childhood injuries and prevention

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Childhood Injuries Childhood Injuries and Prevention and Prevention By By Jim Carpenter MD, MPH Jim Carpenter MD, MPH February 10, 2010 February 10, 2010

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Childhood Injuries and Prevention. By Jim Carpenter MD, MPH February 10, 2010. Goals. Discussion about child safety and the Physician role in Anticipatory Guidance Data on Child Injury Anticipatory Guidance for safety: why and what to say What a DRT is and does Questions. - PowerPoint PPT Presentation

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Childhood Injuries and Childhood Injuries and PreventionPrevention

ByBy

Jim Carpenter MD, MPHJim Carpenter MD, MPH

February 10, 2010February 10, 2010

GoalsGoals

Discussion about child safety and the Discussion about child safety and the Physician role in Anticipatory GuidancePhysician role in Anticipatory Guidance

Data on Child InjuryData on Child Injury Anticipatory Guidance for safety: why and Anticipatory Guidance for safety: why and

what to saywhat to say What a DRT is and doesWhat a DRT is and does QuestionsQuestions

Anticipatory guidanceAnticipatory guidance

Recent lit review:18 of 20 studies showed Recent lit review:18 of 20 studies showed positive effects from injury prevention positive effects from injury prevention counselingcounseling

60% of parents report never receiving injury 60% of parents report never receiving injury prevention counselingprevention counseling

Injury in the U.S.Injury in the U.S.

Injury the leading cause of death and disability Injury the leading cause of death and disability among children and young adultsamong children and young adults

Nearly 150,000 die each year from injuryNearly 150,000 die each year from injury 41,000 - motor vehicle crashes41,000 - motor vehicle crashes 28,000 - fires, drownings, falls, poisonings28,000 - fires, drownings, falls, poisonings 30,500 - suicide30,500 - suicide 25,500 - homicide25,500 - homicide

The Injury PyramidThe Injury Pyramid

EPISODES OF INJURIES REPORTED

EMERGENCY DEPARTMENT VISTS

HOSPITAL DISCHARGES

DEATHS

Injury and AgeInjury and Age

Injury is the leading cause of death in children Injury is the leading cause of death in children and young adultsand young adults

Injuries kills more Americans aged 1-34 than Injuries kills more Americans aged 1-34 than all other disease combined.all other disease combined.

Injury Prevention: Injury Prevention: The Three E’sThe Three E’s

EducationEducation

EnforcementEnforcement

EngineeringEngineering

TIPPTIPP

American Academy of Pediatrics taskforce American Academy of Pediatrics taskforce entitled The Injury Prevention Programentitled The Injury Prevention Program

TIPP componentsTIPP components Policy statement saying safety counseling is a Policy statement saying safety counseling is a

priority and standard of care for PCP’spriority and standard of care for PCP’s Provides counseling schedule which suggests age Provides counseling schedule which suggests age

appropriate topics for each well child visitappropriate topics for each well child visit Materials for PCP’s including a Framingham Materials for PCP’s including a Framingham

Safety survey as well as info sheetsSafety survey as well as info sheets

TIPP tooTIPP too

TIPP encompasses 11 visits between 0-4yrs.TIPP encompasses 11 visits between 0-4yrs. Survey to be completed 2, 15,24 mos. and they allow Survey to be completed 2, 15,24 mos. and they allow

PCP to tailor counselingPCP to tailor counseling Topics are: Safety seats, smoke detectors, crib safety, Topics are: Safety seats, smoke detectors, crib safety,

water safety, firearms, pedestrian, play equipment, water safety, firearms, pedestrian, play equipment, fall prevention, burn prevention, choking, suffocation fall prevention, burn prevention, choking, suffocation prevention, and poisoning preventionprevention, and poisoning prevention

TIPP costTIPP cost

Only takes 22 min of PCP’s time over 4 years Only takes 22 min of PCP’s time over 4 years thus adding an avg. of 1.5 min to the WCC thus adding an avg. of 1.5 min to the WCC visit (estimated as 16min long in 1992)visit (estimated as 16min long in 1992)

Materials from AAP provided at $1.09 per Materials from AAP provided at $1.09 per childchild

TIPP BenefitTIPP Benefit

medical costs saved $5.50 per visit, $60 per medical costs saved $5.50 per visit, $60 per child, 230 million annually at national levelchild, 230 million annually at national level

Work (wages lost to parents not included) Work (wages lost to parents not included) $15.50 per visit, $170 per child, 660 million $15.50 per visit, $170 per child, 660 million annuallyannually

Quality of Life $59 per visit, $650 per child, Quality of Life $59 per visit, $650 per child, 2.5 billion annually 2.5 billion annually

Were did those #’s come from?Were did those #’s come from?

Effectiveness of broad prevention counseling in a Effectiveness of broad prevention counseling in a suburban office reduced child injury rate by 15.3%. suburban office reduced child injury rate by 15.3%. National medical expenditure survey shows avg. National medical expenditure survey shows avg. injury cost $394 per 1injury cost $394 per 1stst 5 yrs of a child’s life 5 yrs of a child’s life

Preventing permanent disabilities and death allows Preventing permanent disabilities and death allows kids to work as adultskids to work as adults

Injury reduces quality of life. Took ratio of QOL cost Injury reduces quality of life. Took ratio of QOL cost to wage loss to injured in data from safety seats and to wage loss to injured in data from safety seats and smoke detectors yields QOL savingssmoke detectors yields QOL savings

Why care about injury preventionWhy care about injury prevention

National Health Interview Survey data National Health Interview Survey data determined an injury rate of 25/100 kids determined an injury rate of 25/100 kids through 0-21yrs of age (26.6 million injuries through 0-21yrs of age (26.6 million injuries per year) Estimate cost $347 billion annuallyper year) Estimate cost $347 billion annually

Death Review TeamsDeath Review Teams

Multidisciplinary team that reviews all coroner Multidisciplinary team that reviews all coroner case deaths of children under 18 in CCCcase deaths of children under 18 in CCC

Classify deaths as “Accidental”, Homicide, Classify deaths as “Accidental”, Homicide, Suicide, Natural or UndeterminedSuicide, Natural or Undetermined

Determine preventabilityDetermine preventability Annual reports include findings and Annual reports include findings and

recommendationsrecommendations

Annual rate of the leading specific cause of injury Annual rate of the leading specific cause of injury hospitalization and death / 100K by 3 month intervals 0-4 yrs hospitalization and death / 100K by 3 month intervals 0-4 yrs

CA 1996-1998CA 1996-1998

Newborn SafetyNewborn Safety

Sleep position and locationSleep position and location Microwave heatingMicrowave heating Animals/petsAnimals/pets CribCrib Water temperatureWater temperature Car SeatCar Seat

Avoid direct sunlight; unable to move or Avoid direct sunlight; unable to move or change positionchange position

Layering of clothingLayering of clothing Never leave alone in vehicle, extreme heat and Never leave alone in vehicle, extreme heat and

extreme cold can killextreme cold can kill Remove guns from home. If not then store Remove guns from home. If not then store

guns and ammo separately with trigger locksguns and ammo separately with trigger locks Don’t leave infant alone with petsDon’t leave infant alone with pets

Post neonatal DeathsPost neonatal Deaths From 1988-1998 12,209 post neonatal (28-364 From 1988-1998 12,209 post neonatal (28-364

days of age) deaths occurreddays of age) deaths occurred avg. 1110/yearavg. 1110/year Majority unintentional injury due toMajority unintentional injury due to

mechanical suffocation i.e. wedging, oronasal mechanical suffocation i.e. wedging, oronasal obstruction by a plastic bag, overlying in bed, obstruction by a plastic bag, overlying in bed, falling earth, lack of air in enclosed space, and falling earth, lack of air in enclosed space, and accidental hangingaccidental hanging

obstructive suffocation from aspirationobstructive suffocation from aspiration motor vehicle crash related deathsmotor vehicle crash related deaths

Car Seat Anticipatory GuidanceCar Seat Anticipatory Guidance

In 1994, 673 kids less that 5 yrs of age killed, 362 In 1994, 673 kids less that 5 yrs of age killed, 362 unrestrained. unrestrained.

Rear facing until 20lbs Rear facing until 20lbs andand 1 yr of age to decrease 1 yr of age to decrease risk of cervical spine injuryrisk of cervical spine injury

Back seat onlyBack seat only Infant seats should not have shields, abd pads, or arm Infant seats should not have shields, abd pads, or arm

rest that can directly contact facerest that can directly contact face In rear facing, shoulder straps should be lower than In rear facing, shoulder straps should be lower than

infants shoulders, clip should be mid sternuminfants shoulders, clip should be mid sternum

Car seat continuedCar seat continued

If child’s head leans forward in rear facing car If child’s head leans forward in rear facing car seat, chair should be reclined until head seat, chair should be reclined until head against back of chairagainst back of chair

Convertible seat at 20 lbs and greater than 12 Convertible seat at 20 lbs and greater than 12 mos. Should be semi upright and forward mos. Should be semi upright and forward facing (ears below top of back of seat and facing (ears below top of back of seat and shoulders below the seat strap slots)shoulders below the seat strap slots)

Booster seat to position lap and shoulder strap. Booster seat to position lap and shoulder strap. Lap across hips and shoulder strap below neckLap across hips and shoulder strap below neck

2-6 Weeks2-6 Weeks

Car SeatsCar Seats Crib safetyCrib safety Sleep PositionSleep Position Sibling jealousySibling jealousy Smoke detectorsSmoke detectors BathwaterBathwater Rolling overRolling over

Infant should always sleep on back to reduce Infant should always sleep on back to reduce risk of SIDSrisk of SIDS

Avoid sofa, soft mattress, waterbeds, Avoid sofa, soft mattress, waterbeds, comforters, crib pads, pillows, quilts.comforters, crib pads, pillows, quilts.

Co-sleeping(bed-sharing) increase risk of Co-sleeping(bed-sharing) increase risk of SIDS and suffocation by 20% or more. Parents SIDS and suffocation by 20% or more. Parents should not smoke, drink, take sedating medsshould not smoke, drink, take sedating meds

Non skid surface for bathsNon skid surface for baths Hot water heater should be at 120 degreesHot water heater should be at 120 degrees

Never leave new infant alone with sibling Never leave new infant alone with sibling under 7. Observe interactions. Children under under 7. Observe interactions. Children under five should not lift a younger siblingfive should not lift a younger sibling

Smoke detectors should be on each floor of the Smoke detectors should be on each floor of the house. Check batteries monthly. Change house. Check batteries monthly. Change batteries yearly(landlords are responsible in batteries yearly(landlords are responsible in many municipalities)many municipalities)

Hot water and burnsHot water and burns

Hot water of 140F takes 6 sec for full Hot water of 140F takes 6 sec for full thickness burns in adultthickness burns in adult

Hot water 150 takes 2 seconds for full Hot water 150 takes 2 seconds for full thickness in adultsthickness in adults

120 takes 2 min to achieve full thickness in 120 takes 2 min to achieve full thickness in adultadult

1.5 to 4 Months1.5 to 4 Months

Baby WalkersBaby Walkers ToysToys Rolling/fallsRolling/falls Infant seat safetyInfant seat safety CribsCribs Car SafetyCar Safety

Crib slats- should be narrower than 2 and 3/8Crib slats- should be narrower than 2 and 3/8 thth inch(soda can)inch(soda can)

1994 AAP recommend ban on walkers, CPSC 1994 AAP recommend ban on walkers, CPSC reports more injuries than any other juvenile reports more injuries than any other juvenile device. Decrease visual feedbackdevice. Decrease visual feedback

Babies can wiggle, kick, scoot never leave Babies can wiggle, kick, scoot never leave alone on surface. Pillow barriers alone on surface. Pillow barriers do notdo not prevent falls and may cause suffocationprevent falls and may cause suffocation

No hot liquids and baby in your armsNo hot liquids and baby in your arms If baby gets burned, cool water, loose If baby gets burned, cool water, loose

bandages, call MDbandages, call MD

FallsFalls

Leading cause of nonfatal injuryLeading cause of nonfatal injury Fatalities usually from heights >2 stories. If Fatalities usually from heights >2 stories. If

not fatal 1/3 cuts and abrasions, fracture most not fatal 1/3 cuts and abrasions, fracture most common serious injurycommon serious injury

Fall less than two stories resulting in injury Fall less than two stories resulting in injury usually head first onto hard surface from usually head first onto hard surface from caregiver’s arms or impact of caregiver onto caregiver’s arms or impact of caregiver onto infantinfant

4-6 months4-6 months

WalkersWalkers ToysToys Infant SeatsInfant Seats RollingRolling Car Seats Car Seats Choking therapyChoking therapy

Toys with small parts or that fit into a toilet Toys with small parts or that fit into a toilet paper roll pose a choking hazardpaper roll pose a choking hazard

Look for age appropriateness labeling on toys Look for age appropriateness labeling on toys and follow it(ie. Not for use by < 3yo)and follow it(ie. Not for use by < 3yo)

Hard pieces of food are choking risks Hard pieces of food are choking risks Gates to block stairsGates to block stairs Encourage BLS, no blind finger sweep, back Encourage BLS, no blind finger sweep, back

blowsblows Pad coffee table and sharp cornersPad coffee table and sharp corners

6-9 Months6-9 Months

WalkersWalkers Toys/ChokingToys/Choking DrowningDrowning Stairs/gatesStairs/gates CrawlingCrawling

Child proof the house Child proof the house Hand to mouth activityHand to mouth activity Plug coversPlug covers BurnsBurns

Walkers let kids get to dangerous areas, head Walkers let kids get to dangerous areas, head and neck protrude unprotected for falls, can and neck protrude unprotected for falls, can pull objects down on themselvespull objects down on themselves

Playpen/crib/ high chair are safe places while Playpen/crib/ high chair are safe places while you are cookingyou are cooking

Kids this age love water, leave no standing Kids this age love water, leave no standing water, close door to bathroom or have toilet water, close door to bathroom or have toilet lock to prevent drowninglock to prevent drowning

Hand to mouth exploration leave no small Hand to mouth exploration leave no small objects or poisonous items within reachobjects or poisonous items within reach

Crawl through house, great perspective to help Crawl through house, great perspective to help child proofingchild proofing

9-12 months9-12 months

BurnsBurns Car seatsCar seats Bath safetyBath safety PoisoningPoisoning Child proofingChild proofing

Kitchen safetyKitchen safety Aspiration risksAspiration risks Hand to mouth activityHand to mouth activity Stairs/gatesStairs/gates

Pedestrian injuries: 1-2 yrs old most likely backed Pedestrian injuries: 1-2 yrs old most likely backed over in drivewayover in driveway

Highest over all rate of injury 495/100K in California Highest over all rate of injury 495/100K in California in 1997in 1997

Never leave alone in bath, even with bath ring, do not Never leave alone in bath, even with bath ring, do not leave in reach of fixturesleave in reach of fixtures

Post poison control number(1-800-876-4766 or 1-Post poison control number(1-800-876-4766 or 1-800-8POISON or1-800-222-1222)800-8POISON or1-800-222-1222)

Lock away all med and cleaners (remind other care Lock away all med and cleaners (remind other care givers as well). Kitchen, bathroom, purses.givers as well). Kitchen, bathroom, purses.

Turn handles of pots inwards, use back burners, kids Turn handles of pots inwards, use back burners, kids in playpen or high chair, not under foot, 3 foot safety in playpen or high chair, not under foot, 3 foot safety zone from stovezone from stove

15-18 Months15-18 Months

Bathtub safetyBathtub safety Electrical cordsElectrical cords Smoke detectorsSmoke detectors Falling/trippingFalling/tripping Hot water tempHot water temp ClimbingClimbing

Most likely fatal fall is from a windows >2 storiesMost likely fatal fall is from a windows >2 stories Remove furniture from windows, install operable Remove furniture from windows, install operable

window guardswindow guards Virtually all kids less than 6 can slip through 6 inch Virtually all kids less than 6 can slip through 6 inch

railing opening (none older that 1 can get through 4 railing opening (none older that 1 can get through 4 inch opening)inch opening)

Unplug appliances when not in use. Keep cords tied Unplug appliances when not in use. Keep cords tied back and out of reachback and out of reach

Kids love to climb to demonstrate new abilities and Kids love to climb to demonstrate new abilities and reach enticing objects. Anchor book shelves. Keep reach enticing objects. Anchor book shelves. Keep chairs away from counters etcchairs away from counters etc

18 –24 Months18 –24 Months

Electric wiresElectric wires Electric outletsElectric outlets Car seatsCar seats ClimbingClimbing Bath timeBath time Pica/leadPica/lead

Ask about lead in home. CBC and Lead level. Ask about lead in home. CBC and Lead level. Sooner if hx of lead exposure. Discourage Sooner if hx of lead exposure. Discourage play near old paint. Remember increased risk play near old paint. Remember increased risk with remodeling, car repair, Greta, Azarconwith remodeling, car repair, Greta, Azarcon

Outlet plugs for higher outlets. Consider Outlet plugs for higher outlets. Consider covers that require better fine motor and more covers that require better fine motor and more strengthstrength

24-30 Months24-30 Months

Car seatsCar seats Electric outletsElectric outlets Knives/gunsKnives/guns Locks on doors and cabinetsLocks on doors and cabinets Car safetyCar safety

Second highest rate of injury in California in Second highest rate of injury in California in 1997 387/100K1997 387/100K

Re-iterate car seat safety. Forward facing. If Re-iterate car seat safety. Forward facing. If out growing then booster seat.out growing then booster seat.

Locks on sliding doors and window guards. Locks on sliding doors and window guards. Consider door jam bumper guardsConsider door jam bumper guards

30-36 Months30-36 Months

Car SeatsCar Seats

Electrical outletsElectrical outlets

Locks on doorsLocks on doors

Knives/gunsKnives/guns

Smoke detectorsSmoke detectors Outdoor safetyOutdoor safety PoisoningPoisoning Water temperatureWater temperature

Pedestrian injuries: 3-4 yrs old most likely Pedestrian injuries: 3-4 yrs old most likely injured in mid-block street entry accidents just injured in mid-block street entry accidents just like older kidslike older kids

Out door safety includes cross streets, play Out door safety includes cross streets, play ground equipment with proper supervision, ground equipment with proper supervision, boundaries of the yardboundaries of the yard

4 year old4 year old

Bike helmetsBike helmets Electrical outletsElectrical outlets Fire lightingFire lighting Smoke detectorsSmoke detectors PoisoningPoisoning Outdoor safetyOutdoor safety

Fire plan to escape home and meeting place Fire plan to escape home and meeting place should be developed and practicedshould be developed and practiced

Bike helmet should be purchased with bike. Bike helmet should be purchased with bike. Appropriate size, chin strap should be used. Appropriate size, chin strap should be used. Reduce serious injury risk by 85%Reduce serious injury risk by 85%

Teach about match safety. No Teach about match safety. No matches/lighters in reach.matches/lighters in reach.

Do not ride bike in the streetDo not ride bike in the street

5-6Year Old5-6Year Old

SeatbeltsSeatbelts Electrical toolsElectrical tools Bike helmetBike helmet GunsGuns Animal safetyAnimal safety

Name and AddressName and Address SwimmingSwimming Lock up dangerous Lock up dangerous

itemsitems Street safetyStreet safety

Street crossing safety, no crossing without Street crossing safety, no crossing without adultadult

Avoid strangers. Kids should be able to Avoid strangers. Kids should be able to memorize name, address, phone (cell), memorize name, address, phone (cell), parent’s nameparent’s name

Peak age for injury from falls related to Peak age for injury from falls related to playground equipment 35/100K in CA 1997playground equipment 35/100K in CA 1997

Also balconies and fire escapes are fall Also balconies and fire escapes are fall dangers. Boys 1.5:1 girls for rate of fallsdangers. Boys 1.5:1 girls for rate of falls

Appropriate age for swimming lessonsAppropriate age for swimming lessons

No power tools until age ten. Proper safety No power tools until age ten. Proper safety gear if helping a parent (i.e. eye protection)gear if helping a parent (i.e. eye protection)

How to approach animals. Never approach an How to approach animals. Never approach an animal while eatinganimal while eating

Car Booster seats until 6 years or 60 pounds(8 Car Booster seats until 6 years or 60 pounds(8 years or 80 pounds). Rear seat until 12 years.years or 80 pounds). Rear seat until 12 years.

7-8 year old7-8 year old

Bike/skatingBike/skating SkateboardsSkateboards Seatbelts vs boostersSeatbelts vs boosters GunsGuns

Smoke detectorsSmoke detectors Learn to swimLearn to swim DrowningDrowning

Proper safety gear for inline skating and Proper safety gear for inline skating and skateboardingskateboarding

No wrist guards for scootersNo wrist guards for scooters Helmets for all wheeled activitiesHelmets for all wheeled activities Guns-telling adult without touchingGuns-telling adult without touching Drowning- always supervise water activitiesDrowning- always supervise water activities

10-13 Years Old10-13 Years Old

Bike/Skating/ SkateboardsBike/Skating/ Skateboards SeatbeltsSeatbelts Learn to swimLearn to swim Guns/KnivesGuns/Knives

Smoking, EtOH, drug avoidanceSmoking, EtOH, drug avoidance Reporting sexual advances, computer safetyReporting sexual advances, computer safety Puberty talkPuberty talk Abstinence vs. safe sex, Plan BAbstinence vs. safe sex, Plan B Supervise water activitiesSupervise water activities Supervise power tool usageSupervise power tool usage Do not ride with driver if they are drinkingDo not ride with driver if they are drinking Do not operate ATV until age 16Do not operate ATV until age 16 Conflict resolution without violenceConflict resolution without violence

Adolescent 14-21Adolescent 14-21

ViolenceViolence SeatbeltsSeatbelts GunsGuns

14-15 Years Old14-15 Years Old

Protective gear for sportsProtective gear for sports Illicit drug use and risk of ODIllicit drug use and risk of OD Driving deaths and drowning risk with EtOHDriving deaths and drowning risk with EtOH Violence- Gun deaths reach 25/100K at age 14 Violence- Gun deaths reach 25/100K at age 14

in CA. 50/1000K at 15 yrs, peaks at 110 at 18 in CA. 50/1000K at 15 yrs, peaks at 110 at 18 yrs for 1997.yrs for 1997.

No one under 16 should operate personal No one under 16 should operate personal water craftwater craft

16-18 Years Old16-18 Years Old

SeatbeltsSeatbelts Driving safety-markedly higher rate of fatal Driving safety-markedly higher rate of fatal

crashes, risk increases further with increasing crashes, risk increases further with increasing passengerspassengers

Drugs Drugs Safe sex and date rape, Plan BSafe sex and date rape, Plan B California 1997 18 yr olds with highest rate of California 1997 18 yr olds with highest rate of

injury per year by age 732/100Kinjury per year by age 732/100K

SummarySummary

Take the opportunity to counsel about safety to Take the opportunity to counsel about safety to help prevent injury, disability, and medical help prevent injury, disability, and medical costscosts

Prompts are great, but only if you act upon Prompts are great, but only if you act upon themthem

Injuries are NOT accidents-they are Injuries are NOT accidents-they are predictable and preventablepredictable and preventable

BibliographyBibliography Agran P, Anderson C, Winn D, Trent R, Walton-Hayes L, Thayer S. Rates of pediatric injuries Agran P, Anderson C, Winn D, Trent R, Walton-Hayes L, Thayer S. Rates of pediatric injuries

by 3-month intervals for children 0-3 years of age. by 3-month intervals for children 0-3 years of age. PediatricsPediatrics 2003;111:6 2003;111:6 Agran P, Winn D, Anderson C, Trent R, Walton Hayes L. Rates of pediatric adolescent Agran P, Winn D, Anderson C, Trent R, Walton Hayes L. Rates of pediatric adolescent

injuries by year of age. injuries by year of age. PediatricsPediatrics. 2001;108:3. 2001;108:3 Committee on Injury and Poison Prevention AAP et. al. Falls from heights: windows, roofs, Committee on Injury and Poison Prevention AAP et. al. Falls from heights: windows, roofs,

and balconiesand balconies. Pediatrics. Pediatrics. 2001;107:5. 2001;107:5 Committee on Injury and Poison Prevention AAP et. al. Selecting and using the most Committee on Injury and Poison Prevention AAP et. al. Selecting and using the most

appropriate car safety seats for growing children: guidelines for counseling parents. appropriate car safety seats for growing children: guidelines for counseling parents. PediatricsPediatrics. 1996;97:5. 1996;97:5

Miller T, Galbraith M. Injury prevention counseling by pediatricians: a benefit-cost Miller T, Galbraith M. Injury prevention counseling by pediatricians: a benefit-cost comparison. comparison. PediatricsPediatrics. 1995:96:1. 1995:96:1

Shrivastava L, Shrivastava N. Anticipatory guidance. Shrivastava L, Shrivastava N. Anticipatory guidance. Clinics in Family PracticeClinics in Family Practice. 2003;5:6. 2003;5:6 Tomashek K, Hsia J, Iyasu S. Trends in post neonatal mortality attributable to injury, united Tomashek K, Hsia J, Iyasu S. Trends in post neonatal mortality attributable to injury, united

States, 1988-1998. States, 1988-1998. PediatricsPediatrics. 2003,111:5. 2003,111:5 Website: www.aap.org/family/tippmain.htmWebsite: www.aap.org/family/tippmain.htm

AcknowledgementAcknowledgement

This talk was modified from “Anticipating This talk was modified from “Anticipating Safety” by Matthew Kraus MDSafety” by Matthew Kraus MD

Questions?Questions?