Injury in the First Year of Life: Risk Factors and Solutions for High-Risk Families

doi:10.1016/j.jss.2006.02.027

Journal of Surgical Research

Volume 133, Issue 1, June 2006, Pages 7-10

Presented at the First Annual Academic Surgical Congress, San Diego, California, February 7–11, 2006.

https://doi.org/10.1016/j.jss.2006.02.027 Get rights and content

Background

Injury is one of the leading causes of death for infants younger than 1 year of age. We investigated potential contributing factors for injury among children born to high-risk families.

Methods

The Fragile Families and Child Wellbeing Study is a longitudinal cohort of approximately 5000 children from mostly unwed parents across the United States. Data from interviews with mothers conducted shortly after birth and follow-up surveys at 1year were used for this analysis. Injuries sustained in the first year of life that required medical attention were studied. Multivariate regression analysis was used to identify independent risk factors for injury in this population.

Results

A total of 13.7% of mothers reported that their child had sustained an injury in the first year of life. We identified 17 potential maternal, paternal, and environmental risk factors for injury, including socioeconomic, mental health, relationship violence, criminal justice system involvement, and substance abuse challenges. Multivariate regression analyses revealed two significant independent risk factors, maternal alcohol use (odds ratio 2.15, P = 0.044) and mother spanking child in the previous month (odds ration 2.32, P = 0.027).

Conclusions

Among this higher-risk group, injury in the first year of life is more than twice the national incidence. Predisposing factors to injury often are complex and interrelated, but with focused education and prevention efforts, including discussions of maternal alcohol use and attitudes toward physical discipline, we may decrease the burden of infant injury in this vulnerable population.

Introduction

Injury is the sixth-leading cause of death for children younger than 1 year of age in the United States. More than 1000 infants every year die from injuries, and more than 200,000 infants are taken to Emergency Departments for treatment of nonfatal injuries [1]. Infants younger than 1 year of age are particularly vulnerable because they are completely dependent on caregivers for all basic needs. The majority of injury-related deaths in infancy are unintentional, but violence accounts for one quarter of all infant fatalities. Falls are the most frequent cause of injury, and most injuries occur in the home [2]. Because small children have disproportionately large heads with a relatively undeveloped neck musculature, head injuries are quite common in infant trauma. Severe head trauma is more rare but is often associated with abuse and carries a poor prognosis [3].

Certain risk factors have been associated with an increased incidence of injury in infancy. Some population-based data have suggested that male and African-American infants suffer higher rates of injury [1], but other population samples have not found this association [2]. Infants living with unrelated caregivers are much more likely to suffer fatal injuries than children living with both biological parents [4]. Socioeconomic status is a well-documented risk factor for both homicide and family violence [5, 6, 7], and infants of lower socioeconomic status may bear a disproportionate burden of injury. In addition, the use of physical discipline is more common among families who have been investigated for abuse, and there is thought to be a continuum between physical discipline and abuse that may impact the incidence of childhood injury [8].

This study examined risk factors for injury in the first year of life among a cohort of families across the United States. Several studies have demonstrated a reduction in childhood injuries among children born to disadvantaged mothers who participated in home-based education and visitation programs [9, 10]. If a high-risk subset of families could be identified through simple screening measures, socioculturally appropriate interventions could be implemented to decrease the burden of injury among these infants.

Section snippets

Methods

Data for this research was obtained from the Fragile Families and Child Wellbeing study. Fragile Families is a nationwide, longitudinal study following approximately 5000 children born between 1998 and 2000, the majority from unmarried households. Permission to use this database was granted from the Fragile Families Collaborative and the Northwestern Institutional Review Board approval was obtained. Data were analyzed using STATA statistical software (Stata Press, College Station, TX).

Data from

Bivariate Analysis

Of the 3808 respondents, 520 mothers (13.7%) reported that their babies sustained an injury requiring medical attention during the first year of life. Of these 520 mothers, 376 (72%) were identified through hospital emergency department visits, 115 (22%) through trips to a health care professional, and 29 (6%) through overnight hospital admissions. There were no deaths attributed to this group. Bivariate analyses were performed between the outcome of interest, injury requiring medical attention

Discussion

Although many factors were significant in the bivariate analysis, the final multivariate regression model found that only two factors independently predicted infant injury. In this study population, mother’s alcohol use and spanking by mother significantly correlated with injury in the first year of life. Despite the presence of covariates we thought might affect the likelihood of injury, such as abuse in the father–mother relationship or history of incarceration, the only true independent

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A Latent Class Analysis of Parental Alcohol and Drug Use: Findings from the Avon Longitudinal Study of Parents and Children
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Previous measures of parental substance use have often paid limited attention to the co-occurrence of alcohol and drugs, or to the between-parent dynamics in the use of substances. These shortcomings may have important implications for our understandings of the relationship between parental substance use and child wellbeing. Using data from the Avon Longitudinal Study of Parents and Children, a UK community-based cohort study from 1990 onwards (n = 9,451), we identified groups of parental substance use using latent class analysis. The 4-class solution offered the best fit, balancing statistical criteria and theoretical judgement. The results show distinct classes across the range of parental substance use, including very low users, low users, moderate users and heavy users. These classes suggest that substance use patterns among mothers are somewhat mirrored by those of their partners, while heavy use of alcohol by mothers and their partners is related to increased mothers drug use. We suggest that studies that investigate the effects of parental substance use on child wellbeing should pay greater attention to the dynamics of substance use by parental figures.
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It is approaching 40 years since Sweden, in 1979, became the first country in the world to introduce legislation that prohibited the corporal punishment of children in all settings, and it is now 10 years since New Zealand controversially became the first English-speaking country to do so. To date, 53 countries have legally banned corporal punishment in all settings, including the home. This chapter presents an overview of world progress towards recognition of every child’s right to physical integrity and to protection from humiliating and degrading treatment, and it reflects upon reasons for the continuing tolerance of corporal punishment of children in family, school, and other institutional settings around the world. Some recent research on corporal punishment will be reviewed. Existing research and the need for further research that consults children and young people about this issue is highlighted. Attention is drawn to international law and the human rights context within which children’s physical discipline continues to be tolerated in many countries, including Australia. Further, it is noted that knowledge stemming from current research on this issue positions the corporal punishment of children not only as an infringement of their human rights but also as a disquieting public health concern. Obstacles and pathways to legislative reform are considered, including the influence of language and tradition, perceptions of the child, children’s status vis-à-vis adults, and questionable distinctions between corporal punishment of children and child abuse. Recent research on parenting programmes designed to challenge parents’ use of corporal punishment as discipline is also discussed. Children, it is argued, are entitled to live in environments that nurture and promote their optimal development, whenever this is possible. Corporal punishment has no place in any child’s childhood.
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Injury researchers should measure SES along a gradient and incorporate individual and area-level SES measures that are appropriate to the injury outcome under study.
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The first cycle of the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS–1998; Trocmé et al., 2001) revealed that 75% of substantiated child physical abuse occurred during episodes of physical punishment, a finding replicated in the second cycle of the study (CIS-2003; Trocmé et al., 2005). In a US study, infants in their first year of life who had been spanked by their parents in the previous month were more than twice as likely to suffer an injury requiring medical attention than infants who had not been spanked (Crandall, Chiu, & Sheehan, 2006). Another US study found that every time children are spanked, their odds of experiencing severe violence (e.g., kicking, punching, burning) increase by 3%; if they are hit with objects, the odds increase by 9% (Zolotor, Theodore, Chang, Berkoff, & Runyan, 2008).
Fifty-two countries have abolished all physical punishment of children, yet Canada has retained its criminal defense to ‘reasonable' corrective force. In 2004, Canada's Supreme Court attempted to set limits on punitive acts that can be considered reasonable under the law. In the present study, we examined the validity of these limits. If the court's limits provide adequate protection to children, most substantiated child maltreatment cases should exceed those limits. We operationalized each limit and applied it to a provincially representative sample of substantiated child physical maltreatment cases. We found that the majority of substantiated physical abuse cases fell within each of the court's limits. In more than one in four substantiated physical abuse cases, not even one of the court's limits was exceeded. The best predictor of whether a report was substantiated was whether spanking was typical in the child's home. The findings suggest that abolition of physical punishment would provide greater protection to children than attempts to set limits on its use.
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Notably, we find that 30% of the 1-year-old children in this study's sample of urban families were spanked by at least one of their parental caregivers in the past month. Although prior studies have shown that parental spanking has adverse consequences for child wellbeing, few studies have examined the consequences of spanking of 1-year-olds (for exceptions see studies by Bugental et al., 2003; Combs-Orme & Cain, 2008; Crandall et al., 2006; Maguire-Jack et al., 2012; Zolotor et al., 2011). To our knowledge, this is the first study using prospective analysis of a community-based sample of families to show that, even after accounting for numerous household and parenting risk factors such as maternal depression, spanking of 1-year-old children is associated with increased risk for household CPS involvement.
The majority of U.S. parents spank their children, often beginning when their children are very young. We examined families (N = 2,788) who participated in a longitudinal community-based study of new births in urban areas. Prospective analyses examined whether spanking by the child's mother, father, or mother's current partner when the child was 1-year-old was associated with household CPS involvement between age 1 and age 5. Results indicated that 30% of 1-year-olds were spanked at least once in the past month. Spanking at age 1 was associated with increased odds of subsequent CPS involvement (adjusted odds ratio = 1.36, 95% CI [1.08, 1.71], p < .01). When compared to non-spanked children, there was a 33% greater probability of subsequent CPS involvement for children who were spanked at age 1. Given the undesirable consequences of spanking children and a lack of empirical evidence to suggest positive effects of physical punishment, professionals who work with families should counsel parents not to spank infants and toddlers. For optimal benefits, efforts to educate parents regarding alternative forms of discipline should begin during the child's first year of life.

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Pediatric/congenital/developmentalInjury in the First Year of Life: Risk Factors and Solutions for High-Risk Families

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Bivariate Analysis

Discussion

J Emerg Med

Child Abuse Negl

Adjusting our view of injury riskthe burden of nonfatal injuries in infancy

Pediatrics

Subdural haemorrhages in infantspopulation based study

BMJ

Child deaths resulting from inflicted injurieshousehold risk factors and perpetrator characteristics

Pediatrics

Race, socioeconomic status, and domestic homicide, Atlanta, 1971–72

Am J Public Health

Race, socioeconomic status, and domestic homicide

JAMA

Nonlethal intimate partner violenceexamining race, gender, and income patterns

Violence Vict

Macrotheorieschild physical punishment, injury and abuse

Community Pract

Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial

JAMA

Pediatric/congenital/developmental
Injury in the First Year of Life: Risk Factors and Solutions for High-Risk Families