Despite the dawn of technology and an increase in public awareness, trauma and injury continue to be common in children and remain an important cause of morbidity and mortality (Holland & Soundappan; 2017). As evidenced in this study, children and young adults are not immune to injury. Our results show that the age of a child poses a higher risk for a particular type and mechanism of injury along with variance in trauma-related outcomes. While both groups have innate qualities that make them heterogenous, the analysis focused on describing and comparing both groups. As a result, we found that the older pediatric trauma population was more likely to be male, suffer a major trauma and spend more days at the hospital compared to their younger counterparts. Of note, in terms of admission trends, there was no significant differences between both groups throughout the study period. Through the years we have seen a decline in deaths from infectious disease and cancer, mainly due to the advantage of performing earlier diagnosis, the advent of immunizations, antibiotics, medical and surgical treatment. All this has given way to increases in deaths from injury-related causes, including motor vehicle crashes, and firearm injuries, among others (Cunningham et al., 2018).
Age, as well as other factors such as gender, behavioral pattern, and environment influence childhood injuries (Lalwani et al., 2018). In our study, we defined children as those who fall under the age of 15 years, the same cutoff used by the American College of Surgeons Committee on Trauma, and we decided to include a second group of patients until the age of 21 years, since in our country, those patients would be treated in a pediatric institution based on their age. Our results showed that the predominant gender affected by trauma out of all patients were males, for both the children/adolescent and youth/young adult group. As seen in previous studies, gender itself is a risk factor for the occurrence of trauma (Alonso et al., 2017; Aoki et al., 2019; Cunningham et al., 2018; Jalalvandi et al., 2015; Lalwani et al., 2018). In our study, the male population presented more often to the hospital due to trauma, this could be because boys are generally considered physically more active and more prone to aggressive behavior than girls, and show more interest in competitive and physical activities (Alonso et al., 2017; Cunningham et al, 2018; Schwebel & Gaines, 2007).
Injuries were classified according to the underlying mechanism (e.g., MVA, GSW, falls) in order to understand the possible associated risk and protective factors, which would allow for the development of effective prevention strategies in the future. For both groups, MVA was the predominant mechanism of injury, similar to other pediatric studies (Avarello & Cantor, 2007; Avraham et al., 2019, Cunningham et al., 2018, Merrick et al., 2004, Oliver et al., 2018). Despite the interplay between technological improvements in safety, legislative initiatives and improved injury care, and an apparent decline in the incidence of such trauma from other studies (Cunningham et al., 2018), the fact is that MVA remains the prevalent mechanism of injury in this population regardless of age (Avraham et al., 2019; Cunningham et al., 2018; Oliver et al., 2018).
While MVA remain the most important cause of pediatric trauma, assaults, including GSWs, was the second most common mechanism of severe injury in 15-to-21-year-olds. These results are consistent with prior studies (Bayouth et al., 2019; Oliver et al., 2018) and highlight an important public health challenge (Oliver et al., 2018). Older children are more likely to engage in more dangerous activities compared to their younger counterparts, as they are less likely to be dependent on their parents, more likely to engage in risk-taking behaviors and be driven by peer-pressure, which would explain the difference in the type of trauma (Bayouth et al., 2019; Schwebel &Gaines, 2007). Some studies have associated the socioeconomic status as a direct risk factor for this specific type of injury mechanism (Bayouth et al., 2019), however, socioeconomic factors seem to be a risk factor no matter the type of injury (Fallat et al., 2006; Schecter et al., 2012; Schwebel &Gaines, 2007). In our study, most patients had private health insurance, consonant with findings by the US Census Bureau (2020). Nonetheless, traditionally low socioeconomic status has been correlated with a higher rate of injury among children (Fallat et al., 2006; Marcin et al., 2003; Merrick et al., 2004).
For the children/adolescent group, the second most common mechanism of injury included pedestrians and falls (Oliver et al., 2018). Pediatric falls are frequently seen among young children and can cause injuries requiring hospitalization (Chaudhary et al., 2018). As a child ages, their mobility naturally increases, from being able to roll over, to sitting up, pulling to a standing position to eventually walking, running, and climbing. As expected, the children/adolescent group had a higher percentage of falls-related trauma. Regardless of the mechanism of injury, the most common site of injury for both pediatric groups were the extremities. This was closely followed by the chest and abdominal region as seen in Fig. 2. Not many studies, specifically in children, take into consideration which body part was the most injured, however, those that do are usually studies that focus on fractures. Out of all the body parts mentioned in such studies, the extremities were the most common site of injury as well (Naranje et al., 2016; Oliver et al., 2018).
For injury severity, clinical profile, and trauma outcomes, we analyzed different sets of variables, including the ISS, LOS, ICU stay, the need for mechanical ventilation, and mortality. The ISS is known as a surrogate for morbidity and mortality. In our study, most patients presented with a low ISS (< 15), comparable to other studies in the literature (Guice et al, 2010; Nesje et al., 2019). However, if we compared both study groups, we see that the proportion of patients with a high ISS > 15 was substantially larger in the youth group compared to the pediatric group. If we take a closer look at the severely injured group (ISS > 15; those who are more likely to suffer greater morbidity, mortality, and longer hospitalization), this group represents roughly 36% of all patients. In a study in Germany, their severely injured group totaled 32%, which is in the same range as our patient group (Schoeneberg et al., 2014).
One aspect to consider during trauma admissions is the LOS, for which we found that the younger adult cohort, spent more days on average compared to the children cohort. In previous studies, LOS could be as low as 2 days and as high as 7 (Nesje et al., 2019; Oliver et al., 2018). When combined, the median for all our pediatric patients was 7 days. The LOS can have a serious economic impact on both the health care system and the patients’ family, however we are not able to address this, but this an area of future research interest. this aspect was not analyzed in our study. It was interesting to notice that, even though more children were admitted to the ICU, it was the older cohort who spent more days in it (3 vs. 10; p < 0.01). It makes sense considering that the youth presented with a higher ISS than the pediatric group. However, despite this stark difference, the use of mechanical ventilation, while higher for the young adults, it was not statistically different than the children group. Likewise, mortality was similar for both groups, with 7.5% on average. In recent literature, the mortality for the pediatric group was found to be as low as 0.9% and as high as 25% depending on the setting of treatment, injury mechanism, the pediatric age cutoff used for their study, among other aspects (Aoki et al., 2019; Jalalvandi et al., 2015; Myers et al., 2019; Schlegel et al.,2018). The risk factors associated with mortality can be both direct (e.g., injury mechanism) and indirect (e.g., lack of health insurance) (Avraham et al., 2016). In our multivariate analysis, the youth trauma population was more likely to be male, suffer major trauma, a penetrating injury, and have a longer hospital stay. All the aforementioned parameters, known risk factors for trauma in previous studies as stated above. Surprisingly, the presence of public health insurance, usually associated with low socioeconomic status and therefore a higher occurrence of trauma, lost its significance once adjusted in our study.
There are several limitations to our study. First, although the study used a cross-sectional design, the study relies on registry-based data that uses medical record information as the source of information. This inherently restrict our data to the information available on the patient’s record. As with any other registry, patient’s documentation may vary affecting the available information for each case entered. Second, this is a single-center study, which may impact the applicability to other centers and populations. However, the PRTH is the only state-designated Level 1 trauma center in Puerto Rico and the Caribbean. The Trauma Registry does not keep track of patients transferred to the nearest pediatric institution once stabilized. Once they are transferred, the information regarding the overall outcome and associated variables are not available to our registry, and thus, not included in the scope of our study.
Given that the PRTH is the only Level 1 Trauma Center, this guarantees that all patients with high ISS or those included in the severely injured category will be treated at our hospital, which translates to adequate representation in our study. However, those patients that fall below the ISS for the category of severely injured may arrive at our PRTH or at another pediatric institution, which may affect the number of cases and the overall incidence of this group of patients in our study. Future research should evaluate multiple pediatric centers, specifically, the trauma encounters at the ER, and include patient follow-up data. This should also include, if available, the intent of injury which is an important aspect in this population as many different types of abuse are disguised as “accidents”. Notwithstanding these constraints, every effort has been made to faithfully represent the scope of the pediatric admissions to the PRTH.
Despite these limitations, the study has some strengths. First, the cross-sectional design allowed the study of multiple parameters associated to age, providing a general knowledge of the potential risk factors that may play an important role in the demographics of pediatric trauma admissions. In addition, since we made use of regression models, the control of confounding was possible having a better estimate of the risk factors studied.