Epidemiology of childhood injuries in Saudi Arabia: a scoping review

Injuries are the leading cause of morbidity and mortality worldwide [1]. According to the Global Burden of Disease (GBD) study, 973 million individuals suffer from injuries that require medical attention, and around 4.8 million die every year [2]. Childhood injuries are of particular concern. In 2011, more than 630,000 children died because of injuries [3]. In the United States, unintentional injuries were the leading cause of death in 2019 [4]. According to the Centers for Disease Control and Prevention (CDC), the leading cause of death from unintentional injuries was MVC followed by drowning, burns, and suffocation, whereas unintentional fall remains the most common cause for nonfatal injuries.

The burden of injuries is not limited to preventable deaths. Millions of children require hospitalization, and some endure lifelong disabilities that could negatively affect their stages of development. According to a report by the World Health Organization (WHO), loss of Disability-Adjusted Life Years (DALYs) worldwide is predicted to be primarily caused by MVC by 2030 [5]. Around 16.6% of loss DALYs among children in Saudi Arabia are due to injuries and of which 8.1% are due to MVC [6].

Injuries are not random events, but they are often associated with predictable factors. Age is associated with a higher risk of serious injury [7]. A previous systematic review suggested a bimodal distribution peaking at the two opposite age extremities [7]. Teenagers between 15 to 19 have an increased risk due to increased exposure to hazards and risk-taking behaviours. On the other hand, young infants are also at a high risk of injuries [7]. Gender also plays a role in the risk of fatal and nonfatal injuries among children [7]. Although males are at a higher risk for mortality due to all types of injury, the male to female ratio varies by the cause of injury. For example, motorcycle crashes, falls, and firearm-related deaths are ten times higher among males, while pedestrian-related deaths are only slightly greater among males [7, 8].

Child injuries are a public health concern for both high-income and low-income countries but more pronounced in countries undergoing extreme urbanization and industrialization [9, 10]. However, the risk of injury-related deaths is higher among low- and middle-income than high-income countries [11]. Children of low- and middle-income countries are exposed to more hostile environments; open fires, unstable construction sites, unprotected stairways, absence of safe play space, and lack of safe storage of chemicals [12]. Poverty is a risk factor for unintentional injuries even within high-income countries [13].

In Saudi Arabia, two injuries were ranked among the ten leading causes of death: transport injuries and unintentional injuries, according to the GBD [14]. The majority of preventable deaths in Saudi children (82.5%) were attributed to injuries [15]. The leading cause for injury mortality was MVC at 60.6% and was most commonly found among 13-18-year-olds, followed by drowning at 13.4% and most commonly found among 6-12-year-olds [15].

Approximately 31% of the Saudi population are children and adolescents [14]. Therefore, the consequences of injuries will have direct effects on population health. Despite that, limited and fragmented exploration of the burden of childhood injuries may negatively impact prevention. Further understanding of the epidemiology of child injuries will facilitate efforts in prevention and guide future research to understand the magnitude of the problem. Therefore, we aim in this review to describe the magnitude of childhood injuries, including the most common types and causes across gender and age groups in Saudi Arabia.

The initial search identified 3,384 studies. After screening titles and abstracts, 3,330 publications were excluded for being irrelevant or duplicates. The full text of 54 studies was assessed for eligibility, where 18 did not meet the inclusion criteria and were excluded. Thirty-six studies have met the inclusion criteria and were included in this scoping review (Fig. 1). In total, 20,136 participants were included. Of the total population, 13,890 were males (69%), and 5,596 were females (27.8%), while gender was not reported for 650 children (3.2%). Twenty-one studies were conducted in the central region - Riyadh, which accounts for the majority (58%) of the studies. As for the remaining studies, five were conducted in the eastern region, four, three, and one were conducted in the western region, Southern region, and Northern region, respectively. Two studies were conducted in several regions of the country.

Of the included publications, eleven studies explored overall injuries. Five studies focused on fractures, five on burns, four on MVC injuries, four on oral injuries, and seven examined poisoning. A visual summary of some of the studies’ findings is presented in Fig. 2. Based on the STROBE checklist, the quality of studies ranged from 5 to 19, with the majority scores being between 13 and 16 (Supplementary file 2). The most common missing items were the explanation of the study size, variables, handling quantitative variables, controlling for bias, and generalizability.

This scoping review suggests that falls and MVC are the leading causes of injuries in the kingdom. Similarly, a global study conducted in low-and middle-income countries found fall and MVC to be the most common mechanism of childhood injuries [53].

Many MVC injuries are preventable using evidence-based safety measures such as seatbelts, car seats, or helmets. However, they remain a neglected focus in the kingdom. In this respect, a study conducted in 2018 to assess the use of child restraint systems found that only one-third of the families reported having child restraint systems while only half of them were consistently using them [54]. Additionally, more than half of the families reported setting children on the passenger’s lap [54]. Therefore, further investment in public health interventions to reduce falls and MVC is warranted to reduce their burden on population health.

Our findings show that males represented most overall injuries, fractures, burns, MVC, and dental trauma. These results are consistent with the public data obtained from the CDC, stating that males accounted for 58.4% of unintentional injuries that occurred between 2001 and 2019 in the United States [55]. Likewise, in low- and middle-income countries, male children were more susceptible to injuries than females [53]. This gender disparity can be attributed to the greater risk-taking tendency in males [56]. Thus, gender-specific prevention strategies may help reduce the burden of associated injuries [57].

Although the mortality rate was relatively low, it may reflect the underlying resources for capturing injury data. However, the rate was exceptionally high among more critical cases such as ICU burns (25.3%) and head injuries (14.7%), followed by fractures (8.3%). Correspondingly, a study on childhood mortality in the eastern region showed that half of the deaths (51%) were attributed to accidents, with male children representing 69% of the cases [58]. In addition, the autopsy has revealed that head injury was the leading cause of death (27%) among the autopsied cases [58]. These are high rates, and national actions need to be undertaken to reduce them.

Primary prevention of injuries provides the best value and return on the outcome. The Child Safety Action Plan (CSAP) in European Union serves as an excellent example for tackling mortality resulting from childhood injuries [59]. This policy was first developed through assessing the situation with government engagement, followed by setting a vision, goals, and objectives, and finally implementing the best evidence-based practices that the government endorsed.

Our findings have some policy and public health implications, namely supporting the Saudi 2030 vision [60]. One of the pillars of this Vision is to extend life expectancy from 74 to 80 and improve quality of life. Our research describes the magnitude of the problem and highlights the need for intersectoral interventions. As the Vision focuses on preventing health risks, preventive interventions of childhood injuries, namely fall, and MVC need to be implemented. One of the Vision’s objectives is to promote traffic safety which could potentially aid in MVC prevention. Another implication is highlighting the need for investing in secondary prevention by dealing with injuries once they occur to reduce their consequences. A recent cross-sectional study found a low level of awareness about first aid to childhood injuries such as burns, drowning, and choking among 39% of Saudi parents [61]. However, most parents (78%) were willing to take a first aid class. This reinforces the need to implement sustainable awareness-raising strategies at the family level.

This is the first scoping review of the epidemiology of childhood injuries in Saudi Arabia to the best of our knowledge. However, we acknowledge that our review has several limitations. First, the lack of socioeconomic data may not reflect the variation of the prevalence and the mechanisms of injuries. Second, we were also unable to capture and generalize the age groups due to the missing continuous data and the inconsistency in age group classification across the studies. Third, most studies were retrospective chart review studies which can be more susceptible to bias. There is a significant need for population-based and longitudinal studies to provide more substantial evidence of the burden of injuries on population health of the kingdom. Fourth, except for one study, the primary focus of the included publications was unintentional injuries, which emphasizes the need to extend the current research in Saudi Arabia to nonaccidental childhood injuries. Finally, there was a substantial difference in publication rates across the regions of Saudi Arabia as more than half of the included studies were conducted in the central region-Riyadh, which affects the generalizability of our findings. This can be attributed to the presence of highly equipped trauma centers and research institutions in the region. Clearly, there is a disparity in our ability to capture the true burden in other regions accurately. Therefore, it is crucial to conduct further studies on the prevalence and magnitude of childhood injuries across all regions of Saudi Arabia while maintaining a high-quality research and reporting practices.

This review found that the leading causes and mechanisms of childhood injuries were falls and MVC. Unfortunately, all types of injuries resulted in substantial mortality rates, and there is a definite need for national action to be undertaken to reduce them. Overall, further research should be carried out to capture the determinants of childhood injuries across all regions of Saudi Arabia.