Introduction

Trauma is defined as the disruption of human tissues or organs caused by mechanical forces1. It encompasses a broad spectrum of external bodily injuries in children, including those resulting from road traffic accidents, falls, blunt forces, cuts, sprains, burns, and abuse, typically occurring unexpectedly. It is the leading cause of unintentional injury during childhood and a significant contributor to pediatric mortality2,3. Approximately 830,000 children die from unintentional injuries annually4. In the United States, approximately 22 million children, or one-third of the pediatric population, experience such injuries annually5. On average, approximately 6000 children (aged 0–14 years) die from injuries annually in the European Union6. In China, trauma accounts for 21.26% of pediatric injuries, with a mortality rate of 28.12 per 100,000 children7. Trauma has surpassed other diseases as the leading cause of death and morbidity among children and adolescents8, imposing a significant physical and psychological burden on the affected children and their families9,10.

The risk factors and characteristics of pediatric trauma vary between developed and developing countries, influenced by social resources and economic conditions. Consequently, the prevention and treatment strategies used by wealthy nations may not be applicable to less prosperous ones. Research suggests that up to 90% of trauma can be prevented through effective interventions11. Trauma is influenced by individual, familial, societal, and regional factors and exhibits regional peculiarities correlated with geographical and economic contexts. The causes of trauma also differ according to age, sex, and living environment12. Therefore, thoroughly understanding the factors contributing to pediatric trauma and meticulously analyzing the triggers and types of injuries are crucial for implementing more effective preventive measures, safeguarding children’s lives, and fostering a secure and harmonious environment conducive to their healthy development. The findings of this study may help guide prevention strategies aimed at reducing the incidence of accidental injuries among children in the Chinese mainland. This study aimed to examine the clinical data of pediatric patients admitted to our hospital’s intensive care unit (ICU) due to trauma over a 10-year period.

Methods

Participants

The inclusion criteria were as follows: (1) timeframe, January 1, 2009 to December 31, 2018; (2) age < 18 years; and (3) trauma resulting from falls, traffic incidents, machinery accidents, or other unintentional injuries, with the incident being the patient’s first traumatic experience.

The exclusion criteria were as follows: (1) intracranial injuries secondary to neurological disorders, such as spontaneous intracranial hemorrhage, brain tumors, and epilepsy; (2) pre-injury cardiac function classified as New York Heart Association Class II or higher, liver function categorized as Child–Pugh Class B or worse, or glomerular filtration rate < 90 mL/min; and (3) presence of congenital metabolic disorders. This article was prepared in accordance with the STROBE reporting checklist. This study adhered to the principles of the Declaration of Helsinki and was approved by the ethics committee of the Children’s Hospital affiliated with Zhejiang University School of Medicine (Hangzhou, China; approval number: 2024-IRB-0127-P-01). Given this study’s retrospective nature and minimal risk, the need for written informed consent was waived. The requirement for informed consent from the study subjects was waived by the IRB of the ethics committee of the Children’s Hospital affiliated with Zhejiang University School of Medicine due to the retrospective study design.

Data collection and statistical analyses

A retrospective analysis was conducted using data collection from pediatric patients with trauma admitted to our hospital’s intensive care unit (ICU) between January 1, 2009, and December 31, 2018. Data analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Statistical methodologies included general descriptive analyses and independent samples t-tests for comparing means from two separate groups. Statistical significance was set at P < 0.05.

Results

Characteristics and demographics of pediatric trauma cases

Over the 10-year period from January 1, 2009, to December 31, 2018, 951 pediatric patients aged 0–18 years were evaluated. They had a mean age of 4.79 ± 3.24 years and a mean weight of 18.45 ± 9.02 kg. Male and female participants accounted for 60.78% and 39.22% of the cohort, respectively. The majority of the patients were from rural areas (64.35%), while the smallest proportion was from urban locales (16.72%). Regarding residency status, local residents constituted the largest group (79.81%), whereas migrant workers represented the smallest proportion (20.19%).

By age group, children aged < 6 years were the most prevalent (70.77%), while those aged 12–18 years were the least represented (2.84%). The majority of injuries occurred on roadsides (49%), with the fewest occurring at schools (0.74%). Single-site injuries dominated (58.78%) over multiple-site injuries (41.22%). Head injuries being the most frequent (81.57%), followed by abdominal (6.08%), respiratory-lung (5.90%), pelvic (2.86%), limb (2.68%), spinal (0.54%), and arterial (0.37%) injuries.

Injury incidents peaked between 12 and 6 PM (44.48%) and were minimal from 12 to 6 AM (1.89%). The daily average of injuries was higher on non-workdays (18.82%) than on workdays (12.47%). Winter had the fewest injury cases (19.24%). Traffic accidents were the leading cause of injury (47.95%), while electric shock was the least common (0.11%). Regarding the types of traffic injuries, pedestrian-vehicle accidents comprised 87.72%, while motor-vehicle accidents comprised 12.28%. Detailed information is provided in Table 1.

Table 1 Demographic and Contextual Characteristics of Pediatric Patients with Trauma (n = 951).
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The mean time to ICU admission post-injury was 10.86 ± 14.95 h (IQR 6.00 [4.00,10.00]). Among the patients, 422 (44.4%) required emergency surgery and 466 (49%) needed mechanical ventilation (mean duration, 70.19 ± 146.62 h) (IQR 14.67 [4.60,72.50]). A total of 422 emergency surgeries were performed, with 289 procedures (68.48%) performed due to head injuries, 66 (15.64%) due to limb injuries, 39 (9.24%) due to abdominal injuries, 16 (3.79%) due to pelvic injuries, 7 (1.66%) due to lung injuries, 4 (0.95%) due to arterial injuries, and 1 (0.24%) due to spinal injuries. The mean ICU stay was 6.24 ± 8.01 days (IQR 4.00 [2.00,8.00]), and the overall hospital stay averaged 16.08 ± 15.56 days (IQR 12.00 [8.00,19.00]). At ICU admission, the mean injury severity score was 18.49 ± 8.86. Following active intervention, 871 patients (91.59%) showed improvement, while 80 (8.41%) succumbed to their injuries.

Different injury characteristics across various age groups

Significant differences were observed in sex and time of injury among age groups. Notably, the number of boys was significantly higher in the “6–12 years” age group compared to the “under 6 years” group (P < 0.05). Furthermore, there was a higher proportion of children injured during the “6–12 AM” period in the “under 6 years” group compared to the “6–12 years” group (P < 0.05) (Table 2).

Table 2 Distribution of Injury Characteristics Across Different Age Groups.
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Significant intergroup variations were also observed regarding injury causes, injury locations, and outcomes across different age groups (P < 0.05). Specifically, the proportion of children who experienced traffic injuries was higher in the “6–12 years” age group than in the “under 6 years” and “12–18 years” groups (P < 0.05). Regarding injury locations, a higher percentage of children in the “under 6 years” age group were injured at home compared to those in the “6–12 years” age group (P < 0.05). Conversely, fewer children in the “under 6 years” age group sustained injuries on roadsides than in the “6–12 years” age group (P < 0.05). Concerning outcomes, a higher proportion of children in both the “6–12 years” and “12–18 years” groups showed improvement than in the “under 6 years” group (P < 0.05). No significant differences (P > 0.05) were found in all other comparisons (Table 3).

Table 3 Injury Causes, Locations, and Outcomes across Age Groups.
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Distribution of injury types by sex, residence, identity, and outcomes

Upon analyzing the distribution of various injury causes, we found no significant differences across groups in terms of sex, place of residence, resident status, or outcome indicators (P > 0.05) (Table 4).

Table 4 Distribution of Injury Types by Sex, Residence, Identity, and Outcome.
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Discussion

To elucidate the epidemiological characteristics of childhood trauma, we conducted a retrospective analysis of pediatric patients with trauma admitted to our hospital’s ICU from January 1, 2009, to December 31, 2018. A total of 951 trauma cases were included, with a male-to-female ratio of 1.55:1, highlighting a slight predominance of boys among trauma victims; this finding is consistent with that reported in a previous study13. Further stratification analysis by age revealed a significantly higher proportion of boys in the “6–12 years” age group than in the “under 6 years” group. Boys are recognized as a high-risk group for accidental injuries, particularly those aged 6–12 years. This age group tends to be more energetic and curious, leading them to engage in behaviors that increase their risk of injury. This sex disparity in childhood injuries is a global phenomenon that intensifies with age.

Our findings were in agreement with existing literature14,15,16, with the majority of the injured children (673 cases, 70.77%) aged < 6 years. This prevalence aligns with developmental stages at this age17, where children aged < 6 years have limited environmental awareness and motor skills, coupled with an inadequate understanding of danger, necessitating close supervision14. As children mature, improved abilities reduce trauma incidence18. Infants, unable to communicate and reliant on caregivers for their needs, are at an increased risk of traffic accidents, falls, and burns/scalds. Consequently, developmental characteristics pertinent to pediatric trauma should inform prevention strategies and be integral to all injury prevention initiatives.

In our study, traffic accidents emerged as the leading cause of trauma, followed by falls, burns/scalds, blast injuries, penetrating injuries, animal attacks, and electrical injuries. Consistently, road traffic accidents are the primary cause of unintentional deaths among children aged 0–14 years in developed countries19,20. Notably, within our sample, the age group “6–12 years” exhibited a higher incidence of traffic-related injuries compared to the “under 6 years” and “12–18 years” groups. Children aged 6–12 years transitioning from kindergarten to primary school have more activities, heightened curiosity, weaker self-control, and insufficient understanding of traffic safety. Since the early 1990s, alongside improved living standards in China, there has been an increase in vehicle production, consequently leading to a rise in traffic injury-related mortality and morbidity rates21. This study analyzed the types of traffic injuries, finding that pedestrian-vehicle accidents accounted for 87.72%, while motor-vehicle accidents represented 12.28%. To mitigate traffic injuries, recurrent training for drivers on relevant regulations and raising public awareness are imperative. Additionally, traffic authorities and educational institutions should enhance traffic management and increase education on child traffic safety to elevate the awareness of children’s safety. A previous study suggested that high fatality rates from traffic injuries in China may be related to the low usage of child safety seats and seat belts22. In China, it is common practice for adults to hold infants in the front passenger seat, exposing them to direct airbag impact in accidents. Therefore, the current traffic laws emphasize the use of child safety seats and seat belts in vehicles23,24. Falls, ranking second to traffic injuries, mainly occur in children due to accidents, while in adults, intentional falls, such as suicides, are more common25. Factors contributing to pediatric falls include an increased incidence of high-rise living, lack of protective barriers around balconies, windows, and staircases, and children’s curiosity-driven risky behaviors, such as climbing26. Installing guardrails on balconies and windows in high-rise apartments, placing carpets to soften falls, and rounding furniture edges can help reduce the risk of injuries. Additionally, enhancing children’s motor skills through supervised climbing and tumbling exercises can minimize falling risks.

Regarding injury etiology, burn/scald injuries, blast injuries, penetrating injuries, animal attacks, and electrical injuries exhibit clear regional characteristics, with a significantly higher incidence observed among children residing in rural or peri-urban areas than among those residing in urban areas. Tailored intervention strategies can be formulated by compiling pediatric trauma data and understanding its epidemiological features27. Effective preventive guidance is derived from comprehensive datasets detailing injuries, which illuminate the shifting risks children encounter throughout their development. Some evidence suggests that burns are the second most common cause of unintentional childhood injuries28. In our study, burn/scald injuries ranked third after traffic accidents and falls. The lower rate of ICU admission due to burns/scalds compared to traffic injuries and falls reflects the typical nature of pediatric burns, which are often caused by hot water at home rather than by fires or chemicals. Childhood burns/scalds are influenced by various factors, including age, sex, environment, behavior, and parents’ socioeconomic status and education levels. Cumulative evidence suggests that 90% of pediatric burns/scalds occur within the home, underscoring the importance of proper first-aid knowledge in such scenarios29. Our findings revealed that the top three injury locations were roadsides (466 cases, 49%), homes (403 cases, 42.4%), and public places (66 cases, 6.9%). The “under 6 years” group sustained more injuries at home than the “6–12 years” group while experiencing fewer injuries on roadsides than the “6–12 years” group, aligning with the discussed causes of injuries in children. Hence, reinforcing traffic safety awareness, enhancing child supervision, and broadly disseminating safety education are of utmost importance.

Our analysis of the timing of injuries found that 423 cases (44.5%) occurred between 12 and 6 PM. Additionally, Saturdays (96 cases, 20.6%) and Sundays (162 cases, 17.0%) showed significantly higher incidences than weekdays, indicating a heightened rate of trauma during non-working days. This may be related to patterns of human activity, with children engaging in more outdoor activities or sports during the period from 12 to 6 PM. This is likely because non-working days involve more outings and activities, increasing the risk of accidents. Particularly on weekends, there are more family gatherings and outdoor activities, which contribute to a higher incidence of trauma in children on non-working days. Seasonally, winter showed a relatively lower trauma incidence, likely due to reduced outdoor activities in colder weather. Notably, among children aged 12–18 years, a higher likelihood of trauma was observed from June through August, coinciding with the nearly 2-month-long summer vacations. During this period, children aged ≥ 12 years gain more independence in mobility, highlighting the imperative for intensified safety education during these months.

Among the 951 pediatric patients, “single-site injuries” (58.78%) were more prevalent than “multiple-site injuries” (41.22%), with head injuries constituting the primary type among single-site trauma (81.57%), followed by abdominal and thoracic injuries. Cranio-cerebral trauma, a common and critical condition in emergency medicine30,31,32, encompasses various forms such as epidural hematomas, subdural hematomas, traumatic subarachnoid hemorrhages, and severe cerebral contusions. These conditions necessitate prompt intervention due to their severity, high mortality rates, and potential for disability33,34. In the United States, approximately 500,000 children annually present to emergency departments for head injuries, resulting in approximately 7000 fatalities35. In our study, 422 patients (44.4%) underwent emergency surgical intervention. Of these, 289 (68.48%) were due to head injuries. Trauma can lead to various complications, with respiratory failure being the most frequent36. Notably, in our study cohort, 466 patients (49%) required mechanical ventilation, with an average duration of 70.19 ± 146.62 h, indicating that invasive ventilation complications significantly impact the duration of ICU stays37.

The incidence of pediatric trauma is intricately linked to economic, cultural, behavioral, and living conditions16,38,39. Furthermore, studies in developing countries have identified inadequate supervision, lower safety standards of household items, insufficient public safety warnings, and uneven road surfaces as risk factors for pediatric trauma40,41. These issues necessitate a more comprehensive investigation to better understand the myriad causes of pediatric injuries in low- and middle-income nations42,43. Prior research has demonstrated distinct geographic and demographic patterns in childhood trauma incidence. Our study also observed differences in injury types and causes among children residing in urban, suburban-rural fringe, and rural areas, noting a lower incidence in urban and suburban-rural fringe areas than rural locales. Despite China’s rapid economic progress, which has narrowed the urban–rural gap, the trauma incidence remains disproportionately high in rural areas. Another report highlights that left-behind children (those residing in rural China while their parents work in cities, typically cared for by extended family members such as grandparents or other close relatives) face a significantly higher risk of injury than their urban counterparts44.

This study, confined to a single-center retrospective summary over nearly a decade, inherently limits its scope in comprehensively depicting the characteristics of trauma. Expanding to a nationwide, multicenter, prospective investigation encompassing diverse geographic regions would provide a broader perspective, enabling a deeper understanding of the current state of trauma in China. Such an endeavor would provide a more nuanced picture of trauma epidemiology and illuminate the effectiveness of educational campaigns, policy improvements, and other preventive measures in mitigating the burden of trauma across the country.

Pediatric trauma constitutes a major public health concern, representing a substantial proportion of unintentional injuries and exhibiting an alarming upward trend in recent years45. Traffic injuries are the primary cause of pediatric trauma, underscoring the importance of appropriate utilization of child restraint systems and protective equipment in prevention efforts. The increased vulnerability of children aged < 6 years and those residing in rural areas, with correspondingly higher injury rates, highlights the pressing need for targeted preventive strategies and public policies tailored to these high-risk demographics. A more thorough comprehension of the characteristics of pediatric trauma can facilitate enhanced public awareness campaigns and educational initiatives, leading to more efficacious prevention measures. Increased transportation times to urban medical facilities and less advanced emergency care in rural regions contribute to this discrepancy. In rural areas, traffic restrictions can lead to prolonged transit times for children needing medical attention in urban centers, thereby delaying access to optimal interventions. Moreover, the relative inadequacy of local emergency response facilities and technological capabilities further contributes to this disparity. A previous study documented that the establishment of trauma systems can reduce mortality rates by 15%46, emphasizing the imperative to strengthen rural healthcare systems and capabilities. Efforts must focus on enhancing medical institutions’ capacity to provide advanced care for injured children and ensuring efficient patient transfer. Collaborative efforts are needed to mitigate the multifaceted physiological and psychological impacts that trauma inflicts upon these young patients.

Conclusions

In this study, we found that traffic injuries, followed closely by falls, were the main cause of pediatric trauma leading to ICU admission. Children aged < 6 years were most commonly affected by trauma incidents, with boys experiencing a higher incidence. Moreover, rural regions showed a heightened occurrence of pediatric trauma compared to urban areas. Traumatic injuries primarily involved head trauma and multiple complex injuries, with non-working days and the afternoon hours between 12 and 6 PM marking the peak periods for such incidents.