Preventable injuries are killing America's children. But some are more at risk than others.
Bonnie Lovette will never forget the face of a 2-month-old infant who was rushed into the emergency room after a car wreck.
The baby girl wasn't properly in her car seat and flew out of the vehicle, said Lovette, a nurse practitioner in Oakland, California. The child died from her injuries.
So whenever children would come into the hospital, Lovette and her team would make sure families left with car seats and that they knew how to use them.
Injuries — like those from car crashes or firearms — are the leading cause of death for children and teenagers in the United States. But kids get hurt or die from injuries at drastically different rates. Lovette saw this in Oakland's Black and brown communities strapped by poverty, which worsens disparities.
Nationwide, children and teenagers who are Black, American Indian, low-income or live in rural communities die from injuries at disproportionate rates compared to white, higher income or urban children.
The inequities are a result of multiple structural barriers, experts say, and communities need to raise awareness and track the problem to better understand where kids are most in danger and why.
“People don't think of it as a public health crisis,” said pediatrician Dr. Sadiqa Kendi, who is leading a new program in Massachusetts that seeks to better review pediatric injuries. “There's just not a recognition, especially in our society, around the significant impact of injuries and the fact that these serious injuries that lead to death are preventable.”
Dr. Donald Warne, a family medicine physician who is a member of the Oglala Lakota Tribe in Pine Ridge, South Dakota, knows too well the toll structural racism has taken on Indigenous children and families.
He called injuries a “chronic condition for young people.”
“It doesn't seem to get as much attention as heart disease and cancer,” said Warne, who codirects the Johns Hopkins Center for Indigenous Health in Baltimore. “We're losing a lot of young people — and therefore a lot of years of potential life lost.”
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What’s behind the disparity?
More than 7,000 children up to age 19 died of unintentional injuries in 2019 – about 20 deaths each day, according to the Centers for Disease Control and Prevention.
In 2020, gun violence was the leading cause of death for children and teens. Along with car crashes and violence, other causes of injury and death include drowning, falls, suffocation and self-harm.
Despite an overall decrease from 2010 to 2019, the latest year CDC data is available, injury remains the leading cause of child death, and disparities persist:
Black children die from injuries at almost 5 times the rate of Asian American children and twice the rate of white children.
American Indian children die at 3.5 times the rate of Asian American children and 1.4 times the rate of their white counterparts.
Kids in rural communities die at twice the rate of urban children.
Among Hispanic children, deaths from poisoning increased 50% between 2010 and 2019 and 37% among Black children, while rates among white children decreased by 24%
Rates of Black children dying from car crashes increased 9% and decreased 24% for white children.
The disparities are rooted in structural disadvantages. A child's risk for injury or death increases due to poverty, their environment, and lack of access to safety equipment, mental health care and other resources.
“It really takes addressing all of those categories to move the needle in addressing inequities,” said Kendi, chief of Boston Medical Center's pediatric emergency medicine division.
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In Oakland, Lovette co-founded a child injury prevention network in 2004 based at the University of California, San Francisco Benioff Children’s Hospital. The network's experts and community leaders from multiple disciplines meet regularly to discuss how to reduce injury disparities, share data and develop policy recommendations.
Throughout her three decades at the hospital, Lovette saw children and teens come into the ER with injuries from gunshots, physical fights, self-harm and car crashes. Often, they were children of color from high-poverty neighborhoods, she said.
Black communities, Kendi noted, are more likely to have large arterial roads run through them, increasing the risk of pedestrian injuries when children and teens cross or walk nearby to get to a park, for example.
“When you have an environment where we don't have safe opportunities for people to cross streets, where there's heavy traffic, where they're near school zones, where they're near where people are living, yes — the kids there are going to have increased risk of injury,” said Keshia Pollack Porter, chair of the health policy and management department at Johns Hopkins Bloomberg School of Public Health, who specializes in pediatric injury prevention and disparities.
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In Indian Country, tribal roadway safety has long been a danger. Unmanaged roadways on reservations — where infrastructure falters due to underfunding and longstanding structural inequities — are often unsafe and become more dangerous in extreme weather conditions. Car crashes, along with other unintentional injuries, are a leading cause of death for American Indian people.
“In a reservation community, quite often we have older vehicles. We don't always have the most recent safety technology, including airbags,” Warne said, adding that a lack of car seats also prevents safe transportation.
Indigenous youth suicide — also a culmination of barriers including lack of access to mental health care — is also a concern. One analysis found injuries, including crashes, homicide and suicide, made up 41% of all deaths among American Indian and Alaska Native children.
“Unresolved psychological and emotional trauma is at the root of many of our challenges, including injury disparities,” Warne said.
“When we look further upstream at the root causes, issues like historical trauma put some populations at greater risk for the social conditions that lead to higher risk with things like injury-related death and morbidity,” he added.
Programs such as the Tribal Injury Prevention Resource Center have aimed to provide specific supports to reservations, offering trainings and resources on car safety.
“The rural and remote nature, substandard roads, less emergency medical services, and longer response times ... no local trauma centers,” Warne said. “We have the perfect storm for bad outcomes related to motor vehicle injuries.”
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Tracking injuries and creating awareness
In counties and states across the nation, multidisciplinary teams gather in what are called child death review committees to discuss cases of pediatric deaths.
But there’s a growing need to track nonfatal injuries that lead to hospitalizations or ER visits, said Kendi, especially from an equity standpoint.
“The fatalities are really the tip of the iceberg,” she said.
Examining hospitalizations "really broadens your view and helps you to think more about inequities," she said.
That’s why she started MassPIER, funded by the Johns Hopkins Bloomberg American Health Initiative. The program, which the university says is the first of its kind, is an equity-centered review process for pediatric injuries in Massachusetts. The aim is to track inequities, collect detailed racial and age-related data, and develop targeted recommendations for alleviating disproportionate injury rates.
Modeling the program after the child death review process, the team created a toolkit with the goal that other communities and local governments can replicate it.
In Massachusetts, American Indian and Alaska Native children saw the highest rates of injury-related deaths followed by Black and Hispanic children between 2016 and 2020, according to MassPier’s analysis of state health department data. More than 800 children died during that time period, the data shows.
To identify underlying causes case-by-case, Kendi and her team incorporated a process that tracks factors linked to injury inequities, such as access to safety equipment like car seats.
Pollack Porter said data often is lacking on nonfatal injuries, and more data-driven programs like MassPier that include socioeconomic factors need to be implemented for injury inequities to be addressed.
That holistic approach – considering the context around what led to a child's death or injury – can "make a difference in saving children's lives and reducing these inequities," she said.
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How groups are working to reduce injuries
While newer car seat and vehicle models come with more safety features, they are often more expensive, and parents need education on how to properly install cheaper models, experts say. Often, children are seated backward or seatbelts aren't tied through the anchors correctly, for example.
At Benioff Children's Hospital, the Childhood Injury Prevention Network's efforts included child passenger safety technicians that helped parents. The hospital and network also partnered with violence interrupters in the community, and implemented infant safe sleep and gun safety initiatives, Lovette explained.
“We made a whole (gun safety) kit with education for pediatric providers, so they would know what conversation to have with parents and be more comfortable having that conversation,” Lovette said, adding each kit included a gun lock.
Education, multilingual outreach and bridging gaps in resources can mitigate risks, said Deirdre Walsh, clinical administrative coordinator of Boston Children’s Hospital’s injury prevention program. Teams should ask if their education materials are accessible.
"Is there a language barrier? If we had given a pamphlet out in a different language, would that have prevented them from coming?" Walsh said.
Her team works with parents, homeless shelters and underserved school systems.
The injury prevention specialists also educate families on bike safety, help install car seats, and meet with parents of children who are hospitalized to discuss how to prevent another injury from happening.
“What we need to remember is what brought them in could have been easily preventable,” Walsh said.
Resources for parents and caregivers
►The American Academy of Pediatrics offers safety fact sheets on how to keep children safe at home, during play, travel and driving, weather events, and more.
►Find and connect to your local Safe Kids chapter.
►The Children's Safety Network provides information on self-harm prevention, pedestrian safety, passenger safety, firearm, poisoning, choking, rural and farm safety and other topics.
►Fact sheets from the UCSF Benioff Children's Injury Prevention Network.
►For safety information from the CDC, click on:
Reach Nada Hassanein at nhassanein@usatoday.com or on Twitter @nhassanein_.
This article originally appeared on USA TODAY: Child injury is leading cause of death. But some kids are more at risk
