2016. A total of 1,884 medical records were evaluated, among which 85 (4.5%) referred to children aged 0–12 years. The information related to the sociodemographic profile of the victims, traffic accidents and clinical variables was collected. The data was analyzed using descriptive and inferential statistics, and a 5% level of significance was adopted.
Results. The victims were predominantly males (64.7%) and 9–12-year-old children (43.5%). Most accidents were recorded in the evening (48.2%) and on the weekend (32.9%). Among the victims, 37.6% were involved in motorcycle accidents. Craniofacial injuries were found in 44.7% of the children. Most victims were not admitted to the intensive care unit (ICU) (80.0%). Craniofacial trauma was significantly associated with motorcycle (p = 0.043) and automobile accidents (p = 0.013).
Conclusions. Our findings suggest that motorcycles are the vehicles most frequently involved in traffic accidents, which predominantly affect males and children aged 9–12 years, and result in a high prevalence of craniofacial trauma.
Keywords: epidemiology, child, maxillofacial injuries, motorcycles
Introduction
Throughout the world, many families are devastated by the loss of a child due to an unintentional injury, which makes these deaths a serious public health problem.1 Unintentional injuries are those caused by traffic accidents, drowning, falls, burns, and poisoning.1 According to the Global Burden of Disease Study,2 the global prevalence of injuries in transport accidents was approx. 241 million individuals in 2016, and studies have shown that these accidents represent the main etiology of craniofacial trauma among children.3, 4
The consequences of trauma in the craniofacial region can include any combination of bone, soft tissue or dental injury.5 The location and pattern of the injury depend on the interrelation between the etiology of the injury and the magnitude of the impact as well as on the characteristics of the victim’s developmental stage.6 Bone flexibility, the presence of dental germs, the smaller size of the paranasal sinuses, the greater cranium/face ratio, and the thick buccal fat pad make children more likely to endure craniofacial trauma.7 A mechanism of injury involving greater impact, such as a traffic accident, is required for this trauma to occur.4
Due to differences in anatomical development, craniofacial trauma can be considered uncommon in children when compared to adults,8 but facial injuries to soft tissues occur more frequently in children.7, 9 Studies indicate that there is a general increase with age in the incidence of facial trauma and a decrease in the incidence of head trauma.8 However, some studies have reported an increasing incidence of craniofacial trauma with increasing age.3, 5
In a retrospective cross-sectional study carried out in the United Arab Emirates, it was observed that from a total of 475 craniofacial injuries, 6.5% occurred in the 1st decade of the patient’s life and 18.4% in the 2nd one.5 A retrospective cohort study carried out in the United States that used the 2012 Kids’ Inpatient Database found that out of 20,070 cases of craniofacial trauma, 35.4% occurred between 0 and 10 years of age, and 63.7% between 11 and 20 years of age.3 Transport accidents were the main etiological factor.3 A cross-sectional survey carried out in the state of Paraíba, Brazil, revealed that 14.4% of the victims of transport accidents were children and adolescents, with head trauma being 5 times more frequent in the age group 0–4 years as compared to children aged 5–9 years.10
Craniofacial injuries in the pediatric population can have negative esthetic and functional effects, causing disfigurement, morbidity, and potential growth and development disorders. Moreover, they cause a great economic burden for families and health systems.3, 6 Therefore, the need to characterize the profile of the victims of craniofacial injuries from this population group and to analyze the different causes of these injuries makes this study relevant. Such knowledge would allow the planning of efficient first aid to obtain relevant recovery, the evaluation of the distribution of work teams, the determination of the related public policies, and assistance in calculating costs for health services.11 Considering these factors, the aim of this study was to describe the epidemiological profile of child victims of traffic accidents and the prevalence of craniofacial injuries in a municipality in the northeastern region of Brazil.
Material and methods
Ethical statement
This study was approved by the Research Ethics Committee of the State University of Paraíba, Campina Grande, Brazil (protocol No. 2.154.228), according to the guidelines contained in Resolution No. 466/12 of the National Health Council.
Study design and location
This documentary study was carried out through the analysis of the medical records of the victims of traffic accidents hospitalized in emergency wards in the municipality of Campina Grande, Paraíba, Brazil. The municipality has an estimated population of 407,472 inhabitants (data for 2018), a Human Development Index (HDI) of 0.72 and a Gini coefficient of 0.58.12 The study was developed at the Dom Luiz Gonzaga Fernandes Emergency and Trauma Hospital in Campina Grande, Brazil – a referral institution for the care of trauma patients.
Inclusion and exclusion criteria
The inclusion criteria comprised the medical records of children of both sexes aged 0–12 years who were the victims of traffic accidents involving pedestrians, cyclists, motorcycles, and automobiles, and were hospitalized for at least 24 h. The medical records of the victims who were hospitalized at the time of data collection, and therefore were not yet available in the Medical Archive and Statistics Service, were excluded. Those that showed a percentage of missing information above 10% were also excluded.
Pilot study
A pilot study was conducted to evaluate the research methodology, to verify the reliability of the data collection instrument and to assess the presence of possible inconsistencies. The pilot study was carried out with 100 medical records of the victims of traffic accidents that happened in 2015; they were not used in the final sample.
Data collection
In total, 1,884 medical records of the traffic accident victims hospitalized in the period from January to December 2016 were evaluated. Data collection was carried out by 3 properly trained researchers between May and December 2017. The following information was recorded: sex; age (0–4 years, 5–8 years, or 9–12 years); care shift (morning (06:00–11:59), afternoon (12:00–17:59), evening (18:00–23:59), or night (00:00–05:59)); day of the week; type of accident (motorcycle, automobile, cyclist, or pedestrian); presence of craniofacial trauma; trauma in other anatomical regions (ribcage, abdominal region, upper limbs, lower limbs, or hips); surgical treatment; admission to the intensive care unit (ICU); and outcome (discharge, transfer, or death).
Statistical analysis
The data was tabulated and analyzed using the IBM SPSS Statistics for Windows software, v. 20.0 (IBM Corp., Armonk, USA). Data analysis involved descriptive (absolute and percentage distributions, mean (M), median (Me), and standard deviation (SD)) and inferential statistics (Pearson’s χ2 test). A significance level of 5% was adopted.
Results
The prevalence of traffic accidents affecting children was 4.5% (n = 85), with a mean age of 7.55 ±3.64 years and a median age of 8 years. The victims were predominantly males (64.7%), with a sex ratio of 1.8:1. Regarding age, the most frequently affected group was 9–12-year-olds (43.5%). Regarding the time of injury according to the care shift and the day of the week, most accidents were recorded in the evening (48.2%) and on the weekend (32.9%). Among all the victims, 37.6% were involved in motorcycle accidents. Craniofacial trauma occurred in 44.7% of the victims. Considering other anatomical regions, the highest frequency was observed for lower limb injuries (53.3%). Surgical treatment was required in 54.1% of cases. Only 20.0% of the victims required admission to ICU and 2.4% of the injuries resulted in death (Table 1).
Table 2 presents the distribution of craniofacial trauma injuries according to such variables as sex, age and type of traffic accident. Craniofacial trauma was significantly associated with motorcycle (p = 0.043) and automobile accidents (p = 0.013).
Discussion
Injuries resulting from traffic accidents are the 8th leading cause of death in all age groups, and the main etiology among children and young people from 5 to 29 years of age.13 Epidemiological data indicates that low- and middle-income countries suffer from a higher burden of traffic injuries and deaths.13 A report published as the global status report on road safety by the World Health Organization (WHO) revealed that systematic data collection in trauma databases, which gather information on the epidemiology of injuries, clinical interventions and health outcomes, is essential for preparing programs to improve clinical quality and for the development of effective prevention strategies.13
The present study, conducted in a referral center for the care of trauma patients, revealed a low percentage (4.5%) of child victims of traffic accidents. According to the Mortality Information System of the Brazilian Ministry of Health, in the years 2014–2018, 3.5% of the total number of deaths from traffic accidents (192,686) regarded children aged up to 14 years, with a decline of almost 40.0% in the period.14 This result demonstrates the importance of measures that were implemented in the country to control this type of accidents after the adoption of the Brazilian Traffic Code in 1997, which defined attributions to the agencies linked to traffic, and established norms and penalties for road users.15 The use of car seats for infants and young children, and mandatory rear seat transportation for children up to 10 years of age16 may have contributed to the lower frequency of accidents in this population group.
The majority of victims in this study were males, which is consistent with data from WHO,13 and with previous studies carried out by researchers in Brazil,10, 17, 18, 19 Sudan,6 Portugal,20 and India.21 It could be inferred that this male predominance exists because of cultural and social restrictions for unsupervised female outdoor activities as compared to male activities.6, 22
The incidence of transport accidents was higher among older children. While younger children generally suffer from trauma due to low-intensity forces, such as falls, older children are more likely to be exposed to high-intensity forces, such as those resulting from traffic accidents, because as they grow, their trauma profile becomes similar to that observed in adults.4, 7 In addition, when they are young, children are protected by their parents against harmful events.3
Regarding the time and day of the week of traffic accidents, the concentration of events in the evening and on weekends corroborates other findings.10, 17, 23, 24 The greater number of accidents at dusk may be associated with poor visibility, stationary vehicles, speeding, disrespect for signs, and the use of alcohol or drugs.23 The higher occurrence of accidents on weekends may be related to risky traffic behavior, such as exceeding the speed limit, disrespecting traffic rules and driving under the influence of alcohol.10 However, the Brazilian “dry law” from 2008 reduced the legal alcohol blood level from 0.06 g/dL to 0.02 g/dL.16, 25 Later, in 2012, any alcohol blood concentration among drivers was considered illegal.26 These measures proved to be important in reducing hospital admissions due to traffic accidents, the length of hospital stay and hospital expenses.27
Regarding the type of vehicle involved in the accident, motorcycles were the most common, as reported by other authors,10, 18, 28 followed by accidents involving cyclists and pedestrians. According to WHO, more than half of all traffic deaths involve vulnerable road users, such as pedestrians, cyclists and motorcyclists.13 In the present study, the prevailing involvement of motorcycles in traffic accidents might be due to the fact that this vehicle is the predominant means of transportation for the population of a lower socioeconomic status in small- and medium-sized Brazilian cities.10 Other factors, such as little or no protection used by motorcyclists,17 difficulty in making motorcycles visible for other drivers, inappropriate traffic behavior, and the lack of respect for traffic laws,28 may contribute to the higher number of traffic accidents involving motorcycles.
Thus, to reduce the number of traffic accidents, additional informational and educational measures must be taken, and safer protection devices must be developed.29 In fact, correct helmet use can reduce the risk of fatal injuries by up to 42% and the risk of head injuries by 69%.13 Fastening seat belts reduces the mortality of front seat occupants by 45–50%, and the risk of death and serious injury among rear seat occupants by 25%. In addition, restrictive laws for children regarding their seating in vehicles can lead to a 60% reduction in deaths.13 The prevalence of craniofacial trauma was similar to that reported in a previous study.18 Factors such as speed, the victim’s position, the lack of use of safety devices, and impact geometry are mainly responsible for injuries due to traffic accidents.30
Statistically significant associations between craniofacial trauma and accidents involving motorcycles and automobiles were observed. Motorcyclists are vulnerable to these injuries due to little or no protection during an accident.17 In addition, in general, automobile accidents produce greater impact than other types of accidents, resulting in more serious and complex craniofacial injuries.3
Limitations
There are some limitations to this study. It was impossible to investigate cause-and-effect relationships due to the cross-sectional design, and there may have been incomplete data from some of the medical records. Nevertheless, this research presents relevant epidemiological data about traffic accidents as a public health problem in children up to 12 years of age, providing knowledge about the risk factors for craniofacial trauma, so that better surveillance and continuous education on traffic safety can be implemented.
Conclusions
Older male children are the predominant victims of traffic accidents. There is a greater frequency of accidents involving motorcycles, with a high prevalence of craniofacial trauma.