Epidemiological profile of unintentional accidents in children over a period of 4 years.

: Background: Unintentional injuries are one of the most important public health problems among children in developed and some developing countries. Aim: Our purpose is to determine the prevalence of everyday life unintentional injuries among children admitted for at least 24 hours in the pediatric surgical emergencies (PSE) department, Children’s hospital of Rabat, Morocco. Methods: A cross-sectional study of unintentional injuries in children was undertaken over 4 years (2016- 2019) in the pediatric surgical emergencies (PSE) department, Children’s hospital of Rabat, Morocco. The data were analysed by statistical software Jamovi 1.6.23. Drownings and foreign bodies were excluded. Results: 1204 patients were screened, of which 545 files were studied. The median age was 8 years (cid:2) 4;12 (cid:3) with 36,5% were less than 6 years old, 70,4% were boys. The most injuries occurred mostly during winters and summers (41,6 vs 33,8%). The medical insurance plan was provided by compulsory medical insurance (AMO) and RAMED (Medical Assistance Scheme) (30,4% and 46.5% respectively). The main circumstances were accidents of everyday life (52%) with predominance of falls. For the public road accident, pedestrians were predominant. Hospital stay did not exceed 24 hours (73%) mainly in the surgical emergency department.


Introduction:
Unintentional injuries constitute a public health burden in the majority of developed countries [1,2,3]. Despite dramatic advances in other areas of clinical medicine, we have the feeling that injury prevention is poorly targeted, inadequately funded and seldom evaluated [1]. The World Health Organization published in 2008 a report on the prevention of child injuries which demonstrated that approximately 950 000 adolescents under 18 years old died of injury every year in the world [4]. Epidemiologic studies of injury indicated that there were enormous differences in the prevalence, economic burden, consequences and prevention of injuries between high income and middle-low-income countries [5].
Childhood Unintentional Injury Surveillance calculated that nearly 50 % of children under 12 y had a unintentional injuries severe enough to requires presentation to an emergency room (ER) and had some form of disability [14]. In the United States, the current situation and the possible outcomes of child and adolescent accidental injuries could be determined from injury monitoring data. In contrast, in middle-lowincome countries, it is difficult to obtain adequate information about injuries because of the lack of comprehensive injury monitoring systems. In Morocco, only few articles have been published on the issue [2,3,7,8,9].
Children are more susceptible to injuries. Their physical, and emotional immaturity limits their physical and cognitive abilities, the curiosity and the desire to experiment, the inability to avoid dangerous situations, the motivation to imitate and repeat behaviour, impatience, and anatomical characteristics are predisposing factors to injuries [1,4]. We aim to describe the general characteristics of unintentional accidents in children less than 12 years old establishing an epidemiological profile.

Material and methods:
A cross-sectional study was conducted from January 1 st 2016 to December 31 st 2019 in the paediatric surgical emergencies (PSE) department, children's hospital of Rabat, Morocco. All children aged less than 16 years with unintentional injuries were screened. Trauma related to foreign bodies, drowning and suicide attempt were excluded because in our structure they used to be admitted in other departments. Data were collected from PSE register, cross-checked with the hospitalization register. We used a questionnaire covering the demographic, socioeconomic and injury characteristics. The cause of trauma was divided into two groups: Road traffic accident (RTA) and everyday life accident (EDL). The circumstances of everyday life accident were divided into 3 groups: falls, collision and burns. We also divided the patients by age groups: infant and newborn (0 to 2 years), pre-school child (2 to 6 years), schooled (6-12 years) and adolescent (>12 years) and by gender. The data was analysed by Jamovi software 1.6.23. Khi2 used to variables [9] 3. Results: During 4 years, 1245 patients consulted for unintentional accidents of which 545 files were selected. 234 (42.2%) resulted in hospitalization in the PSE department of Children's Hospital in Rabat, Morocco at least during 24 hours. As shown in table 1, the median age was 8 y [4; 12] mostly with predominance of schooled child (40%) and boys (70.4%). Winter and summer accommodate most patients (Graph 1). The place of accident was studied too. Most of accidents sustained at home (46.4%), in the street (25.3%) and on the road (13.2%). More than a half (54.6%) of the children were alone at the time of injury. The injuries related to everyday life were predominant (81%) mostly due to falls (68%). Falls occurred from ground level (53,5%) followed by variable height (32%). The RTA's victims were mostly pedestrians (71%), followed by cyclists (16,5%) while car passengers represented only 12,7%. Fracture is the most common injury (67%) then comes the head trauma (18.7%). Hematomas and burns represent 8% and 4% respectively. Others injuries regroup abrasions, crushing, lacerations, finger tips… ( Figure 2). Limbs represents 53% of parts of body injured followed by head (27%). Most of children (81.8%) had moderate injuries that only require hospitalization less than 48 hours and about 2.5 % had severe injuries leading to several complications.     In this study, we compare the results by age group distribution (table 3). The patients were divided in 3 groups (toddlers less than 2 years, children aged 2 to 6 years old, between 6 and 12 years and finally more than 12 years old. The majority of boys and girls are aged between 6 and 12 years. Everyday life injury is more frequent in children older than 6 years. The road traffic accidents are more expected in children between 6 and 12 years old. Parts of body injured were studied with differences in each age range. Indeed, limb's injury predominates in children more than 6 years old (Table  2). Moreover, head trauma is frequent in children less than 12 years. There are no differences in the duration of hospitalization between age groups. Most hospitalization takes place in the PSE department. But complications that lead to a hospitalization in Intensive care unit were more common in toddlers. Surgery was performed in the majority (53%), more frequently among children between 6 and 12 years.

Discussion:
The World Health Organization estimates that, in 2004, around 830 000 children under the age of 18 years died as a result of an unintentional injury. Our study found that everyday life accidents are more common than road traffic accidents, which is in agreement with the literature [5,9]. They occur mostly at home especially for the preschooler children younger than 4 years [22]. Over the age of five years, road traffic injuries and fires are the predominant causes "Geneva" [4].
The present study shows a significantly higher proportion of unintentional injuries in boys than girls because of their dynamic lifestyle and less controlled behavior [1,11] and because of the characteristics of Moroccan society where the boys are used to be fearless, stronger, and more independent than girls. They are less supervised and protected by parents. This is in concordance with studies across the globe [12,13]. Also, authors suggest that parents are more concerned about girls during playing [1,14].
Socio-economic results shows that most families are from low and middle-income families. Few studies established a link between socio economic level and prevalence of accident like Faelker [23]  On the other hand, the etiology of injuries and the age of the child are linked to the impact of injury [15]. The most common site of injury is limb followed by head. The size of the child' head, the soft and elastic bones of the skull and weaker neck supporting structures contribute to head impact, which is different from the adult. The child's head is proportionately larger than in the adult [16] Most of patient stayed at hospital less than 24 hours, without differences in ages. Our study shows that the result distribution is different depending of age group.
Our results indicate that the children aged between 4-12 years had a higher injury rate than other groups; this is in discordance with research from the USA and Pakistan [13,15]. Halawa and al. showed that 70% of patients were preschool children, followed by children more than 6 years of age (21,5 %) [17, 19,20]. Also, few studies reported a bimodal distribution with a higher rate of injury in children between (1-5 years) and older than 10 years [18]. HU and al. reported that the prevalence of non-fatal injuries in 5-9-year-old children was significantly higher (19.3 per 1000 subjects) than in 10-14 years old children (15.1 per 1000 subjects) [4]. In our study the most common site of injury is limb in children older than 6 years, and head injury is more common in

Conclusion:
There is a strong association between the stage of life and the type of injuries sustained by a child. The age of a child, the stage of his or her development, how the child interacts with the world, and the type of activities the child undertakes are relevant to this association. The quality of access to medical center is an important factor that can influence an injury in the long-term consequences. Our study summarizes a general overview of unintentional accident in children in Morocco, and allows a better understanding of the common mechanisms and patterns of injuries, essential to predict, treat and prevent unintentional accident.