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ACADEMIA Letters Unintentional Pediatric Injury and the COVID-19 Pandemic: Data Trends and Prevention Strategies Casie H. Morgan Kristyn N. Jeffries David C. Schwebel The devastating consequences of the COVID-19 pandemic have now surpassed 137 million infections and 2.95 million deaths worldwide. Secondary health effects of the COVID-19 pandemic are less clear but beginning to emerge as well. Documented increases in domestic violence, child maltreatment and abuse, mental illness, and substance abuse are reported widely in the scientific literature (Roe & Zane, 2021). One issue that has received somewhat less attention is the pandemic’s influence on children’s unintentional injuries. The hypothesized pathway for increased likelihood of unintentional child injury risk during the COVID-19 pandemic is rather straightforward. Social distancing, remote working, and virtual schooling have overturned families’ daily interactions and schedules. Children are home more than usual, and parents are distracted trying to complete their daily tasks while managing stressors of the global pandemic. During shelter-in-place mandates and family quarantine periods, parents and other adult caregivers must juggle typical daily home and work duties with consistent and active supervision of young children while also orchestrating safe entertainment and responsibilities for older children. Balancing these tasks is stressful for parents (Spinelli et al., 2020). Recent research highlights both economic (e.g., loss of income and employment) and personal (e.g., fear of contracting the virus; experiencing illness and deaths of friends/family from the virus) stressors faced by parents (Brown et al., 2020). Further, these stressors are associated with increased fatigue, anxiety, and depression – all correlates of increased child injury risk (Koulouglioti et al., 2009; Schwebel & Gaines, 2007). Academia Letters, April 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: David C. Schwebel, schwebel@uab.edu Citation: Morgan, C.H., Jeffries, K.N., Schwebel, D.C. (2021). Unintentional Pediatric Injury and the COVID-19 Pandemic: Data Trends and Prevention Strategies. Academia Letters, Article 902. https://doi.org/10.20935/AL902. 1 Children also face worries and challenges. During stay-at-home orders and lengthy quarantines, children confront changes in routine, boredom, and separation from peers. The natural tendencies of child development compel children to seek physical and mental stimulation, extending their physical and cognitive experiences (Fischer, 1980). This exploration can lead to risk-taking. The confluence of environmental and familial changes in response to COVID-19, plus children’s natural inclination to explore the environment, may introduce heightened injury risk. Toddlers might venture across the living room and discover a bottle of hand sanitizer. Teens might discover a firearm in their home and flaunt it with siblings. In both cases, youth demonstrate underdeveloped cognitive, motor, and social development skills that could lead to poor judgement about the safety of their actions and consequential risk for injury (Schwebel & Pickett, 2012). The occurrence of such behavior patterns and their consequences are supported by early data emerging concerning pediatric injury rates during the COVID-19 pandemic, which seem to indicate increases in child injuries especially within specific domains associated with pandemicrelated behavior (Schroeder, 2021). One set of exposures has to do with increased use of disinfecting cleaners. In a dataset focused on unintentional ocular exposures to alcohol-based hand sanitizer, for example, children experienced far higher injury rates between the months of April and August 2020 compared to the same months in 2019 (Martin et al., 2021; Yangez et al., 2021). Data from poison control center exposure calls support this finding, with marked increases in calls concerning cleaner and disinfectant exposures in March 2020 compared to 2019 (Chang et al., 2020). Another domain where pediatric injuries seem to have increased dramatically is in outdoor recreation. Several US states – including Colorado, Georgia, and Vermont – report increases in youth off road vehicle-related injuries during summer 2020 compared to summer 2019 (Weintraub, 2020). As an example, Arkansas Children’s Hospital noted a 33% increase in ATV-related injuries between March and July 2020 (Howington, 2020). Similarly, in a detailed report of injuries treated at the Emergency Department of the Children’s Hospital in Montreal (Keays et al., 2020), rates of cycling injuries increased dramatically (but other sports-related injuries, plus motor vehicle injuries, showed decreases in the early months of the pandemic, likely due to reduced athletic and driving activities during this time). Finally, injuries in the home seem to have increased during the pandemic. A study of emergency department visits and hospitalizations in Padova, Italy, for example, reported substantial increases in pediatric injuries in the home in spring 2020 compared to spring 2019, and contrasted those data patterns to the relatively low number of pediatric emergency visits and hospitalizations from COVID-19 infection during that time period (Bressan et al., 2021). A report from the Children’s Hospital of Philadelphia supports these findings, citing increasAcademia Letters, April 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: David C. Schwebel, schwebel@uab.edu Citation: Morgan, C.H., Jeffries, K.N., Schwebel, D.C. (2021). Unintentional Pediatric Injury and the COVID-19 Pandemic: Data Trends and Prevention Strategies. Academia Letters, Article 902. https://doi.org/10.20935/AL902. 2 ing rates of fractures in the home (including from cycling and trampolines), but decreasing rates from sports and playground injuries (Bram, 2020). As we confront child injury prevention during and after the COVID-19 pandemic, we urge a return to fundamentals of classic injury science. Child injury rates and patterns appear to have changed during the pandemic and may persist for the foreseeable future, but the lessons of how to prevent those injuries have not changed. Guided by theory-driven models like the 3 Es of prevention (Baker, 1973) and the Haddon Matrix (Haddon, 1970), policymakers and industry must ensure products like household chemicals and ATVs are marketed and sold with appropriate safety devices and warnings. Parents must provide appropriate supervision of young children and prevent reckless use of dangerous items by older youth. Health care providers must educate parents to heed relevant safety practices, and safety programs delivered by schools and community organizations like YMCAs, Boy and Girl Scouts, and 4-H must continue to be delivered, either virtually or in person while following appropriate COVID-19 safety precautions. Of course, we also must always remain grounded in science. Efforts to educate the public must be effective, supported by public health theory, and evidenced for efficacy by empirical research. Legislative initiatives and industry efforts must be actively pursued, guided by consumer need, and based in data. Continued research is needed also. Multi-disciplinary collaborative efforts should identify the most prevalent injury risks, affected populations, and effective injury prevention strategies during the COVID-19 pandemic. This effort begins with accurate injury incidence data and is then promoted through interdisciplinary collaboration to innovate, develop, evaluate, and implement successful injury prevention programs. Our recommendations for prevention are not new, but the impact of COVID-19 has elevated their importance. Available data are compelling: they suggest child unintentional injury rates may have increased in the pandemic era, especially in domains associated with pandemic behavior. Renewed efforts for prevention are urgently needed. References Baker, S. P. (1973). Injury control, accident prevention and other approaches to reduction of injury. In P. D. Sartwell (Ed.), Preventive Medicine and Public Health (10th ed). Appleton-Century-Crofts. Bram, J. T., Johnson, M. A., Magee, L. C., Mehta, N. N., Fazal, F. Z., Baldwin, K. D., … Apurva S. (2020). Where have all the fractures gone? The epidemiology of pediatric fractures during the COVID-19 pandemic, Journal of Pediatric Orthopaedics, 40(8), 373- Academia Letters, April 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: David C. Schwebel, schwebel@uab.edu Citation: Morgan, C.H., Jeffries, K.N., Schwebel, D.C. (2021). Unintentional Pediatric Injury and the COVID-19 Pandemic: Data Trends and Prevention Strategies. Academia Letters, Article 902. https://doi.org/10.20935/AL902. 3 379. doi:10.1097/BPO.0000000000001600 Bressan, S., Gallo, E., Tirelli, F., Gregori, D., & Da Dalt, L. (2021). Lockdown: more domestic accidents than COVID-19 in children. Archives of Disease in Childhood, 106(2), e3. http://dx.doi.org/10.1136/archdischild-2020-319547 Brown, S. M., Doom, J. R., Lechuga-Peña, S., Watamura, S. E., & Koppels, T. (2020). Stress and parenting during the global COVID-19 pandemic. Child Abuse & Neglect, 110, 104699. https://doi.org/10.1016/j.chiabu.2020.104699 Chang, A., Schnall, A. H., Law, R., Bronstein, A. C., Marraffa, J. M., Spiller, H. A.,…& Svendsen, E. (2020). Cleaning and disinfectant chemical exposures and temporal associations with COVID-19—national poison data system, United States, January 1, 2020– March 31, 2020. Morbidity and Mortality Weekly Report, 69(16), 496-498. http://dx.doi.org/10.15585/mmwr.mm6916e1 Fischer, K. W. (1980). A theory of cognitive development: The control and construction of hierarchies of skills. Psychological Review, 87(6), 477-491. doi:10.1037/0033295X.87.6.477 Haddon Jr, W. (1970). On the escape of tigers: an ecologic note. American Journal of Public Health, 60(12), 2229-2234. doi:10.2105/ajph.60.12.2229-b Howington, J. (2020, July 30). Doctors say child ATV cases are on the rise. 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JAMA Ophthalmology. doi:10.1001/jamaophthalmol.2020.6346 Academia Letters, April 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: David C. Schwebel, schwebel@uab.edu Citation: Morgan, C.H., Jeffries, K.N., Schwebel, D.C. (2021). Unintentional Pediatric Injury and the COVID-19 Pandemic: Data Trends and Prevention Strategies. Academia Letters, Article 902. https://doi.org/10.20935/AL902. 4 Roe, D., & Zane, D. (2021). COVID-19 + injury connections: A literature review. Unpublished manuscript available from: https://cdn.ymaws.com/www.safestates.org/resource/ resmgr/covid/COVID-19_Injury_Literature_R.pdf Schwebel, D. C., & Gaines, J. (2007). Pediatric unintentional injury: Behavioral risk factors and implications for prevention. Journal of Developmental & Behavioral Pediatrics, 28(3), 245-254. doi:10.1097/01.DBP.0000268561.80204.2a Schwebel, D. C., & Pickett, W. (2012). The role of child and adolescent development in the occurrence of agricultural injuries: An illustration using tractor-related injuries. Journal of Agromedicine, 17(2), 214-224. https://doi.org/10.1080/1059924X.2012.655120 Schroeder, T. (2021). Effect of novel coronavirus pandemic on 2020 preliminary NEISS estimates (March–September, 2020). United States Consumer Product Safety Commission Memorandum. Retrieved from: https://cpsc.gov/Newsroom/News-Releases/2021/ Hospital-Emergency-Room-Treatment-for-Some-Product-Related-Injuries-Rose-During-thePandemic-Even-as-Overall-ER-Visits-Dropped Spinelli, M., Lionetti, F., Pastore, M., & Fasolo, M. (2020). Parents’ stress and children’s psychological problems in families facing the COVID-19 outbreak in Italy. Frontiers in Psychology, 11, 1713. https://doi.org/10.3389/fpsyg.2020.01713 Weintraub, R. (2020, July 1). Off-highway injuries increase in at least five states since stay at home orders issued. Consumer Federation of America. Retrieved from: https:// consumerfed.org/press_release/off-highway-injuries-increase-in-at-least-five-states-sincestay-at-home-orders-issued/ Academia Letters, April 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0 Corresponding Author: David C. Schwebel, schwebel@uab.edu Citation: Morgan, C.H., Jeffries, K.N., Schwebel, D.C. (2021). Unintentional Pediatric Injury and the COVID-19 Pandemic: Data Trends and Prevention Strategies. Academia Letters, Article 902. https://doi.org/10.20935/AL902. 5