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Commentary From the Council on Injury, Violence, and Poison Prevention

October 19, 2023

Commentary From the Council on Injury, Violence, and Poison Prevention

The importance of injuries as a leading cause of morbidity and mortality to children and youth is not a new phenomenon. In 1948, Dr. George Wheatley published an editorial in Pediatrics calling for pediatricians to “adopt a more critical attitude toward the cause of accidents…approach accidents with the same inquiring mind that we bring to the study of disease.”1 In this editorial he announced the American Academy of Pediatrics (AAP) was beginning a national effort to reduce injuries in young children, which became the creation of the AAP’s Committee on Accident Prevention in 1950.2 This AAP group has now evolved to be the Council on Injury, Violence, and Poison Prevention (COIVPP). Although the name has changed, the mission remains the same—to decrease intentional and unintentional injuries to children and youth through education and communication to the public and clinicians, engineering with design modification and safety equipment, and enforcement through advocacy for regulation and legislation focused on child safety.

The first publications in Pediatrics on the subject of injury prevention appeared in the 1950s. Although the methods of injury prevention research have evolved over 75 years, we also see the nidus of current approaches in early works. To identify publications in Pediatrics from 1948-2022 related to injury and injury prevention, we conducted a Web of Science database search, using a comprehensive approach for terms related to injury. In each of our 2 commentaries, the COIVPP chose to highlight at least one sentinel publication from each of the 3 quarter centuries of Pediatrics. As injury prevention efforts continue to advance, let us learn afresh by reflecting on the elegant research of the past.

The Evolution of Injury Prevention Research Over the Last 75 Years

Katherine Flynn-O’Brien, MD, MPH, FAAP1, Alison Culyba, MD, PhD, MPH, FAAP2, Maya Haasz, MD, FAAP3, Andrew Kiragu, MD, FAAP4, Terri McFadden, MD, MPH, FAAP5, Kevin Osterhoudt, MD, FAAP6, Frederick Rivara, MD, MPH, FAAP7, Lois Lee, MD, MPH, FAAP8

Affiliations: 1Children’s Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin; 2Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh PA; 3University of Colorado School of Medicine, Aurora, CO; 4Children’s Minnesota, University of Minnesota, Minneapolis, Minnesota; 5Emory University, Atlanta, Georgia; 6Children’s Hospital of Philadelphia, University of Pennsylvania; 7Seattle Children’s, University of Washington; 8Boston Children’s, Boston, Massachusetts

Highlighted Articles From Pediatrics

In 1954, we witnessed pioneering efforts to describe childhood injury. Drs. Dennis and Kaiser collaborated with 7 Rochester-based hospitals and the local health bureau to complete “accident report cards” on non-fatal injuries in children treated in emergency departments.3 Research staff visited homes, collected information on each incident, and completed a checklist to “insure uniformity and completeness of recording.” Herein we see the origins of the National Trauma Databank, which publishes an annual data standard including edit checks to ensure uniformity and completeness. Many of the data elements captured in 1954 are also used today. In fact, Dennis and Kaiser’s “Chart 3” could be seen in any injury-related publication today (Figure 1). Unique to their work at the time, they evaluated mechanical (eg, house needing repair, improper use of equipment) and personal (eg, fatigue, lack of knowledge) factors associated with injury. The authors classified 58% of injuries as preventable with employment of strategies such as supervision, removal of dangerous objects, use of protective devices, legal interventions, and improved home and product design.

Figure 1: Adapted with permission from Dennis JM, Kaiser AD. Are home accidents in children preventable? Pediatrics. 1954;13(6):568-575.

Jumping to 1978, Dr. Kenneth Feldman and colleagues reported on tap water scald burns in children.4 This investigation included novel analysis of a large national database that is still in use today (the National Electronic Injury Surveillance System), medical record review, and surveys. In a household, Dr. Feldman’s survey intentionally included households from diverse racial and socio-economic communities. Investigators personally tested water temperatures and examined water heaters. Among 57 homes tested, the mean bathtub hot water temperature was 61± 14ºC (142± 26ºF). There was no association between water temperature and economic background or neighborhood, knowledge of the risk of hot tap water, or satisfaction with the temperature. Although all water heaters examined were adjustable, fewer than half had previously been adjusted. Most strikingly, the temperatures of the water heaters adjusted by the power company were usually 60-66ºC (140-150ºF), sufficiently hot to cause a scald burn within minutes.

Feldman importantly identified that 45% of tap water injuries involved the victim or a peer turning on the water. A survey determined physician knowledge was inadequate regarding hot water safety to provide effective safety counseling. To reduce hot water injury, advocacy efforts targeted the Consumer Product Safety Commission (CPSC) standards requiring temperature limits on new products and engagement of fire departments, power companies, news media, and health care providers to provide education and safety checks. The CPSC regulation recommendation is an example of “passive preventative techniques,” which do not rely on an individual to take preventive action. Engineering controls to prevent injury were novel at the time, yet today are the backbone of injury prevention work. The innovation of individually testing water from bathtubs in patients’ households was an intimate but critical aspect of the work, contributing to its long-term effect.

Two decades after Feldman’s seminal work, Dr. Maureen Durkin and colleagues in 1999 reported on the Harlem Hospital Injury Prevention Program (HHIPP), which highlighted the success of community participatory research. HHIPP aimed to reduce the incidence of pediatric injuries from falls, traffic, and assaults.5 It included school and community-based traffic safety education, construction of new playgrounds and improvement of existing playgrounds, bicycle safety clinics and helmet distribution, and a range of supervised recreational activities for children in the community. These programs were successful, and traffic and pedestrian injuries among school-aged children declined relative to the preintervention period, by 36% and 45%, respectively.

Drs. Dennis and Feldman outlined how advancing the understanding around injury circumstances is essential to inform prevention strategies. These works demonstrate the principle outlined in the Haddon Matrix of injury prevention to examine the phases in time of injury (pre-, during, and post-) and the contributing factors (individual, agent, and physical/legislative environment), a model still used today.6,7 In 1999, Dr. Frederick Rivara reported on “where we have come and where we must go” to reduce unintentional injuries among children and adolescents further.8 He described a 45.3% reduction in injury mortality between 1979 and 1996, and successful injury control efforts, including motor vehicle restraint use. He also highlighted areas needing outcomes research. He concluded, “the increasing focus on basing interventions in medicine on evidence has become a prominent feature of injury control, especially in the last decade…. Increasing investment in research will expand this evidence base and allow additional effective interventions to be implemented.”

Entering the 75th anniversary of Pediatrics, we see a heed to Dr. Rivara’s call for increasing evidence-based injury prevention research (Figure 2). That said, there is more work to be done than ever before because both intentional and unintentional injuries remain the leading cause of death and disability in children.9 We know many of these injuries are preventable using strategies to remove unsafe products, improve safety features, implement regulations and legislation, and educate clinicians and caregivers. We must continue to conduct rigorous research and advocate for change at the individual, community, and federal levels. Much progress has been made, and there is still much work to be done to decrease non-fatal and fatal injuries and ultimately to improve health outcomes for all children.

Figure 2: Pediatrics publications on injury prevention by decade. Data source: Web of Science search for articles using comprehensive injury-related terms.


We thank the entire membership of the AAP, and specifically the COIVPP, for their commitment to the health and well-being of children.


  1. Wheatley GM. Child accident reduction: a challenge to the pediatrician. Pediatrics. 1948;2:367-368
  2. Commitee on Injury and Poison Prevention. The AAP Committee on Injury and Poison Prevention and the Section on Injury and Poison Prevention. In: Widome M, ed. Injury Prevention and Control for Children and Youth. 3rd ed. American Academy of Pediatrics; 1997:415-424
  3. Dennis JM, Kaiser AD. Are home accidents in children preventable? Pediatrics. 1954;13(6):568-575
  4. Feldman KW, Schaller RT, Feldman JA, McMillon M. Tap water scald burns in children. Pediatrics. 1978;62(1):1-7
  5. Durkin MS, Laraque-Arena D, Lubman I, Barlow B. Epidemiology and prevention of traffic injuries to urban children and adolescents. Pediatrics. 1999;103(6):e74
  6. Dorney K, Dodington JM, Rees CA, et al. Preventing injuries must be a priority to prevent disease in the twenty-first century. Pediatr Res. 2020;87(2):282-292
  7. Haddon W. A logical framework for categorizing highway safety phenomena and activity. J Trauma. 1972;12(3):193-207
  8. Rivara FP. Pediatric injury control in 1999: where do we go from here? Pediatrics. 1999;103(suppl 1):883-888
  9. Centers for Disease Control and Prevention. Web-based Injury Statistics Query Reporting System (WISQARS). Accessed December 1, 2022.


Advances in Child Passenger Safety

James Dodington, MD, FAAP1, Sadiqa Kendi, MD, FAAP2, Lois Lee, MD, MPH, FAAP3, Aimee M. Grace, MD, MPH, FAAP4, Bonnie Kozial, BA5, Benjamin Hoffman, MD, FAAP6

Affiliations: 1Department of Pediatrics, Yale School of Medicine, New Haven, CT; 2Division of Pediatric Emergency Medicine, Boston Medical Center, Boston, MA; 3Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA; 4Office of Strategic Health Initiatives, University of Hawaiʻi System, Honolulu, HI; 5American Academy of Pediatrics, Itasca, IL; 6Department of Pediatrics, Oregon Health and Science University, Portland, OR

Highlighted Articles From Pediatrics

The success of child passenger safety (CPS) stands as a shining example in the field of injury prevention. Over the last 50 years, pediatric morbidity and mortality from motor vehicle crashes (MVCs) has decreased substantially. This is in large part due to the work of CPS researchers and advocates, who brought about innovations, policies, and legislative developments that have saved countless lives. Many of the leaders of this field worked through the American Academy of Pediatrics (AAP) and disseminated their research and policy recommendations through landmark publications in Pediatrics.

In 1960, the AAP Committee on Accident Prevention surveyed AAP members on their use of “seat belts in their own family cars.” The findings of this survey were published in Pediatrics in 1962, citing the overall low (33%) use of belts in their sample, and more surprisingly, that only 37% of those with belts recommended their use to families in their practice.1 The article concluded with a very strong recommendation to use seat belts and “see that the lag between the scientific knowledge and public application is reduced to the minimum.”1 This initial report on CPS established the safety of children and adolescents in motor vehicles as a priority for decades to come.

In the 1970s, the charge of the Committee on Accident Prevention was taken up by leaders like Dr. Robert Sanders, who became the chair. In 1977, he led the push to create the Child Passenger Protection Act in Tennessee, the first law in the United States to mandate the use of federally approved child safety restraints for children younger than 4 years. Many states followed with their own laws, and a cycle emerged in which AAP leaders directly influenced legislative changes to improve CPS. 

Over the next decade, the AAP moved to become more directly involved in advocacy around CPS. One landmark program was First Ride/A Safe Ride, as discussed in a key Pediatrics publication by Dr. Leonard Krassner, entitled “TIPP Usage,” (TIPP—The Injury Prevention Program).2 The program’s goal was “to have, by 1983, 75% of newborns born in the US going home from the hospital in approved infant seat restraints.”2 This effort represented the AAP’s advocacy to incorporate injury prevention goals and anticipatory guidance around injury prevention as a central part of pediatric practice. This comprehensive approach of issuing policy statements and promoting programs to assist pediatricians in best practices, and working directly on legislative advocacy, became the new standard for the committee.

Over the next 30 years, the committee became the Council on Injury, Violence, and Poison Prevention (COIVPP), as it stands today. The council continues to publish groundbreaking recommendations with its AAP policy statements and technical reports in Pediatrics. These have ranged from the development of standards for transporting children with special health care needs to school bus safety, spearheaded by the pioneering work of Dr. Marilyn Bull and Dr. Joseph O’Neil.3,4 In 2011, the council published another significant policy statement, led by Dr. Dennis Durbin, which recommended that children 2 years of age and younger should remain rear-facing until they reach the weight or height limit of their car seat.5 The recommendations for this policy statement resulted in innovation within the child passenger safety industry to offer products with higher rear-facing weight and height limits. Although international research had demonstrated the protective effect of using rear-facing restraints, a controversy around a retracted paper in Injury Prevention required the council to update its policy statement in 2018. The new policy statement followed the science that the best practice was to keep children rear-facing until they reached the weight or height limit of their seat and also clarified guidance on the specific claims that could not be supported.6,7 These events showed the vigilance of the council to incorporate new science and current best practices, as the AAP remained a leading reference point for child safety and legislation development.

The work of the council in bringing forward CPS research to establish policy and to advocate for programmatic and legislative developments has been central to the success in reducing injuries and deaths for children. Key publications in Pediatrics have led to further innovations in other areas of injury prevention. However, CPS laws vary by state and, unfortunately, racial, socioeconomic, and geographic inequities in CPS persist. Areas of growth for the council and the field going forward include continuing to bridge research and policy and working to create a more uniform national landscape for CPS laws that incorporates a greater focus on equity and inclusion.


  1. Committee on Accident Prevention. Seat belts in the prevention of automobile injuries: report of the committee on accident prevention. Pediatrics. 1962;30(5):841–843
  2. Krassner L. TIPP usage. Pediatrics. 1984;74(5):976-980
  3. Committee on Injury and Poison Prevention. Transporting children with special health care needs. Pediatrics. 1999;104(4):988-992
  4. O’Neil J, Hoffman BD; Council on Injury, Violence, and Poison Prevention. School bus transportation of children with special health care needs. Pediatrics. 2018;141(5):e20180513. Erratum in: Pediatrics. 2018;142(1):e20181221
  5. Durbin DR; Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):e1050-e1066
  6. Durbin DR, Hoffman BD; Council on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2018;142(5):e20182460
  7. Henary B, Sherwood CP, Crandall JR, et al. Car safety seats for children: rear facing for best protection. Inj Prev. 2007;13(6):398-402. Retraction in: Inj Prev. 2018;24(1):e2
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