Prof. Aigars Pētersons: Latvia tops the charts in paediatric injuries

This article on paediatric injuries appeared in the September issue of Ārsts.lv, the Latvian Medical Association’s journal. Below is a conversation between journalist Alise Blumberga and Rector of Rīga Stradiņš University (RSU), Professor Aigars Pētersons.

I haven't seen severely injured children standing in long queues anywhere except in Latvia!

Although there are no unified statistics on paediatric injuries in Latvia, data from the Children’s Clinical University Hospital are shocking: within a single month this summer, 913 children were admitted to the emergency room with a variety of injuries (statistics at the end of the article)! RSU Rector Professor Aigars Pētersons reveals that Latvia stands out among EU countries with its bleak numbers: Latvia tops the charts when it comes to paediatric injuries.

Is it possible to prevent paediatric injuries and how? Who is to blame? What is the role of parents, teachers, general practitioners (GP)?

How closely are paediatric injuries related to parental understanding and education on these issues?

Parental and societal education is crucial. It is, in fact, the cornerstone to preventing paediatric injuries. How can we reduce injuries? First, we can educate young parents more than we are at the moment. Second, we can educate children themselves. Third, we can educate teachers, lecturers, and/or GPs. We can also shape societal opinion with various campaigns.

Parental education must begin before a baby is born. That’s why in many highly developed countries like, for example, the Scandinavian countries, a family must attend special courses on child safety before a child is born. These courses explain everything like placement of the crib, how to prepare for labour, what kind of car seat to purchase, etc. I know that families are not discharged from the maternity ward if they have not purchased a car seat. Recommendations like this have also been made in Latvia, and they are available on the website of the Centre for Disease Prevention and Control. Young parents must be informed about issues like this before the baby is born.

Some of the most severe injuries are the so-called “home injuries”. Paediatric injuries can be analysed according to age group. The first group consists of new-borns, and the second is children aged 1-4. In both these groups home injuries prevail: injuries that have occurred at home, or in the yard. Injuries differ greatly according to age, but the unifying feature is that these injuries are often extremely dangerous, like infant suffocation or drowning in 4 to 5-year-olds. The ideal scenario would be for the doctor overseeing a woman’s pregnancy to check how a new family has prepared themselves for welcoming the baby into the world and how safe this world is going to be. I know that something like this is already in place in some Latvian municipalities, but in these cases it is a local initiative that, unfortunately, is not organised nation-wide.

Working with parents, a lot of attention must be devoted to educating them on what to do when they bring the baby home. One way to tackle this, for example, would be that when a GP arrives for a home visit, they could evaluate the conditions and safety at home, like the location of the changing table, the heaters, check how high or low items are, and how safe this environment is for a baby. This “supervision” must be ongoing because different injuries occur at different ages. Issues that are relevant during the child’s first year, are not relevant during their teenage years.

I don’t doubt that parents can affect the outcome of at least 70% of cases and successfully reduce paediatric injuries.

Is there a certain age group in which children are injured most often?

Not really. Children are injured in all age groups, and different age groups have different main external causes of death. Up to 1 year of age, it's mainly obstructed breathing: choking and suffocation. From ages 1 to 4 it’s drowning. From ages 5 to 14 it is traffic accidents. Unfortunately, in the age group of 1-5, Latvia takes the first place in paediatric injuries in the EU. In other age groups, Latvia places second or third in the EU, which is also a very grim indicator. I should mention that there are many disabled children in Latvia, especially those who have become disabled after an injury.

The aforementioned home injuries are often severe and tend to repeat within the same family. Can we conclude that the parents are responsible rather than a hyperactive child or coincidence?

Consider that each time that a child is injured, it’s a stressful situation within the family - stressful for the patient and for the parents. Of course, it’s a crisis situation. As you know, people in crises think and react very differently. I don’t think that assigning blame is the right approach. The right approach is analysing these cases and drawing conclusions, and, most importantly, correcting these mistakes! We must come to a place where parents don’t repeat the same mistakes. Unfortunately, we have noticed that in some families these mistakes are not corrected. We see that injuries repeat in a family and that the right conclusions are not drawn. I’m not talking about violence in the family—that’s a different topic. I’m talking about various accidents.

That’s why we must return to your first question again and again: the question on parental education and our own understanding. Children have parents for a reason: through love and enormous patience they help their children deal with difficult life situations which they have not yet experienced. For example, their first walk home from school, their first bike ride, their first ride on public transportation, or the first time they ski down a hill. We, as adults, are well aware of these situations and we can help children learn to act safely and prevent the risk of injury. Home injuries are prevalent in young children up to the age of 5, and who other than the parents are responsible for a safe environment at home? 

Various advertising and social campaigns could definitely be useful for parental education. Often enough new parents can’t really imagine the things that might actually be very dangerous.

Yes, of course. We must use all possible channels for education. I believe that one of the most effective methods is so-called “shock therapy”. This approach is very popular in Sweden and the United Kingdom where there are reports on TV and online that a certain number of children have died during a certain period of because their seatbelt wasn’t fastened, or they weren’t in their car seat, or they played sports without protective equipment. This information is accompanied by terrifying scenes from traffic accidents etc. If this is done regularly, then it is very effective.

An equally successful method is educating children in school or kindergarten. For example, when a father is placing his child in the car without a car seat, the child would ask: ‘Dad, but where’s my car seat?’ Or a child riding a bike without a helmet would ask: ‘Where’s my helmet?’ A key aspect here is that no means of education is going to succeed if the adults in the family don’t act as positive role models for their children. A parent who doesn’t wear their helmet, or use a seatbelt can’t be surprised if their child doesn’t want to use them. 

There are still many parents who believe that if you just take a quick drive to the store that you don’t need a car seat. The argument often is—we didn’t have car seats in our childhood and we have all grown up safe and sound...

This observation isn’t based in statistics. There is no register for various types of paediatric injuries in Latvia! It’s been talked about for 15–20 years and there have been attempts at starting, but we’ve always found reasons to keep this idea just that. Many health institutions believe that you shouldn’t fill out reports, that it’s only a waste of time, but it is from reports that we can see what types of injuries there have been!

Speaking of us driving without car seats and being safe and sound—it’s very characteristic of people to base their opinion on their own experience, but we should understand that it’s not the same as overall statistical data or scientific research. And it can’t be used as an argument to avoid safety precautions.

Regarding data available in Latvia, the indicators are grim: though the overall number of births are decreasing, paediatric injuries are slowly increasing each year.

I’ve been to and worked at many children’s hospitals in Europe and the US, and I can say that what’s happening in Latvian emergency rooms doesn’t happen anywhere else. In no other country have I seen queues of patients with their heads cracked open, broken bones, burns, fingers torn off, and other severe injuries.

Are there any types of injuries that could be considered “new”?

Yes - trampoline injuries. These have become frequent over the last few years, moreover, they are one of the most severe injuries. Injuries from trampolines do not only include broken bones, like arms and collar bones, but also severe central nervous system injuries. Even severe spinal injuries which can result in a lifelong disability.

Another classic example is electric scooters. You can see how many there are on the streets. Unfortunately, the number of injuries is also increasing. Many children are severely injured with long treatment times and might even result in disability. The state, which should be responsible for imposing regulations to make electric scooters a safe means of transportation for both the driver and other people on the street, is doing nothing. In France, for example, there is a law that prohibits electric scooters from driving in parks and on the pavement, and children up to a certain age are prohibited from driving them. We have no regulations—take it and drive it! At least we’re now finally starting to talk about it.

Yet in Latvia the law often exists on paper with no real control over implementation.

Yes, exactly! I remember my battle with vinegar essence: it took almost nine years for things to change! Each year about 30–40 children ingested vinegar essence, became disabled or died, or suffered through countless surgeries to replacing their digestive tract. Nine long years passed until the right ministries understood the scope of the situation and wrote into law that concentrated acetic acid cannot be available on store shelves. Of course, there are still similar injuries from time to time, but in these cases it is mostly household chemicals that are ingested. Injuries from acetic acid have, however, decreased significantly.

Compare our statistics on paediatric injuries to our neighbouring countries - Estonia and Lithuania.

Estonia is significantly ahead of us - they have a special policy to limit paediatric injuries, and they have received help from Finland to develop and implement this policy. There are real and large fines in for not wearing a bike helmet or transporting a child without a car seat. Their schools have safety lessons that Finns have developed.

Lithuania and Latvia unfortunately top the lists of paediatric injuries.

Children’s Clinical University Hospital 2018 statistics on paediatric injuries: In total: 20,776 cases

The most common injuries

1. Falls and bruises
2. Road traffic accidents
3. Dog bites
4. Burns
5. Accidents on trampolines
6. Consumed medication
7. Sexual, physical, emotional violence
8. Psychotropic substances

A single summer month in the Children’s Clinical University Hospital

• Within a single month, 913 children visited the hospital.
• In 248 cases injuries occurred falling from furniture, stairs, trees, fences. Also by heavy objects falling onto them or them catching their fingers in a door.
• In 206 cases children were injured falling from a bike, scooter, or skateboard.
• There were 104 cases of children falling in a playground, amusement park, or out of a swing.
• In 78 cases injuries occurred by jumping on a trampoline or falling from it.
• In 50 cases an item was swallowed, or poisonous or chemical liquids or medicine were ingested.
• In 49 cases children poured hot liquid onto themselves, touched a grill, stepped onto coal.
• In 30 cases children were bitten by dogs, scratched or bitten by cats, or injured by horses.

Common injuries in the summer

• 299 cases: arm injuries
• 259 cases: head injuries
• 224 cases: leg injuries
• 145 cases: full-body injuries

Who are injured the most—boys or girls?

Within a single summer month 537 boys and 376 girls were injured.

Professor (Dr. habil. med.) Aigars Pētersons

Member of the Latvian Academy of Sciences
Rector of Rīga Stradiņš University
paediatric surgeon