Pediatr Surg Int (1998) 13: S1S-S18, © Springer-Verlag 1998 LL —— F. A. Abantanga - C. N. Mock Childhood injuries in an urban area of Ghana A hospital-based study of 677 cases Accepted: 24 November 1997 Abstract To the best of our knowledge, there has not been any recent available study of trauma-related hos- pitalisation of paediatric patients in an urban area of the sub-Saharan countries. Accidental injury, especially among children, has become one of the most serious major health problems facing developing countries, in- cluding those in sub-Saharan Africa. We reviewed 677 children admitted to the Komfo Anokye Teaching Hospital in Kumasi, Ghana, from August 1995 to July 1996 to elicit the incidence of various injuries, causes, rates of injury, and survival of children aged 0 to 14 years who had sustained trauma during this period. The most common mechanisms of injury were pedestrian knockdowns (40.0%), falls (27.2%), and burns (17.6%). The annual rate of injury was 230/100000 children. Boys sustained higher injury rates in all age groups than girls, with an overall rate of, 136/100000 children as com- pared to 92/100 000 for girls. Rates of injury were higher for children over 5 years of age in six of the seven specific ‘causes of injury studied. When analysing the region of principal injury, for severe injuries (abbreviated injury scale 3-5) the extremities suffered most, followed by the skin and head. There was increased mortality for pa- tients with an injury severity score >20. The overall mortality for this study was 5.5%. There is, therefore, a need to establish prevention priorities and to design ef- fective prevention strategies for children of school-going, age, who are most at risk of sustaining trauma. Key words Epidemiology - Trauma - Childhood injuries - Injury rate Introduction Trauma is a well-known major cause of death and dis- ability in industrialised countries in both children and adults. However, the impact of injury in developing nations has not been as extensively studied and is, therefore, often not fully appreciated. Traditionally, in- fectious diseases have predominated as a cause of mor- tality in developing nations {5, 8]. Nonetheless, injury is, a major cause of severe disability and death among, children in developing countries. Data on injuries, es- pecially childhood trauma, in the least-developed na- tions are scarce and extremely limited —_[8}. Transportation-related injuries stand out as being one of the leading causes of morbidity and mortality, especially in those developing countries that have undergone in- creased mortorisation in recent years [9]. The most ‘common injuries in children that result in loss of days of normal activity are pedestrian injuries, burns, and falls (7) ‘The purpose of this study was to determine the inci- dence, aetiology, rates of injury, and mortality among, injured children aged less than 15 years in an urban area of a developing sub-Saharan country. ‘This study was funded in part by an American Association for the Surgery of Trauma, Davis & Geck Research Scholarship. FA. Abuntanga (2) Department of Surgery, University of Science and Technology Kumasi, Ghana CAN. Mock Department of Surgery, University of Washington, Seattle, WA, USA, Corresponding address: Department of Surgery, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana Materials and methods ‘This prospective study was carried out in the Kumasi metropolitan area inthe Ashanti region of Ghana. This area has a population of (88,514, of which 294,424 are children. Kumasi is the second largest city in Ghana. A hospital-based surveillance system was established 10 identify children aged less than 1S years who sus {ained injuries resulting in hospitalisation andor death. The details fof the medical records of children who sustained injuries from I August 1995 to 31 July 1996 were entered onto a standard ques tionnaire. The records were then analysed for age and sex distri bation, mechanism of injury, rates of injury, principal regions of injury, and survival. Rates of injury were calculated as the numbersie of eases divided by the population in each age group. Thus, the total rates and rates by age group by specific cause of injury wer ccalulated. Also, each of the body parts was graded as to the se verity ofthe injury using the 1990 Abbreviated Injury Seale (AIS), ‘The coding was from I (eninor injury) to 5 (most severe injury), and then based on this grading system an overall injury severity core (SS) ~ a numeric score summarising all injures ~ was assigned, Results During the I-year study period, 677 children aged 0-14 years were hospitalised or died as a result of an injury. There were 405 boys and 272 girls, a boy/girl ratio of 1.5:1.0. The crude annual rate of injury was 230/100000 children (Table 1). With age-specific injuries, the rates were higher for the 5-9, 10-14, and I-4-year groups, but were low for the <|I-year age group. The annual injury rate for boys was 136/100000 compared to 92/100000 for girls. Boys also sustained higher rates of injury in each age group than girls Overall, the leading cause of serious injury resulting in hospitalisation and jor death was transportation-re- lated (Table 2). In this group, pedestrian knockdowns formed the largest subgroup with an annual injury rate of 74/100000 children, followed by motor-vehicle crashes with children as occupants (14/100000), and then bicyclists struck down by motor vehicles (4) 100000). Pedestrian injuries were the leading cause of trauma among the $-9 and 10-14-year age groups, with rates of injury being 111/100000 and 83/100000 ct dren, respectively. The second most common mechanism of injury to children in this study was falls from various heights (62/ 100000 children). Here again, falls were the leading cause of injury among the 5-9 and 10-l4-year age groups (92/100000 and 52/100000, respectively), fol- lowed by the I-4 year group (49/100000). The third, very important cause of injury hospitalisation was, burns, with an injury rate of 40/100000 children. The ‘Table 1 Annual rates of injury per 100000 population (pop.) of children hospitalised by mechanism and age (n ‘Table 2 Mechanism of injury of children admitted and mortality Cause No.of Percent of Mortality Children otal eo) Transportrelated 271 400 74 Falls iss 22 16 Burns 19 176 sa Lacerations 00. Miscellancous 49 Total on 8s rates were high for children under 1 year and 1-4 years and decreased in the 5-9 and 10-14 year groups such that the rate for those aged 10-14 years was 4 to 5 times less than in those less than I and I-4 years. About 64.7% of the burns were sustained by children under $ years. ; The rates of laceration and assaults were among the lowest for the causes studied. Assaults were rare among, all age groups. The annual rate of lacerations was 7/ 100000 children and was highest for the 10-14-year age group. The lacerations were mostly unintentional and were caused when the children worked at school or on the farm with sharp implements such as cutlasses or ‘carpentry instruments Figure | indicates the distribution by region of principal injury. There were more minor injuries (AIS 1-2) to the head and cervical spine than to any other region of the body; this was followed by the lower ex- tremities, skin, and upper extremities. In very severe injuries (AIS 3-5) the lower extremities suffered most, followed by the skin, head, and upper extremities. The least severely injured body regions were the chest and abdomen, Of the 677 children who sustained injuries during the study period, 94.5% survived. The overall mortality from trauma was 5.5%, Mortality was significantly in- fluenced by age and ISS. Mortality among the children 7) (Pedestrian pedestrian knockdown, MVC motor vehicle crash, NA not applicable) All apes = lyear 14 years 5-9 years 10-14 years Pop. 294424 issi2 S470 9682 91500) No. Rate No. Rate No. Rate No. Rate No Rate Mechanism Pedestrian 4 2 NA x0 36 un 8 Falls e 3 NA a » 92 2 Burns 40 " 58 66 8 28 is mvc in 1 NA 10 2 7 5 Lacerations 7 ° NA 1 NA NA 15 Bicycling 4 0 NA 2 NA NA NA Asstults NA ° NA o NA NA NA Others 25 ° NA 3 30 23 2 All cases 230 7 9 sor 287 217 Sex: Boys 405 36 9 NA ww? 121 170 las 136 Girls mm 92 5 NA 2 6 116 116 15 2PERCENT REGION OF INJURY Fig. 1 Region of principal injury in children with trauma HEAD includes cervical spine, CHEST ABD chest ind abxiomen, UEXT upper extremities, LENT lower extremities in this study decreased with age, being as high as 29.4% in children aged less than | year and as low as 6.3% in those aged 1 to 4 years, 4.5% in those aged 5 to 9 years, and 4.0% in those aged 10 to 14 years. For minimally. injured children mortality was low; 27 children had an ISS of over 20. In these latter children, the mortality was very high (66.7%, Table 3). Of the 37 deaths in the study, 9 were the result of a very severe head injury. In general, 43.2% of the deaths occurred as a result of head injury. This hospital-based study, carried out in the second largest city in Ghana, showed an annual rate of injury hospitalisation of 230/100 000 children aged less than 15 years. The highest injury rate was among the 5-9 year age group, with 287/100 000, followed by the 10-14 year, age group, with 217/100000 children. Attempts at comparing these results with similar ones in the sub- Saharan region failed because of a lack of existing data. But when compared with those from the developed countries [1, 3, 4], these rates are much lower. ‘Table 3 Mortality in chikiren with injury and injury severity sore ass) Iss No. of children Mortality (4) 580) 02 SI 176 is aL a 455 9 a4 si7 A major limitation of this study is that it is hospital- based and the analysis is based only on data for patients who were admitted to and/or died in hospital. All the same, the study shows that despite the fact that Ghana is, a developing nation, transportation-related injuries are increasing among children, especially pedestrian injuries. In the study by nii-Amon-Kotei et al. [7] and other studies from developed countries (I. 3, 4], falls were the leading cause of injury in children. In the present study, the leading cause was pedestrian knockdowns. This, we believe, is a result of a recent increased use of motorised transport with most of the drivers being illiterates, and therefore not being conversant with the road. signs, traffic rules, and regulations. In addition, many of the vehicles are suspect with respect to roadworthiness. Transportation-related injuries accounted for 40% of injury admissions and were also the leading cause of injury-related mortality (54.1%). In a similar hospital- based study in an urban area of Nigeria, Elechi et al. (2), also confirmed that transportation-related injuries are fone of the leading causes of severe injury and that road-traflic-related injuries accounted for 26% of injury- related emergency hospital visits and 68% of injury- related deaths. In studies by Mock et al. [5, 6), transportation-related injuries accounted for 29% of injury admissions and were the leading cause of injury- related mortality (41%) even in a rural setting in Ghana. W0=I4-year-age- groups. These children fell off play- ground equipment or in sports-related activities and also, from trees and high walls. In studies from the developed countries falls are the leading cause of injury across all age groups and, in particular, the less-than-1 and |-4- year age groups have higher rates of falls per 100000 children than the remaining groups [1]. According to this study, the infants fell from furniture and household objects, and toddlers fell out of windows and off bal- conies. Our study rather showed that children in these age groups were less prone to falls. The infants and toddlers mostly fell from the backs or hands of parents, or servants, and hence, the smaller number of children in the study. In our region, burns turned out to be a major cause of injury hospitalisation of children under 1 year and 1-4 years of age. A majority of the burns (73.1%) were ‘caused by scalds from hot liquids such as water, soup, etc. Toddlers and infants suffered most — toddlers because of their clumsiness, infants because of careless- ness on the part of mothers and/or servants. Lacerations ‘occurred mostly in the 10-I4-year age group. They were all unintentional and occurred either at school, at home, or on farms. Children aged more than 5 years had the highest rate of injury for all seven mechanisms studied except burns. Such children were at increased risk of being knocked down as pedestrians, falling from heights, being involved in motor vehicle crashes, or receiving lacerations and