using home safety checklists to identify potential...
TRANSCRIPT
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Using Home Safety
Checklists to Identify
Potential Hazards
Bruce J. McIntosh, M.D.Statewide Medical Director
Child Protection Team System
September 6, 2018
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Preventing Unintentional InjuriesTake-Home Points
▪ Most injuries and injury-related deaths
in children could be prevented by better
supervision by parents and other caretakers
▪ Sometimes hazardous conditions in the home
and inadequate supervision are the result of
ignorance, sometimes of negligence
▪ Inadequate supervision and neglect are even
more dangerous to children than abuse
▪ Age-specific Home Safety Checklists can assist
in identifying hazards in the home
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Deaths Due to Abuse and NeglectFlorida Death Review Program
Florida Child Abuse Death
Review Committee Annual
Reports
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State of Florida Abuse Death Review Committee. Annual Report,
December 2017, page 18.
Deaths Due to Abuse and NeglectFlorida Death Review Program, 2011 - 2016
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Abuse and Neglect in FloridaDistribution of 68 Verified Deaths in 2016
State of Florida Abuse Death Review Committee. Annual Report,
December 2017, page 17.
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Abuse and Neglect National Reporting Trends 1990 - 2005
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Home Safety ChecklistsAn Approach to Reducing Deaths and Injuries
▪ Age-specific
▪ Birth – 6 months
▪ 6 – 12 months
▪ 12 – 24 months
▪ 2 – 6 years
▪ To provide guidance to
those visiting homes in
identifying hazardous
conditions and behaviors
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Preventable Deaths and InjuriesSeldom Is There a Single Cause
▪ Child Medical problems, disability,
prematurity, one of too many
▪ Parent Alcohol or other substance
abuse, mental health issues, ignorance,
low IQ, non-nurturing childhood
▪ Family Domestic violence, criminal history, too
many kids
▪ Society Poverty, lack of health insurance,
isolation, lack of community supports
Dubowitz H. Child Neglect: A Child’s Perspective. First Coast
Conference on Child Maltreatment, Jacksonville, FL, April 2001.
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Supervision-Related Injuries and DeathsA Spectrum of Responsibility and Response
Accident
(Not avoidable
by reasonable
degrees of
supervision)
Culpable Negligence
(Resulting from an
“utter disregard” for
supervision and
safety)
Simple Neglect
(Avoidable by
reasonable
degrees of
supervision)
Support, referral
for treatment or
grief counseling
Removal of other
children, arrest and
criminal prosecution
Services such as
home safety check,
parenting classes
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Home Safety Checklist: Birth - 6 Months
Checking for Unsafe Sleep
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Florida Child Abuse
Death Review Committee.
Annual Report, December
2017, page 21.
Florida Child Abuse Death CommitteeMost Common Causes of Preventable Deaths
85 sleep-related
asphyxia deaths
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Safe Sleep for Infants: Crib SafetyCharacteristics of a Safe Crib
▪ Vertical slats no
more than 2 3/8
inches apart
▪ Corner posts flush
with end panels (or
very tall)
▪ Mattress should fit
snugly within sides
Bass M. Asphyxial Crib Death. NEJM 296, 555, 1977.
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Safe Sleep for Infants: Crib SafetyCharacteristics of a Safe Crib
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Safe Sleep for Infants: Crib SafetyAdditional Regulations - June 28, 2011
▪ Traditional drop-side
cribs cannot be
made or sold
▪ Repair kits are not
allowed to retrofit
older cribs
▪ Wood slats must be
made of stronger
wood to prevent
breakage
▪ Crib hardware must
have anti-loosening
devices to keep it
from coming loose
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Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 33.
Florida Child Abuse Death ReviewHow Old Are the Children Who Suffocate?
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Florida Child Abuse Death Review
Committee. Annual Report,
December 2017, page 29.
Florida Child Abuse Death ReviewWhere Do Infants Suffocate?
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Florida Child Abuse Death Review Committee. Annual Report, December
2017, page 29.
Florida Child Abuse Death ReviewWhere Do Infants Suffocate?
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Terminology Is Important
“Co-Sleeping” vs “Bed-Sharing”
▪ Much of the confusion about the dangers of
sleeping with infants comes from inconsistent use
of terms
▪ To most people, Co-Sleeping means sleeping together on
the same bed or couch – which is very dangerous
▪ To others, Co-Sleeping means sleeping in the same room
– which is safe and a good thing
▪ To avoid confusion when speaking with families, it is
best to speak of “Bed-sharing” and discourage it, and
“Room-Sharing” which is fine
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Advocates for Bed-SharingEncouraging a Dangerous Practice
1976 2002
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Bed-Sharing Is on the RiseA Dangerous Trend
▪ In the United States the incidence of
bed-sharing has increased from 5.5%
in 1993 to 12.8% in 2000.
▪ Bed-sharing is most common in:
▪ Parents under 18 years old
▪ Low income parents
▪ Unmarried
▪ Trend accompanied by in increase in
the incidence of infant deaths from
asphyxia
Source: Archives of Pediatrics and Adolescent Medicine,
January 2003.
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Safe Sleep for InfantsConsumer Product Safety Commission Study
▪ Comparing data from the 1980’s with that from the 1990’s researchers found that:
▪ Suffocation deaths in cribs fell from 192 to 107
▪ Suffocation deaths in adult beds rose from 152 to 391
▪ Suffocation deaths in chairs and sofas rose from 22 to 110
▪ The risk of suffocation for infants sleeping in adult beds was 40 times higher than for those sleeping in cribs.
Scheers et al. Where Should Infants Sleep? A Comparison of Risk for
Suffocation of Infants Sleeping in Cribs, Adult Beds,and Other Sleeping
Arrangements. Pediatrics 112:883, October 2003.
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Should We Tell Parents Not To
Sleep with Their Infants?
Physician’s Weekly,
Vol. XVI, No. 5,
January 21, 2000.
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Where Do Sleeping Babies Suffocate?42 Deaths in Florida in 2009
▪ 31 (74%) were co-sleeping
▪ 19 were co-sleeping in beds
▪ 5 were co-sleeping on sofas
▪ 4 were co-sleeping on a mattress or pallet
▪ 2 had no documentation as to type of bed
▪ 1 was co-sleeping in an over-sized chair
▪ 11 (26%) were placed in un-safe sleep environments
▪ 2 were placed in cribs or bassinet with pillows, blankets or other
unsafe items
▪ 3 were placed on adult beds with pillows surrounding
▪ 3 were placed on sofas or recliners
▪ 2 was placed on the floor with pillows surrounding
▪ 1 was placed on a bunk bed and found wedged against the wall
State of Florida Abuse Death Review Committee. Annual Report,
December 2010, page 74.
25 had cribs, bassinets or
playpens in the home that were
not being used.
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Infant Death by SuffcationWhat Happens?
▪ Entrapment/wedging
▪ Overlying
▪ Bedding
▪ Plastic
▪ Stangulation
▪ Other and unknownScheers et al. Where Should Infants Sleep? A Comparison of Risk for
Suffocation of Infants Sleeping in Cribs, Adult Beds,and Other Sleeping
Arrangements. Pediatrics 112:883, October 2003.
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▪ Parents should place healthy babies to sleep in
supine position (on their backs)
▪ Do not expose to cigarette smoke, either during
pregnancy or after birth
▪ Make sleep environment as safe as possible
▪ Use a safe crib
▪ Avoid soft bedding materials
▪ Keep plastic wrap and cords out of crib
▪ Breast feed rather than bottle feed
Carroll JL and Siska ES. SIDS: Counseling Parents
to Reduce the Risk. American Family Physician
57:1566, 1998.
Sudden Infant Death SyndromeNot Neglect or Abuse – But Preventable
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Supine Sleeping CampaignEffect on SIDS Rate in the US
Trachtenberg FL, et.al. Risk Factor Changes for Sudden Infant Death Syndrome
After Initiation of Back to Sleep Campaign. Pediatrics 129:630, April 2012.
Back to Sleep Campaign
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Jacksonville Times-Union,
July 20, 2000.
SIDS and RaceDisparities Persist
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Safe Sleep for InfantsGood Advice for Parents
▪ Avoid soft bedding
▪ Comforters
▪ Sheepskins
▪ Pillows
▪ Large stuffed animals
▪ Extra padding
▪ Use only the mattress
and pad provided by the
manufacturer
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Home Safety Checklist: Birth - 6 Months
Checking for Unsafe Sleep
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Safe SleepInformation Available on DCF Website
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Safe SleepInformation Available on DCF Website
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National and Florida StatisticsDeaths and Injuries in Motor Vehicle Accidents
▪ Motor vehicle accidents are the leading cause of unintentional injury deaths in
children ages 5 – 14 years old in the United States and the second leading
cause of injury deaths in children ages 1 – 4, causing a total of 7,882 deaths
in those age groups in 2015
▪ In Florida in 2015 there were 666,091 motor vehicle accidents involving
children less than 18 years old, resulting in 35,992 injuries and 149 deaths
among children in that age group
▪ Injuries to children and teens in Florida due to motor vehicle accidents resulted
in costs of $339 million in 2013, with total injury costs in all age groups totaling
$3.02 billion, the largest total of any state in the Southeast
Centers for Disease Control: https://www.cdc.gov/injury/images/lc-
charts/leading_causes_of_injury_deaths_unintentional_injury_2015_1050w760h.gif
Florida Highway Safety and Motor Vehicles:
https://www.flhsmv.gov/pdf/childsafety/crashes-by-county.pdf
Centers for Disease Control: https://www.cdc.gov/motorvehiclesafety/pdf/statecosts/fl-
2015costofcrashdeaths-a.pdf
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Home Safety Checklist: Birth - 6 Months
Checking for Safety in Vehicles
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Accidents: DefinitionMost “Accidents” Are No Accident
Ac’ ci-dent: An event
that takes place without
one’s foresight or
expectation, especially
one of an unfortunate or
afflictive character.
Webster’s New Collegiate Dictionary, 1960, page 6.
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Deaths
Injuries
Unintentional Deaths vs InjuriesThe Tip of the Iceberg for Children
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Hazardous Conditions in the Home Common Cause of Death and Injury
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Preventing Fall InjuriesSupervision for Injury Prevention
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Preventing Fall Injuries
▪ Parents should never to leave infants of any age unattended on a changing table, bed or couch
▪ Fall injuries in infants too young to get themselves up onto beds and couches are the result of negligent care
▪ When toddler-aged children who can climb are injured in short-distance falls, the injuries can be considered accidental
“I Didn’t Know He Could Roll Over”
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Failure to Supervise
Baby G
▪ Six week old infant
brought to ED by mom
with complaint of
swelling on side of head
▪ Infant alert an active, but
X-ray revealed linear
skull fracture
▪ Mom related baby was
on edge of bed and fell
off when she sat down
on bed
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Home Safety Checklist: Birth - 6 MonthsPreventing Falls and Burns
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Home Safety Checklist: 6 – 12 Months
Preventing Falls
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Preventing Fall Injuries: WalkersOfficially Discouraged by the AAP
▪ Increase risk and
severity of injury
▪ Significant head
injuries common
▪ Delay walking
Fazen LE and Feliberto PI. Baby
Walker Injuries. Pediatrics
70:106, 1982.
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Discourage WalkersEncourage Use of “Exercisers” Instead
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Home Safety Checklist: 6 – 12 Months
Preventing Poisonings and Choking
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Home Safety Checklist: 6 – 12 Months
Burn Prevention and Car Seat Use
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Kitchen BurnsOften the Result of Negligent Supersion
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Kitchen BurnsOften the Result of Negligent Supersion
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Failure to Supervise
Baby W
▪ Eight and a half month old infant brought to ED with burns on hand
▪ Sixteen year old mom says that 4 days previously child had pulled up on edge of stove door and put arms and hands on hot inner surface
▪ Many abuse reports on mom as a victim when she was a child
Medical Neglect
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Iron BurnsOften Result from Negligent Supervision
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Home Safety Checklist: 12 – 24 Months
Preventing Burns
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• Hot dogs
• Round candies
• Peanuts or nuts
• Grapes
Harris CS. JAMA 251:2231, 1984.
Supervision for Injury Prevention: Choking
Common Causes of Death by Asphyxiation
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Keep floors clear of small
objects
Be especially careful of older
child’s toys
All parents should know how
to perform the Heimlich
maneuver
Allow Only Toys Too Big to Fit in Mouth
Supervision for Injury Prevention: Choking
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• Assume everything will
go in the mouth
• Keep floors clear of
small objects
• Be especially careful of
older child’s toys
• All parents should know
how to perform the
Heimlich maneuver
Supervision for Injury Prevention
Preventing Choking
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Home Safety Checklist: 12 – 24 Months
Choking Prevention
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▪ Parents should keep medications in a locked cabinet
▪ Medications should be kept in child-proof containers
▪ Life-threatening ingestions often involve prescribed or recreationally-acquired opiates
▪ Many families of children with toxic ingestions have other problems requiring services
Toxic IngestionsMost Result From Caretaker Negligence
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Supervision for Injury Prevention: Poisonings
Hazardous Substances in Food Containers
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Home Safety Checklist: 12 – 24 Months
Poisoning Prevention
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Supervision for Injury Prevention: Overview
Better Parents Know to Child-Proof the Home
▪ Keep small objects off floor
▪ Use safety latches on cabinets
▪ Put plug covers in electric outlets
▪ Run electric cords behind furniture
▪ Put breakable things out of reach
▪ Install barrier gates to limit access
▪ Crawl around to check work
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Supervision for Injury Prevention: Overview
Child-Proofing the Home
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Home Safety Checklist: 12 – 24 Months
Automobile Safety
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Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 24.
Florida Child Abuse Death ReviewLocation of Drownings and Barriers
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Supervision for Injury Prevention: Bathtub Drownings
Parent Always Gone “Just a Minute”
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Drowning: Bucket Hazards
160 Deaths in U.S. Over Six Year Period
Mann NC et al. Bucket-Related Drownings in the United States,
1984 Through 1990. Pediatrics 89:1068, 1992.
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Home Safety Checklist: 6 – 12 Months
Preventing Drownings
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Florida Child Abuse Death
Review Committee. Annual
Report, December 2017,
page 21.
Florida Child Abuse Death ReviewMost Common Causes of Preventable Deaths
63 Drownings Deaths
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Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 32.
Florida Child Abuse Death ReviewWhat Are Typical Ages for Drowning?
82% less than 6
years old
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Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 24.
Florida Child Abuse Death ReviewLocation of Drownings and Barriers
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Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 27.
Florida Child Abuse Death ReviewHow Did Barriers Fail?
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▪ There were 91 drowning deaths reported, of which 42 were verified as due to neglect
▪ Number of cases reviewed indicates serious under-reporting to the registry
▪ “Adequate supervision is defined as an attentive person responsible for watching children and who is not under the influence of drugs or alcohol. The person must always be proximate to the child (eyes on) to provide continuous supervision.”
▪ According to caretakers, most child victims were missing from sight for less than five minutes.
Child Drownings in Florida - 2010Number One Cause of Preventable Death
State of Florida Abuse Death Review Committee. Annual Report,
December 2010, page 18.
Annual Report, December 2009, page 50.
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Causes of Abuse and Neglect Deaths Role of Substance Abuse
State of Florida Abuse Death Review Committee. Annual Report,
December 2011, page 13.
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Florida Child Abuse Death Review Committee. Annual Report,
December 2016, page 26.
Florida Child Abuse Death ReviewRisk Associated with Substance Abuse
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Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 41.
Florida Child Abuse Death ReviewRisk Associated with Substance Abuse
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Home Safety Checklist: 12 – 24 Months
Drowning Prevention
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▪ Consider every allegation or suspicion
of supervisory neglect individually
▪ Be aware of age-specific guidelines
enforced by child protective services
▪ Some child injury risks are unpredictable and
unavoidable
▪ Caretakers may already suffer an emotional
burden when a child suffers and avoidable injury
AAP Committee on Child Abuse and Neglect. Pediatrics 118:1296,
September 2006.
When Is Lack of Supervision Neglect?The American Academy of Pediatrics’ Answer
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▪ How long and at what time of the day was
the child unsupervised?
▪ Does the child have any physical, emotional,
developmental, behavioral, psychiatric or
cognitive disabilities?
▪ Has the child previously shown an ability to
look after himself and make good judgments?
▪ What is the inherent danger in the environment
in which the child was left unsupervised?
AAP Committee on Child Abuse and Neglect. When Is Lack of
Supervision Neglect? Pediatrics 118:1296, September 2006.
When Is Lack of Supervision Neglect?Consider Each Case Individually
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▪ Have there been past instances or allegations of
supervisory neglect?
▪ How many children of what ages and maturity
were under the caretaker’s supervision?
▪ Are there any physical, emotional or mental
limitations of the designated caretaker?
▪ Does the child have an adequate knowledge of
emergency telephone numbers and access to a
parent or other informed caretaker?
AAP Committee on Child Abuse and Neglect. When Is Lack of
Supervision Neglect? Pediatrics 118:1296, September 2006.
When Is Lack of Supervision Neglect?Consider Each Case Individually
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Choking Hazards: BalloonsMost Common Cause of Toy-Associated Fatalities
▪ Responsible for 121 deaths between 1973 and 1988
▪ Not considered safe for children under eight
▪ Hazardous as an office favor
Henderson JM. American Family Physician 40:171, 1989.
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National and Florida StatisticsDeaths and Injuries in Motor Vehicle Accidents
▪ Motor vehicle accidents are the leading cause of unintentional injury deaths in
children ages 5 – 14 years old in the United States and the second leading
cause of injury deaths in children ages 1 – 4, causing a total of 7,882 deaths
in those age groups in 2015
▪ In Florida in 2015 there were 666,091 motor vehicle accidents involving
children less than 18 years old, resulting in 35,992 injuries and 149 deaths
among children in that age group
▪ Injuries to children and teens in Florida due to motor vehicle accidents resulted
in costs of $339 million in 2013, with total injury costs in all age groups totaling
$3.02 billion, the largest total of any state in the Southeast
Centers for Disease Control: https://www.cdc.gov/injury/images/lc-
charts/leading_causes_of_injury_deaths_unintentional_injury_2015_1050w760h.gif
Florida Highway Safety and Motor Vehicles:
https://www.flhsmv.gov/pdf/childsafety/crashes-by-county.pdf
Centers for Disease Control: https://www.cdc.gov/motorvehiclesafety/pdf/statecosts/fl-
2015costofcrashdeaths-a.pdf
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Winston FK et al. The Danger of Premature Graduation to Seat
Belts for Young Children. Pediatrics 105:1179, 2000.
Supervision for Injury Prevention
The Safety Gap: Age 4 – 8 Years
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Home Safety Checklist: 2 – 6 Years
Automobile Safety
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Accident or Neglect?Questions to Ask in All “Accidents”
• How foreseeable and preventable
was the injury?
• How do the caretaker’s actions compare to
the standard in the community?
• What is the overall level of concern about the
child’s welfare?
• What is the potential for the child to be injured
again if no services are provided?
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Child DeathsPrior Involvement of DCF
Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 39.
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Types of Caretaker ImpairmentIt’s Not All Drugs
Florida Child Abuse Death Review Committee. Annual Report,
December 2017, page 42.
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Risk Factors for Child DeathsThe Big Three
Age Less Than 5 Years Negligence
Substance Abuse
State of Florida Abuse Death Review Committee. Annual Report,
December 2011.
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Home Safety ChecklistsAn Approach to Reducing Deaths and Injuries
▪ Many of those who do home
inspections don’t really know what
to look for or how to explain the
hazard to the family
▪ Digital original copies are of the
Home Safety Checklists are
available on the conference
website
▪ Encourage those in your agencies
to use Home Safety Checklists to
assist in identifying hazardous
conditions and behaviors
▪ We can decrease preventable
deaths and injuries to children
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