Characteristics and trends of pediatric trauma on Jeju Island, Korea: a community-level serial cross-sectional study
Article information
Abstract
Objective
This study aimed to investigate the characteristics and epidemiological trends of pediatric injuries among patients visiting emergency departments on Jeju Island, Korea.
Methods
Using a community-level serial cross-sectional analysis, we targeted pediatric patients 18 years or younger who visited emergency departments for injuries over a 10-year period. A comprehensive examination of injury characteristics and epidemiological trends was performed using the data sourced from the Jeju Injury Surveillance System. This included an evaluation of the annual incidence and overall trends in pediatric injury cases.
Results
The study found toddlers (42.5% of cases) to be the most frequently injured age group. Male patients were more prone to injuries, with a male to female ratio of 1.7:1. Injuries among visitors accounted for 17.3% of cases, with a seasonal spike in summer, evenings, and weekends. Most incidents occurred at home, were predominantly accidental in nature, with adolescents more likely to require emergency medical system services. The common mechanisms of injuries were blunt force (49.2%), slips/falls (22.0%), and motor vehicle collisions (13.2%), leading to bruises, cuts, and sprains. Over the decade, a general increase in pediatric injuries was observed. Accidental injuries initially surged but later stabilized; however, self-harm/suicide and assault/violence injuries showed a concerning upward trend. Age-specific analysis revealed increasing trends in infants and adolescents.
Conclusion
The results of the present study underscore the crucial need for targeted injury prevention and resource allocation strategies, particularly for high-risk groups and time of injury, to effectively mitigate pediatric trauma on Jeju Island.
INTRODUCTION
Pediatric trauma has become a major cause of death and injury in children due to an increased incidence [1]. Pediatric trauma occurs in many locations during various activities and the characteristics change over time [2]. Furthermore, with the development of the nuclear family system, pediatric trauma is of major importance in a family, and more children have been visiting the emergency medical centers (EMCs) [3]. Accordingly, many studies have addressed pediatric trauma and related preventive programs, including education programs. However, there are few studies of pediatric trauma specifically in Jeju Island, Korea [2,4].
Because Jeju Island is geographically isolated from the Korean peninsula, most of the pediatric trauma patients are initially treated in the EMC of the island. All data for pediatric trauma patients in the EMC of Jeju Island were collected using the Jeju Injury Surveillance System (JISS). There is an advantage in understanding the characteristics and trends of pediatric trauma, especially because more than one million tourists, many of whom are children, visit Jeju Island every year [5]. Because pediatric trauma associated with sports and leisure activities has been increasing, there is a need for preventive programs for pediatric trauma [6,7].
This community-level cross-sectional observational study investigated the characteristics and trends of pediatric trauma patients who visited emergency departments (EDs) on Jeju Island.
METHODS
Ethics statement
The study was approved by the Institutional Review Board of Jeju National University Hospital (No. 2023-11-011). Informed consent was waived due to the retrospective nature of the study.
Study design and setting
This study undertook a serial cross-sectional analysis at the community level on Jeju Island, targeting pediatric patients aged 18 years or younger who visited EDs due to injuries. We aimed to delineate the epidemiology and trends of pediatric injuries using comprehensive data from the ED-based JISS that covers all EDs on the island. The study period spanned 10 years, from January 2008 to December 2018. The research was conducted on Jeju Island, covering an area of 1,836 km2, with a residential population of 641,597 in 2016. The established emergency medical services (EMS) at that time included four prehospital fire departments deploying 30 ambulance units and six emergency medical facilities (a regional EMC, four local EMCs, and an additional local EMS institution), collectively providing 141 operational emergency beds. During the year, the EDs handled approximately 184,370 patient visits, with approximately 31% of these cases related to trauma.
Data source and collection
The primary data source for this study was the JISS, an ED-based system established in 2007, to fulfill the requirements for recognition as an International Safe Community by monitoring injury epidemiology within the community. Operational since 2008, the JISS comprehensively tracks all injury cases handled by prehospital ambulance units and EDs across Jeju Island. The JISS systematically collects data on patient identifiers, demographics, injury specifics, prehospital details, and clinical characteristics and outcomes. Data collection is conducted by independent investigators at each ED who input the information into an electronic form and transmit it in real time to the Fire Safety Headquarters' server.
Study population
Our study targeted patients aged 18 years or younger who visited EDs on Jeju Island from January 2008 to December 2018 and were diagnosed with injury-related conditions as per the International Classification of Diseases, 10th Revision codes S00–T88 (injury, poisoning, and certain other consequences of external causes). Among 524,413 ED visits due to injury recorded in the JISS, 391,715 were excluded: 391,703 who were 18 years or older and 12 of unknown age. The remaining 132,698 pediatric injury cases were divided into four age groups for detailed analysis: infants (<1 year), toddlers (1–5 years), children (6–12 years), and adolescents (13–17 years).
Investigated variables
In this study, we applied the Haddon Matrix model to systematically categorize the data. Variables were classified into three factors of host (the involved individual), agent (the entity or substance causing the injury), and environment (the setting of the incident) and were analyzed across two phases, prehospital and in-hospital. Host factors included demographic details such as sex, age, residency (resident or visitor), and nationality. Agent or environmental factors consisted of time of injury (season, weekday, time), intent (accidental, self-harm/suicide, assault/violence, or other), and mechanism (e.g., motor vehicle collisions, falls/slips, blunt/laceration injuries, burns, foreign body ingestion). These factors also included anatomical site of injury, location (home, school, street, public, commercial, or rural area), activity at the time of injury (e.g., daily living, education-related, leisure/play), alcohol involvement, and use of EMS ambulance services. Clinical characteristics and outcomes were delineated based on care stage, encompassing ED arrival mode, resuscitation efforts, mortality upon arrival, mental status, need for surgical intervention, and final disposition of patients.
Statistical analysis
We conducted descriptive statistical analysis on collected pediatric injury data, presenting demographics and injury characteristics across four pediatric age groups. Categorical variables were summarized as frequencies and percentages, and continuous variables were described using means, standard deviations, medians, and interquartile ranges based on their distribution. We compared these demographics and injury characteristics across age groups using analysis of variance, Kruskal-Wallis, chi-square, or Fisher exact tests based on the data distribution. Despite rejecting the null hypothesis of equal distributions across groups, we did not perform post-hoc pairwise comparisons, as the primary aim was not comparative inferences. Subsequently, we analyzed epidemiological trends of pediatric injuries at the community level over a 10-year period. Age-standardized incidence rates were calculated annually and adjusted for demographic changes using direct standardization to the 2010 Korean census. The temporal trends were evaluated using the LOWESS (locally weighted scatterplot smoothing) regression models, with the year as the independent variable and the annual standardized incidence rate as the dependent variable. The direction and magnitude of the annual trend were computed using the reverse adjacent contrasts, comparing each year with the previous. In addition, the annual changes were estimated from the slope and P-value of the Poisson regression model to quantify the mean change in incidence rates per year over one decade. All statistical analyses were performed using Stata ver. 17.0 (Stata Corp), with a significance threshold set at P<0.05 for two-tailed tests.
RESULTS
Demographics, environmental characteristics, and injury profiles of the study population
The study included a total of 132,698 pediatric patients who visited EDs on Jeju Island for injuries over a 10-year period. The age distribution showed a higher incidence of trauma in toddlers, accounting for 42.5% of the total cases (Fig. 1). The decade-long demographics, environmental characteristics, and injury profiles of the study population are summarized in Tables 1 and 2. A higher incidence of injury was observed in male patients across all pediatric age groups (male to female ratio, 1.7:1), and this trend increased with age. Visitor injuries accounted for 17.3% of cases, without age-specific variance. Seasonal fluctuations were minimal, with a slight uptick in summer; however, evenings had significantly higher injury incidence, especially during weekends, compared proportionally to weekdays. Clinically, the majority of pediatric patients were alert upon ED arrival (99.7%), with adolescents being the most likely to require EMS ambulance services (16.5%). The general preference was for arrival by private vehicle or on foot.
Flowchart of the study population. ED, emergency department; JISS, Jeju Injury Surveillance System.
Characteristics of host and environmental factors in pediatric trauma
Injury epidemiology in pediatric trauma
The home environment was the leading location of injuries, especially for infants, followed by schools and kindergartens, with a notable incidence among school-aged children. Streets and highways were also common injury sites, particularly for adolescents. Regarding activity at the time of injury, activities of daily living and leisure were the most common, with leisure activities peaking notably on weekends. Accidental injuries vastly outnumbered other intentions across all age groups. Incidence of assault and self-harm was low compared with other types of injury but presented a critical concern for adolescents. The leading mechanisms of injury were blunt/penetrating force (49.2%), slips/falls (22.0%), and motor vehicle collision (13.2%), collectively contributing to 84.4% of the overall injuries. The most common injury types were bruises/abrasions (50.1%), cut/open wounds (25.2%), and sprain/dislocation (13.8%), accounting for 89.1% of the pediatric cases.
The majority of pediatric injuries were not severe, with a high percentage resulting in discharge directly from the ED. A small but significant proportion of patients required hospitalization (4.2%), with a notably higher incidence in adolescents (7.4%), which may reflect more severe injuries in this group. Fatalities were rare, and overall crude mortality was 0.04%.
In visitors, the countryside (sea, river) was the leading geographic location for injuries, and leisure was the leading activity at the time of injury. The most common injury type was bruises/abrasions, and the leading mechanism of injury was blunt/penetrating injury (Supplementary Tables 1, 2). Specifically, in countryside (sea, river) injury, leisure was the leading activity at the time of injury. The most common injury type was bruises/abrasions, and the leading mechanism of injury was blunt/penetrating injury (Supplementary Tables 3, 4).
Epidemiological trends over 10 years
Fig. 2 shows the decade-long trends of pediatric injuries on Jeju Island, categorized as overall, accidental, self-harm/suicide, and assault/violence cases based on the intentionality of the injury. Overall, pediatric injuries showed an increasing trend, with a subtle yet steady rise in incidence rate per 100,000 people, as depicted by the LOWESS regression. Accidental injuries, which constituted the majority, initially surged and then reached a plateau. Incidences of self-harm and suicide, although less common, showed a notable increase over the years. Assault- and violence-related injuries, despite year-to-year variations, generally indicated an upward trend throughout the decade (Table 3).
The decade-long trends of pediatric injuries on Jeju Island, Korea, categorized by intentionality of the injury. (A) Overall pediatric injury cases. (B) Self-harm/suicide cases. (C) Accidental injury cases. (D) Assault/violence cases. LOWESS, locally weighted scatterplot smoothing; CI, confidence interval.
The age-adjusted incidence, hospitalization, and mortality rates of pediatric group and year of life lost
Fig. 3 shows age-specific trends in pediatric injuries, with a steady increase without sudden spikes in cases among infants. The injury rates in toddlers initially rose and then stabilized. Childhood injury incidences spiked early, followed by a decline, and adolescent cases consistently rose, underscoring the ongoing need for intervention strategies for older children. The annual change fluctuated by year, underscoring specific years that deviate significantly from the overall trend. The bars showed years with notable shifts, both increases and decreases in injury cases, indicating the effects of various external factors during those times.
The decade-long, age-specific trends of pediatric injuries on Jeju Island, Korea.(A) Infant injury cases. (B) Toddler injury cases. (C) Children injury cases. (D) Adolescent injury cases. LOWESS, locally weighted scatterplot smoothing; CI, confidence interval.
The hospitalization and mortality rates did not significantly change during the study period based on age distribution (Table 3). Furthermore, the mortality rate of pediatric injury by mechanism did not significantly change during the study period (Table 4). The incidence of pediatric injury in visitors was increased during the study period. Based on intentional pediatric injury, daily living activity injury, leisure injury (play, exercise, tour), and education-related injury were increased during the study period (Tables 4, 5). However, the hospitalization and mortality rates of pediatric injury based on intention did not significantly change during the study period (Table 5).
The age-adjusted incidence and mortality rates of injury mechanism in pediatric injury
The age-adjusted incidence and mortality rates of special groups in pediatric injury
DISCUSSION
We performed a retrospective, cross-sectional, observational study to investigate pediatric trauma patients who visited an ED on Jeju Island to analyze the characteristics and trends of pediatric trauma. Moreover, this study focused on a comprehensive epidemiological overview of pediatric trauma in Jeju.
The results confirmed that pediatric trauma occurred more frequently in male children, tended to significantly increase with age, and was likely due to differences in activities between boys and girls [3]. Because Jeju Island is visited by many tourists, the pediatric trauma experienced by visitors accounts for a large portion of the cases. Most of the patients visited the ED in the evening, and the incidence of pediatric trauma was significantly increased as the evening progressed because such cases cannot be treated in the outpatient clinic due to the increase in dual-income parents [4]. Furthermore, many cases of pediatric trauma were treated in the ED because the outpatient clinic was closed [8]. In the present study, most patients visited the ED without using an EMS ambulance and were discharged after ED treatment. Shanon et al. [1] reported that 94.7% of pediatric trauma patients who visited the ED were discharged after ED treatment, and only 4.0% of pediatric trauma patients were admitted for further treatment. You et al. [3] also reported that 94.6% of pediatric trauma patients who visited the ED were discharged after ED treatment. Therefore, the severity of pediatric trauma experienced by patients who visited the ED may be low.
In the present study, the most common location of injury was the home, followed by the countryside (sea, river). Lee et al. [9] also reported the most common place of pediatric injury to be the home, although that was followed by a road (small or general road). You et al. [3] also reported the most common place of pediatric injury in Korea to be the home, though the second most common location was a playground. The results showing the countryside (sea, river) as the second most common place of injury are unique to Jeju Island. Therefore, preventive programs for pediatric trauma injury in the countryside (sea, river) should be developed to reduce pediatric injury on Jeju Island.
Although most of the patients were injured during daily living activities, this proportion decreased with age. However, leisure (play, exercise, tour) injuries increased with age, likely due to increased performance of such activities as age increases. Furthermore, leisure-related injuries tended to increase over time. Physical activity including organized sports and leisure activity provides numerous benefits for health and well-being of children [10]. However, participating in physical activity is a major risk factor for unintentional injury and hospitalization in adolescents and children [6,7,11]. In a recent study, neuromuscular training reduced the risk of physical activity-related injury in organized sport [12]. Furthermore, the rate of leisure time physical activity injury was reduced when using protective equipment such as a helmet [13]. Therefore, to prevent leisure-related injuries, neuromuscular training and protective equipment may be effective. Supervision and continuous attention may also be needed during leisure activities.
In the present study, most of the pediatric trauma on Jeju Island was low-energy injury (blunt/laceration or slip/fall) or superficial injury (bruise/superficial injury or cut/open wound). Kang and Kim [2] also reported that most pediatric injuries of patients visiting the ED were superficial including abrasions or open wounds. Although protective equipment is beneficial in specific risk-prone activities, broader preventive measures such as enhancing supervision and public education regarding common hazards may be more appropriate and effective for reducing these types of injuries in general settings. Furthermore, safety strategies such as using handrails, keeping shoes tied, and not climbing on furniture and trees, could help reduce slip/fall injuries.
The fertility rate in Korea has rapidly decreased overtime, contributing to a decreased pediatric population. The fertility rate on Jeju Island has also decreased over time. However, the incidence of pediatric injuries on Jeju Island has increased over time. Therefore, effective preventive programs are necessary to manage the rapid increase of pediatric trauma on Jeju Island.
The proportion of visitor-related pediatric trauma tended to increase over time on Jeju Island. The number of tourists who visited Jeju Island during the study period increased, with an annual increase of approximately 10% [5]. Due to the increased number of tourists, the proportion of trauma tourists experienced also increased [5]. Ball and Machin [14] reported a higher risk of injury during leisure than of daily life. Therefore, systematic and strategic approaches are required to prevent travel-related injuries [5]. For visitors, the countryside (sea, river) was the major location for injuries, and leisure was the most frequent activity at the time of injury. The most common injury type was bruises/abrasions, and the leading mechanism of injury was blunt/penetrating injury. More specific education regarding leisure activity and protective equipment for superficial injuries is needed for visitors to prevent pediatric injury on Jeju Island.
The present study had several limitations. First, generalizing the results is difficult because the study population was identified from JISS. However, we investigated the characteristics and trends of pediatric trauma patients on Jeju Island. Second, because this study was performed retrospectively based on JISS data, there may be inaccurate classification due to insufficient records.
In conclusion, the incidence of pediatric injury on Jeju Island has increased over time. Therefore, this study underscores the crucial need for targeted injury prevention and resource allocation strategies, particularly for high-risk groups and time of injury, to effectively mitigate pediatric trauma on Jeju Island.
Notes
Author contributions
Conceptualization: CL, SWS, MO; Data curation: JHO, JRY, SYK, JHK, SKL; Formal analysis: WJ, GMS, HJL; Methodology: CHK, JHM, IS, HJY; Visualization: CHK, JHM, IS; Writing -original draft: CL; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
This work was supported by a research grant from Jeju National University Hospital in 2022.
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.
Supplementary material
Supplementary materials are available from https://doi.org/10.15441/ceem.24.203.
Supplementary Table 1.
Characteristics of host and environmental factors in visitors
Supplementary Table 2.
Injury epidemiology in visitors
Supplementary Table 3.
Characteristics of host and environmental factors in the countryside (sea, river)
Supplementary Table 4.
Injury epidemiology in the countryside (sea, river)
References
Article information Continued
Notes
Capsule Summary
What is already known
Pediatric trauma is a leading cause of death and injury among children, with an increasing incidence. These injuries occur in various places and during diverse activities, with characteristics changing over time.
What is new in the current study
This study identified key patterns in the incidence and nature of pediatric injuries, highlighting age group-specific trends and predominant injury types. Analysis showed a male predominance in trauma cases, primarily occurring as accidental injuries at home, with a significant increase during summer evenings and weekends. Trend analysis over the decade indicated a general increase in pediatric injuries, with specific patterns observed across age groups and injury types. Our study highlights the urgent need for targeted prevention and resource allocation to reduce high-risk pediatric injuries, particularly in identified settings and times at the community level.