I am Handle me with care!

ChildhoodChildhood

IInjurynjury((ACCIDENTS IN CHILDRENACCIDENTS IN CHILDREN))Dr mohammad nurul huq Bdangladesh Medical College

In HICs

At the end of this you will learnAt the end of this you will learn Impact of injury is Impact of injury is devastatingdevastating 95% child injuries 95% child injuries (CI) (CI) occur in L&MICsoccur in L&MICs Drowning Drowning is a great killeris a great killer

Control of CI is essential to achieve MDG4Control of CI is essential to achieve MDG4 ID and Mn. are controlled, but CI is clearly a big problemID and Mn. are controlled, but CI is clearly a big problem Most CI are preventable!Most CI are preventable! Px program must be integrated Px program must be integrated

into all child health initiativesinto all child health initiatives

CI: child injuries.CI: child injuries. Px: preventionPx: prevention

L&MIC:L&MIC: low-income -, MIC: middle-income countrieslow-income -, MIC: middle-income countries

InjuryInjury

Definition: Definition: is the intentional/un- damage to body from ac. is the intentional/un- damage to body from ac. exposure to thermal, mechanical, electrical, or chemical exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat/O2energy or from the absence of such essentials as heat/O2

90% are unintentional90% are unintentional

>2k/d or 9,30,000 U-18y die/y 9,30,000 U-18y die/y from from unintentional unintentional CICI:: (= (=to to death from DPT, measles, poliodeath from DPT, measles, polio.. >50% from >50% from RTA , RTA , drowningdrowning

Tens of millions are admitted/y for non-fatal CITens of millions are admitted/y for non-fatal CI CI is CI is a significant MM since 1y age anda significant MM since 1y age and the leading c/of the leading c/of

death for >9y agedeath for >9y age Impact of CI is hidden by other c/of U-5MImpact of CI is hidden by other c/of U-5M

MM: morbidity and mortalityMM: morbidity and mortality

World Figure of CI: World Figure of CI: >12% of disease burden>12% of disease burden

Common CIs: Common CIs: drowning, RTA, burns, falls, homicide, drowning, RTA, burns, falls, homicide,

poisoning. poisoning. Drowning is number 1 killer among Drowning is number 1 killer among

1-1- 4y age in Bangladesh4y age in Bangladesh

In HICs: CIs account for 40% of all child deaths;In HICs: CIs account for 40% of all child deaths; but many but many

countries have reduced it by 50%countries have reduced it by 50%

World Figure of CI …World Figure of CI …

CIs are strongly related to social determinantsCIs are strongly related to social determinants

Children are at greater riskChildren are at greater risk

Children live in a world built for adults: strong association Children live in a world built for adults: strong association between injuries andbetween injuries and– his age, developmental stagehis age, developmental stage– his interactions and activities with/in the worldhis interactions and activities with/in the world– lack of supervision, access to protective materialslack of supervision, access to protective materials

Simply reproducing injury Px. strategies for adults may not Simply reproducing injury Px. strategies for adults may not be effective for childrenbe effective for children

World becomes dangerous for them: cleaning chemicals, World becomes dangerous for them: cleaning chemicals, outlets, ovens, sharp corners, kerosene lamps, bodies of outlets, ovens, sharp corners, kerosene lamps, bodies of water, traffic, etc.water, traffic, etc.

Impact of CIImpact of CI

• Losing a child unexpectedly has a huge impactLosing a child unexpectedly has a huge impact

on families and communities on families and communities • Disabled Disabled children may have poor social dev., children may have poor social dev.,

education, work, etc.education, work, etc.

• CIs place significant strain on overstretched CIs place significant strain on overstretched health care systems in L&MICshealth care systems in L&MICs

Injury Px is a v. cost-effective!Injury Px is a v. cost-effective!

RTA: leading c/of death in 10-19yRTA: leading c/of death in 10-19y• 720 children 720 children die/d. 10million non-fatally injured/y die/d. 10million non-fatally injured/y • The biggest killer in 15-19y and the 2The biggest killer in 15-19y and the 2ndnd in 10-14y in 10-14y

• RTA and falls are main c/of disabilitiesRTA and falls are main c/of disabilities

• HICs: HICs: most victims are occupants of vehicles most victims are occupants of vehicles • L&MICs: L&MICs: they are usually pedestrians or cycliststhey are usually pedestrians or cyclists• The most common injuries: head injuries and fractureThe most common injuries: head injuries and fracture

RTI: road traffic injury. RTA: - - accidentsRTI: road traffic injury. RTA: - - accidents

RTI: What works?RTI: What works? Road safetyRoad safety

Helmets. Minimum drinking-age lawsHelmets. Minimum drinking-age laws Lower BAC for novice drivers and zero toleranceLower BAC for novice drivers and zero tolerance Graduated driver licensing systemsGraduated driver licensing systems Seat-belts, child-restraints. Speed reduction (Seat-belts, child-restraints. Speed reduction (school, residence, play school, residence, play

areas)areas) Separating road users: Separating road users: bicycle and pedestrian lanesbicycle and pedestrian lanes Daytime running lightsDaytime running lights Enforce traffic law, straighten roadsEnforce traffic law, straighten roads

BAC: BAC: blood alcohol concentrationblood alcohol concentration

11

Falls:Falls: the leading c/of ED visit the leading c/of ED visit

• 47,000 children die /y47,000 children die /y• For every fatal fall 690 For every fatal fall 690

children miss school children miss school • Falls are the leading c/of Falls are the leading c/of

long term disabilitylong term disability

c/of: cause of. ED: emergency c/of: cause of. ED: emergency departmentdepartment

Falls: World FactsFalls: World Facts 130 die/d: 60% from a height130 die/d: 60% from a height In some countries: 50% children ED visits are for fallIn some countries: 50% children ED visits are for fall Non-fatal falls: Non-fatal falls: significant Disability Adjusted Life Years lostsignificant Disability Adjusted Life Years lost Commonest falls: Commonest falls:

– prams, baby walkers, changing tables prams, baby walkers, changing tables – cots, beds, bunk bedscots, beds, bunk beds– rooftops, windows, stairs rooftops, windows, stairs – playground equipmentplayground equipment– Trees; sportsTrees; sports

Children playing on roofs is a common sight in Children playing on roofs is a common sight in many Asian countriesmany Asian countries

Falls Falls are leading c/of CI in are leading c/of CI in Bangladesh Bangladesh and 1 of the and 1 of the major c/of permanent disabilitymajor c/of permanent disability

770 children are injured/d and 770 children are injured/d and 5 die5 die 10 are disabled/d10 are disabled/d Major Major categories: from trees, cliffs, buildings, windows, categories: from trees, cliffs, buildings, windows,

roofs, furniture, jumping/diving into waterroofs, furniture, jumping/diving into water

Infants have the highest rates of Infants have the highest rates of fatal fallsfatal falls

Common causes of falls in BangladeshCommon causes of falls in Bangladesh The roads in rural areas become slippery when wetThe roads in rural areas become slippery when wet The concrete slabs around tube-wells also become The concrete slabs around tube-wells also become

slippery when wetslippery when wet

Children fall from their beds or cots, or slip from the lap of Children fall from their beds or cots, or slip from the lap of another childanother child

Young children also fall when they learn how to walkYoung children also fall when they learn how to walk

Falls: What works?Falls: What works? Redesigning nursery furniture and other productsRedesigning nursery furniture and other products Safe playground: appropriate surface, material, height of Safe playground: appropriate surface, material, height of

equipment and maintenanceequipment and maintenance Legislating for window/roof guards, rLegislating for window/roof guards, railingailing Multifaceted community programs: Multifaceted community programs: ‘Children can't fly’‘Children can't fly’

All should be careful about childrenAll should be careful about children Prevent them from climbing and slippery surfacesPrevent them from climbing and slippery surfaces Hold children on rickshawsHold children on rickshaws Ensure children’s shoes are not slipperyEnsure children’s shoes are not slippery

Burns: Burns: only CI more common in girlsonly CI more common in girls

Burns: World FactsBurns: World Facts

260 die from burn/d260 die from burn/d The death is x11 in L&MICsThe death is x11 in L&MICs Infants are at highest riskInfants are at highest risk Smoke inhalation alone can be fatalSmoke inhalation alone can be fatal 25% from fire, 75% from hot liquids, steam, electricity, etc25% from fire, 75% from hot liquids, steam, electricity, etc Many children are disfiguredMany children are disfigured

Burns in Bangladesh

Risk factors for burn in BangladeshRisk factors for burn in Bangladesh

Young children are the most vulnerableYoung children are the most vulnerable Rural children: >4 times at riskRural children: >4 times at risk Homes are the most common placeHomes are the most common place The kitchen is the most hazardousThe kitchen is the most hazardous KupiBati KupiBati (kerosene lamp): 10% of the total flame burns(kerosene lamp): 10% of the total flame burns

46% of burns occur between breakfast to lunch46% of burns occur between breakfast to lunch

Burns: What works?Burns: What works? Laws for smoke alarmsLaws for smoke alarms Child-resistant lightersChild-resistant lighters Laws for tap water temp.Laws for tap water temp. Educating the public Educating the public Caution in transporting hot water, drinksCaution in transporting hot water, drinks Rx at a dedicated burns centreRx at a dedicated burns centre

Poisoning: Poisoning: World FactsWorld Facts >45,000 die/y Highest for U-1y, but peaks again at 15y and older as they Highest for U-1y, but peaks again at 15y and older as they

experiment with substancesexperiment with substances Fatal poisoning is x4 in L&MICs than HICsFatal poisoning is x4 in L&MICs than HICs

The most common poisons in L&MICs are paraffin, The most common poisons in L&MICs are paraffin, household products and drugshousehold products and drugs

In HICs these are OTC drugs, household products, In HICs these are OTC drugs, household products, prescription drugsprescription drugs

Substances found in and around the home are most Substances found in and around the home are most commonly involved in childhood poisoningcommonly involved in childhood poisoning

• Many millions of calls are made to poison control centres, most of which are resolved over the phone

• Children <1y of one are at greatest risk of fatal poisoning.

Poisoning: What works?Poisoning: What works? Toxin free home. Removing the toxic agent Child-resistant packaging of drugs and poisons Packaging drugs in non-lethal quantities Store out of reach of children Air pollution, smoking, arsenic mitigation Establishing poison control centres

World Child Health ProjectsWorld Child Health Projects

Convention on Rights of a Child: Convention on Rights of a Child: 19891989 Protect childrenProtect children. They have the right to the best health . They have the right to the best health

care and a safe environ., free from injury and violencecare and a safe environ., free from injury and violence

WHA resolutionsWHA resolutions Children are frequently mentioned in all Children are frequently mentioned in all resolutionsresolutions

8 MDGs: 48 MDGs: 4thth

to cut 2/3to cut 2/3rdsrds U-5MR; not attainable if CI is not controlled U-5MR; not attainable if CI is not controlled

UNGA: UNGA: A world fit for children A world fit for children (including(including CI) CI)

Child Survival Child Survival is an important issue globally. It is “the is an important issue globally. It is “the most pressing moral dilemma”most pressing moral dilemma”

The Bellagio PapersThe Bellagio Papers CI Px should be integrated into all child health initiativesCI Px should be integrated into all child health initiatives 2/32/3rdsrds of 11million U-5MR can be reduced by adding 23 of 11million U-5MR can be reduced by adding 23

proven cost-effective interventions for CIproven cost-effective interventions for CI

U-5MR from ID is now low: U-5MR from ID is now low: CI is aCI is a major killer major killer 14% of all death: 50/100,00014% of all death: 50/100,000 53% death in 5-17y-age53% death in 5-17y-age

(increasing with age)(increasing with age) U-18y MRU-18y MR

CI mortality: CI mortality: 30,000/y 30,000/y (drowning (drowning

17,000/y)17,000/y)– injury morbidity: injury morbidity: 9,55,500/y (9,55,500/y (permanent permanent

disabilities13,134/y) disabilities13,134/y) contdcontd

Bangladesh ScenarioBangladesh Scenario

U-18y CI mortality: 30,000/y– Drowning: 17,000 (46 /d) – RTA 3,400– Animal bite 2,600– Suicide 2,200

(15-17y; 6/d)– Others 4,800

U-18y CI morbidity9,55,500: 30% of all morbidity: 16/1000 (13000 permanent disability)

– Fall 2,81,500– Burn 1,73,000– Cut 1,22,500– RTA 1,11,500– Near drowning 68,800– Others 1,98,200

Every 2 min a child is injured. Lack of care and supervision Every 2 min a child is injured. Lack of care and supervision are main reasonsare main reasons

Caregivers are often preoccupied (poor, both parents Caregivers are often preoccupied (poor, both parents working, living in cities)working, living in cities)

Low awareness of or indifference to risksLow awareness of or indifference to risks Harmful practices often make situations worse with Harmful practices often make situations worse with

absence of first-aid knowledgeabsence of first-aid knowledge

Bangladesh …Bangladesh …

Impact of Injury (BD)Impact of Injury (BD)

38,000 are orphaned/y38,000 are orphaned/y 36/d are disabled 36/d are disabled (bleak future, trapped in poverty, denied (bleak future, trapped in poverty, denied

for Rx, education, protection; can’t cope with environ.)for Rx, education, protection; can’t cope with environ.) It brings devastation for the poorIt brings devastation for the poor Many families are pushed to poverty or even family Many families are pushed to poverty or even family

dissolution due to Rx and rehab. costdissolution due to Rx and rehab. cost

RTA loses 2% GDPRTA loses 2% GDP

Why must we act now?Why must we act now?

If not, the burden of CI will riseIf not, the burden of CI will rise We can now prevent better by more resources, good We can now prevent better by more resources, good

health knowledge and culturehealth knowledge and culture

... make our roads safe for children; plan cities, caution ... make our roads safe for children; plan cities, caution against flood or mud flows, droughts, desertification or against flood or mud flows, droughts, desertification or rises in sea levelrises in sea level

Child injuries are preventableChild injuries are preventable 12 Proven interventions could 12 Proven interventions could

save >1000 children/dsave >1000 children/d Many HICs have been able to Many HICs have been able to

reduce CI deaths by 50% over the past 3Dsreduce CI deaths by 50% over the past 3Ds

CI prevention is cost effectiveCI prevention is cost effective

Challenges in CI Px in BangladeshChallenges in CI Px in Bangladesh

Lack of Lack of datadata Lack of Lack of political willpolitical will Lack Lack of fundof fund, human , human resourcesresources Appropriate Appropriate technologytechnology for DCs for DCs Perception that CI is a chancePerception that CI is a chance Poor collaboration and cooperation between agenciesPoor collaboration and cooperation between agencies

Overall RecommendationsOverall Recommendations Integrate CI into a Integrate CI into a comprehensive approachcomprehensive approach to child to child

health and developmenthealth and development Develop Develop CI prevention policy and implement actionsCI prevention policy and implement actions

Strengthen Strengthen health systemshealth systems to address CI to address CI Enhance Enhance datadata for CI prevention for CI prevention Priorities for Priorities for researchresearch Invest Invest for CI preventionfor CI prevention

WHO

“The cost of doing nothing for CI is unacceptable”

It would be tragic to achieve significant gains in child survival only to lose to CI

Make CI top PH policy and practice

PH: public health

Drowning Drowning

and and Near DrowningNear Drowning

Drowning: death within 24 hrs of submersion

Near drowning: survival after 24 hrs of submersion (may die later)

Drowning: World FactsDrowning: World Facts 480 children die/d. 480 children die/d. >98% in L&MICs, usually in open >98% in L&MICs, usually in open

bodies of water. Most happen in and around the homebodies of water. Most happen in and around the home 1111thth U-5MR. 4 U-5MR. 4thth c/of death among 4-14y-age. 1 c/of death among 4-14y-age. 1stst in 1-4y in 1-4y 2-3million/y get into trouble in water (close to drowning)2-3million/y get into trouble in water (close to drowning) U-5 children are at greatest risk – infants can drown in a U-5 children are at greatest risk – infants can drown in a

few CM of waterfew CM of water

In HICs: most drowning happen in swimming poolsIn HICs: most drowning happen in swimming pools

Bangladesh Scenario Bangladesh Scenario Drowning is number 1 killer in 1-4y ageDrowning is number 1 killer in 1-4y age 2007 flood: 87% of U-5MR was from drowning2007 flood: 87% of U-5MR was from drowning In pre-vax. era, it was equal to measles as killer (9% of In pre-vax. era, it was equal to measles as killer (9% of

deaths in 1-4y in 1983); now 53% in 2000deaths in 1-4y in 1983); now 53% in 2000

Most Drowning OccurMost Drowning Occur in pools. (>75% within 20m of house), in the monsoon in pools. (>75% within 20m of house), in the monsoon

(April – Sept), (April – Sept), during flood; between 9 am-noon: during flood; between 9 am-noon: mother is mother is busy!busy!

46% were <4y: 46% were <4y: cant swimcant swim

Male Female RatioMale Female Ratio

overall overall 3:1 3:1

Teenagers Teenagers 10:110:1

Age of drowningAge of drowning <1 y<1 y 5% 5% 1-4y1-4y 37%37% 5-9y5-9y 15%15%10-14y10-14y 15%15%15-19y15-19y 28%28%

Age 1-4 y: most D occur in residential poolsAge 1-4 y: most D occur in residential pools

PlacesPlaces

PondsPonds Bath tubsBath tubs BucketsBuckets Swimming poolsSwimming pools

LakesLakes StreamsStreams FloodFlood RiverRiver Ocean beaches Ocean beaches

Infants mostly drown in bathtubs, buckets, or toiletsInfants mostly drown in bathtubs, buckets, or toilets

Bucket drowning is 24% of all toddler drowningBucket drowning is 24% of all toddler drowning

Risks Factors of DrowningRisks Factors of Drowning Lack of supervision: Lack of supervision: most drowned childrenmost drowned children

– were last seen in home in care of parents!were last seen in home in care of parents!– had been out of sight for had been out of sight for <5 min!<5 min!

Water recreation, alcohol, illicit drugsWater recreation, alcohol, illicit drugs Epilepsy (x13 rise)Epilepsy (x13 rise) Child abuseChild abuse

Most pediatric drowning victims drown silentlyMost pediatric drowning victims drown silently

Recreation waters: Recreation waters: majority >15y. Recreational majority >15y. Recreational boating: hypothermia, trauma, CO poisoning, etcboating: hypothermia, trauma, CO poisoning, etc..

Alcohol:Alcohol: in 25-50% of teenager and adult drowningin 25-50% of teenager and adult drowning affects balance, coordination, judgmentaffects balance, coordination, judgment effect is effect is by sun and heat by sun and heat

Epilepsy:Epilepsy: drowning is the greatest c/of death (bathtub drowning is the greatest c/of death (bathtub highest risk)highest risk)

Pathophysiology Pathophysiology

Immediate hypoxiaImmediate hypoxia– cardiac arrest (? catechol. induced fatal arrhythmia): cardiac arrest (? catechol. induced fatal arrhythmia):

ischemia to all tissuesischemia to all tissuesLaryngospasmLaryngospasmPulmonary aspirationPulmonary aspiration (absent in 15%)(absent in 15%)

HypothermiaHypothermiaComaComaTerminal apnea Terminal apnea (medullary depression)(medullary depression)

HeartHeart– Cardiac arrestCardiac arrest– Initial tachycardia, severe hypertensionInitial tachycardia, severe hypertension bradycardia bradycardia

and arrhythmiasand arrhythmias

CNSCNS:: fails in 3min of hypoxiafails in 3min of hypoxia– Cerebral edemaCerebral edema– Increased ICPIncreased ICP

LiverLiver:: raised transaminasesraised transaminases

LungsLungs– ARDS; aspiration pn. (gastric, caustic, fluid)ARDS; aspiration pn. (gastric, caustic, fluid)– Pulmonary edemaPulmonary edema

Kidneys: Kidneys: ATN, cortical necrosisATN, cortical necrosis

CirculationCirculation:: DIC, hemolysis, low plateletDIC, hemolysis, low platelet

GITGIT:: abrasions, bloody stools, infxabrasions, bloody stools, infx..

PancreasPancreas: : raised serum enzymesraised serum enzymes

FEBFEB (derangement not common)(derangement not common)

– Sea waterSea water: hemoconcentration, : hemoconcentration, hypernatremiahypernatremia– Fresh waterFresh water: water intoxication: water intoxication

hemodilution, hyponatremiahemodilution, hyponatremia hemolysis: ARF, hyperkalemiahemolysis: ARF, hyperkalemia

– SIADHSIADH

Temperature: Temperature: commonly hypothermiacommonly hypothermia

Bradycardia, Bradycardia, myocardial contraction myocardial contractionloss of vasomotor tone, hypotension, shockloss of vasomotor tone, hypotension, shock

Resuscitation Resuscitation Clear airwaysClear airways Don’t press abdomen!Don’t press abdomen! Vomits commonly Vomits commonly M2M/M2N breathingM2M/M2N breathing IntubationIntubation Temp. maintenanceTemp. maintenance Venous catheterVenous catheter ECGECG Correction of Correction of hypoglycemiahypoglycemia

Prognosis: depends onepends on

– Circumstances of the incidentCircumstances of the incident– Duration of submersionDuration of submersion– Speed of rescueSpeed of rescue– Effectiveness of resuscitationEffectiveness of resuscitation

Cardiac arrest requires aggressive prolonged Cardiac arrest requires aggressive prolonged resuscitationresuscitation

A: adult supervisionA: adult supervision

Must watch children with a distance of an arm’s lengthMust watch children with a distance of an arm’s length

Look in the pool first if a child is missingLook in the pool first if a child is missing

Get a lifeguard for social gatheringsGet a lifeguard for social gatherings

Prevention: ABCDPrevention: ABCD

Adult supervision is critical! Adult supervision is critical! A lapse of <5min is seen in most drowningA lapse of <5min is seen in most drowning May drown in 1-2in. of waterMay drown in 1-2in. of water Frequently occurs in bath tubs, buckets, toilets, diaper pails Frequently occurs in bath tubs, buckets, toilets, diaper pails

and wading poolsand wading pools Taking an eye off a Taking an eye off a

child in water for child in water for

2 sec puts a child at risk!2 sec puts a child at risk!

A swimming teacher teaches children to swim

B means BarriersB means Barriers

A non-climbable (4F) fence for pool/spa. No items usable A non-climbable (4F) fence for pool/spa. No items usable for climbing near fencefor climbing near fence

Self-closing, -latching gates to pool/spa, Self-closing, -latching gates to pool/spa, (latches above a (latches above a child's reach)child's reach)

Power operated pool safety coversPower operated pool safety covers Secure locks for all openings to pool/spa when not in useSecure locks for all openings to pool/spa when not in use Doors and windows could be alarmed when openedDoors and windows could be alarmed when opened

Fence keeps children away from water

Use of waist bells

C means Classes C means Classes (swimming, CPR)(swimming, CPR)

Swimming by an instructorSwimming by an instructor Teach children toTeach children to

– leave the water if adult leavesleave the water if adult leaves– enter the water only with a swim suitenter the water only with a swim suit– first enter the water in the shallow endfirst enter the water in the shallow end

Teach adults CPR, rescue techniques, Teach adults CPR, rescue techniques, risks ofrisks of– Bath tubs, buckets, commodes, washing machineBath tubs, buckets, commodes, washing machine– Close toilet and bath doorsClose toilet and bath doors– Cover commodeCover commode

D means DevicesD means Devices

Poolside emergency phonePoolside emergency phone Install a life saving ring, shepherd's hook and CPR poster Install a life saving ring, shepherd's hook and CPR poster

by the poolby the pool Children must wear Personal Flotation Device (PFD) when Children must wear Personal Flotation Device (PFD) when

at water sitesat water sites Wear PFD while in a boatWear PFD while in a boat

Also, never…Also, never…

leave full bucket/tubs, nor leave full bucket/tubs, nor leave a child alone near leave a child alone near water or let swim alone, nor use "floaties" or inflatable water or let swim alone, nor use "floaties" or inflatable toys as life jackets or substitutes for supervisiontoys as life jackets or substitutes for supervision

leave toys in or around the pool/spaleave toys in or around the pool/spa consider a child as consider a child as ''drown-proofdrown-proof' ' despite despite

swimming skills, or experienceswimming skills, or experience use alcohol or drugsuse alcohol or drugs swim in thunder or lightningswim in thunder or lightning dive into unfamiliar or shallow bodies of waterdive into unfamiliar or shallow bodies of water

MDG 4 and drowning To achieve MDG4 we must reduce drowning by 50% GoB has included CI as 1 of 5 PH prioritiesGoB has included CI as 1 of 5 PH priorities Make homes, schools, communities safe for children; Make homes, schools, communities safe for children;

students will learn CI prevention, 1students will learn CI prevention, 1stst Aid Aid Importance of learning swimming and supervisionImportance of learning swimming and supervision Awareness: mass media, educn., P2P communicationAwareness: mass media, educn., P2P communication Develop teachers’ manuals for CIDevelop teachers’ manuals for CI For working children make workplace safeFor working children make workplace safe

MCQMCQ

Drowning is the greatest injury-death among children Drowning is the greatest injury-death among children Near drowning means there is no aspiration in the lungsNear drowning means there is no aspiration in the lungs

Drowning in sea water causes water intoxicationDrowning in sea water causes water intoxication The brain can tolerate hypoxia up to 9 minThe brain can tolerate hypoxia up to 9 min

Most children in this country drown in out door poolsMost children in this country drown in out door pools Preventing drowning can achieve MDG4Preventing drowning can achieve MDG4

THANKTHANK YOUYOU