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A longitudinal study on quality of life after injury in children Schneeberg, Amy; Ishikawa, Takuro; Kruse, Sami; Zallen, Erica; Mitton, Craig; Bettinger, Julie A; Brussoni, Mariana Aug 26, 2016

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RESEARCH Open AccessA longitudinal study on quality of life afterinjury in childrenAmy Schneeberg1,2,3, Takuro Ishikawa2,3, Sami Kruse3, Erica Zallen3, Craig Mitton1, Julie A. Bettinger3,4,5and Mariana Brussoni1,2,3,4*Schneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 DOI 10.1186/s12955-016-0523-6Vancouver, BC V6H 3 V4, CanadaFull list of author information is available at the end of the article1School of Population & Public Health, University of British Columbia,Vancouver, BC, Canada2British Columbia Injury Research & Prevention Unit, F508 – 4480 Oak Street,* Correspondence: mbrussoni@cfri.ubc.caAbstractBackground: In high income countries, injuries account for 40 % of all child deaths, representing the leading causeof child mortality and a major source of morbidity. The need for studies across age groups, and use of health relatedquality of life measures that assess functional limitations in multiple health domains, with sampling at specific post-injurytime points has been identified. The objective of this study was to describe the impact of childhood injury and recoveryon health related quality of life (HRQoL) for the 12 months after injury.Methods: In this prospective cohort study parents of children 0-16 years old attending British Columbia Children’sHospital for an injury were surveyed over 12 months post-injury. Surveys assessed HRQoL at four points: baseline(pre-injury), one month, four to six months and 12 months post injury. Generalized estimating equation modelsidentified factors associated with changes in HRQoL over time.Results: A total of 256 baseline surveys were completed. Response rates for follow-ups at one, four and twelvemonths were 74 % (186), 67 % (169) and 64 % (161), respectively. The mean age of participants was 7.9 years and30 % were admitted to the hospital. At baseline, a retrospective measure of pre-injury health, the mean HRQoLscore was 90.7. Mean HRQoL ratings at one, four and 12 months post injury were 77.8, 90.3 and 91.3, respectively.Both being older and being hospitalized were associated with a steeper slope to recovery.Conclusions: Although injuries are prevalent, the long term impacts of most childhood injuries are limited. Regardlessof injury severity, most injured children recuperated quickly, and had regained total baseline status by four monthpost-injury. However, although hospitalization did not appear to impact long term psychosocial recovery, at fourand 12 months post injury a greater proportion of hospitalized children continued to have depressed physicalHRQoL scores. Both older and hospitalized children reported greater impact to HRQoL at one month post injury,and both had a steeper slope to recovery and were on par with their peers by four month.Keywords: Pediatrics, Unintentional injury, Health related quality of lifeAbbreviations: BC, British Columbia; BCCH, British Columbia children’s hospital; ED, Emergency department;GEE, Generalized estimating equation; HRQoL, Health related quality of life; PaedCTAS, Pediatric Canadian triageand acuity scale; PedsQL™, Pediatric quality of life questionnaire© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Schneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 2 of 11BackgroundInjuries account for 40 % of all child deaths in high-income countries, representing the leading cause of childmortality and a major source of morbidity [1]. In theUnited States, each year more than 9,000 children aged 19and under die from unintentional injuries, and another225,000 are hospitalized [2]. Although indicative of theenormous public health problem that injuries comprise,mortality and hospitalization statistics are inadequate tofully understand the burden of injury.The World Health Organization’s definition of health in-cludes physical, mental and social dimensions [3]. Whilephysiologic measures of injury severity are important to cli-nicians, measures of functional capacity and wellbeing canbe of greater importance to individuals [4]. Measuringhealth related quality of life (HRQoL) after injury facilitatesquantifying the impact on multiple dimensions of healthand the recovery process. As a multidimensional, patientcentered outcome, HRQoL measures encompass a widerange of experiences to given health states, including phys-ical and psychosocial function as well as spiritual wellbeing[5]. It is important to identify potential long-term impactof injuries on HRQoL in order to provide timely and on-going support. Research following child injury on psycho-logical outcomes, is currently investigating predictors andearly intervention strategies, and the present study canhelp build towards these interventions [6–8].Studies examining HRQoL after injuries in adult popu-lations have found that the impacts of injury can vary intime and extent, and that injury severity is not the onlypredictive factor [9]. These studies typically focus on pa-tients with severe injuries, limiting our understanding ofoutcomes for the majority of injuries which do not resultin death or severe disability [10]. It has been estimatedthat for every individual who dies from an unintentionalinjury, there are approximately six other individuals whoare hospitalized, 45 individuals with emergency depart-ment (ED) visits and 48 individuals with visits to primaryhealthcare providers [11]. Thus, it is important to con-sider the impact less severe injuries may have given thehealth care burden they represent.Study methods used to assess post injury HRQoL varywidely with respect to sample population, measurementinstruments used, and timing of measurements, and theyrarely include a baseline HRQoL measurement for com-parison to pre-injury state [10]. Further, studies withpediatric samples are rare despite the fact that the im-pact of childhood injuries can differ substantially fromadults [9, 10]. Therefore, studies across age groups, anduse of HRQoL measures that assess functional limita-tions in multiple health domains, with sampling at spe-cific post-injury time points are needed [10]. Pediatricstudies using generic measures of HRQoL with baselinemeasurements of health and wellbeing are required tounderstand the impact injuries have on this uniquepopulation. Available studies have found that the impactof injuries on HRQoL can extend well into the yearfollowing treatment. One study that examined the healthstatus of children in the six months following admissionto hospital for injury found that general health percep-tions, physical functioning, social and physical roles,behavior, parental impact including emotional and familyactivities all remained lower at discharge, one month,and six months post-injury relative to a population ofhealthy children [12]. Although this study demonstratedthat the impact of injuries can remain at six months posthospital admission for both the child and parents, theydid not explore less severe injuries not requiring admis-sion to hospital, nor did they explore factors, outside ofseverity, that may be used to predict depressed physicaland emotional functioning. Other studies that included lesssevere injuries not requiring hospitalization, have foundthat a small proportion (8 %) of children still reportedfunctional limitations at nine months post injury and thatsome injured children had depressed HRQoL scores up totwo years post injury [13, 14], however these studies ex-cluded very young children (< 5 years of age).There are gaps in the literature regarding the immediateand long-term impacts of injury and recovery, particularlyin pediatric populations. The objective of this research isto better understand the impact of a broad spectrum ofchildhood injuries of varying severity on HRQoL and toidentify demographic and diagnostic variables associatedwith a significant relationship with HRQoL.MethodsStudy populationThis study collected data longitudinally from a sample ofparents of children aged 0 to 16 years who presented witha primary injury diagnosis at the British Columbia Chil-dren’s Hospital (BCCH) ED or were admitted to the hos-pital wards between February 2011 and December 2013.For children 0 to 5 years old, only parents completed sur-veys. For all other ages, both children and parents com-pleted surveys. For consistency, the present paper presentsonly parents’ reports for all participants.Data collectionA research assistant recruited directly from the ED andhospital wards on different days of the week and times ofday. In addition, real time hospital admissions data werereviewed twice daily during regular office hours to identifychildren presenting with injury for study recruitment. Be-cause most medically attended visits for injuries do not re-sult in hospitalization, injuries requiring hospitalizationwere proportionately over-sampled to ensure a mix of pa-tients with injuries of varying severity. Thirty percent ofthe study sample was hospitalized relative to only 10 % ofthe population of all children presenting to the hospitalwith an injury.Before approaching parents in hospital wards, researchersgained permission from the nurse or physician responsiblefor the child’s care. In the ED, parents were approached inwaiting rooms, after triage confirmed that the primary rea-son for the visit was injury. All participants gave writtenconsent. Parents who did not speak English or did not havean address in British Columbia (BC) were excluded fromthe sample. Twenty four parents indicated their child suf-fered from a disability or long-term health problem beforethe injury. Since these children had relatively rare condi-tions that can increase risk of injury and hospitalizationtheir parents’ data were excluded from analysis. While wedid not begin the study deliberately excluding intentionalinjuries (e.g., self-harm, assaults), we recognized that therewould be different impacts on HRQoL. Only three partici-pants with intentional injuries agreed to participate, whichwas insufficient for meaningful analysis, thus, they wereexcluded from the analyses reported herein. See Fig. 1 for aflowchart outlining participant disposition. This study wasreviewed and approved by the University of BritishColumbia/Children’s and Women’s Health Centre of BritishColumbia Research Ethics Board.A study specific survey instrument incorporating thePediatric Quality of Life Questionnaire (PedsQL™) wasadministered to parents/guardians at baseline and one,four and 12 months post injury, as per guidelines out-lined by van Beeck et al. [10]. At baseline, PedsQL™ wasassessed as a retrospective measure of pre-injury healthand asked about the child’s HRQoL in the month prior toinjury. The questionnaire was piloted among a sample of10 parents to ensure clarity and comprehension. Compo-nents of the questionnaire had previously been validated(the PedsQL [15, 16]) however, validity and reliability werenot measured for questions related to demographics andthe circumstances of the injury. Parents could complete ahard copy of the questionnaire and return in a stampedself-addressed envelope, or through an online link. Re-search shows, mode of administration (pen and paper, on-line or telephone) does not influence scores [17]. At thetime of recruitment and with each subsequent follow-up,Schneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 3 of 11Fig. 1 Study population dispositionSchneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 4 of 11parents were offered a $2 gift card to a local coffee andpastries merchant for participating in the study, irrespec-tive of whether they completed the survey or not.Descriptive variablesAt baseline, the survey instrument included questionsabout the circumstances around the injury and demo-graphic information including the child’s age, and sex.Hospital records were used to determine each child’slength of hospitalization Pediatric Canadian Triage andAcuity Scale (PaedCTAS) score. The PaedCTAS is a scaleused to triage patients based on urgency. PaedCTAS hasfive ordinal categories ranging from 1 (requires resuscita-tion) to 5 (non-urgent), and it is assigned to all childrenpresenting in Canadian EDs [18]. This score can be usedto predict the nature and scope of care that is likely to berequired. The scoring is highly standardized, as nursesassigning the score receive continuous training. BothPaedCTAS score and hospitalization status were used asindependent proxies of injury severity. Research indicatesthe utility of the PaedCTAS as an alternate proxy of injuryseverity that is not as sensitive to extraneous factors thatcan influence hospitalization status [19]. Participants’ pos-tal codes were used to derive a measure of socioeconomicstatus (neighbourhood income quintiles) using StatisticsCanada’s Postal Code Conversion File Plus [20].Health related quality of lifeThe PedsQL™ 4.0 Generic Core and the PedsQL™ InfantScales were developed to assess HRQoL in children, ages 2to 18 years and 0 to 24 months, respectively. The PedsQL™4.0 Generic Core is a 23 item scale and includes four sub-scales: physical functioning, emotional functioning, socialfunctioning and school functioning [21]. The PedsQL™ In-fant Scale is an instrument composed of 45 items and fivesubscales: physical functioning, physical symptoms, emo-tional functioning, social functioning and cognitive func-tioning [22]. Both PedsQL™ instruments use a five pointLikert response scale ranging from “never” to “almostalways” to assess the extent to which different items haveaffected the child in the previous month. For both mea-sures, individual item scores have been obtained by reversescoring items and linearly transforming them to a scale of0 to 100, with 100 representing perfect health. Total scoreshave been obtained by adding the sum of items and divid-ing them by the number of items answered. Studies thathave reviewed tools for the purpose of long-term follow-upand assessing outcomes in pediatric trauma populationshave identified the PedsQL™ as one of very few that is ap-propriate for a large age range that also has robust psycho-metric properties [22, 23]. A difference of 4.5 for parentproxy have been previously established as the minimal cli-nically meaningful difference for this tool [24]. To betterunderstand the true burden of injury overtime both themean HRQoL score at each time point, as well as the pro-portion of children who continue to report depressedHRQoL scores at each time point (prevalence of outstan-ding impact) has been investigated.Statistical analysisLogistic regression was used to compare the final analyticsample, the children for whom at least one follow-up sur-vey was available (n = 204), to the entire sample of chil-dren presenting with injury to BCCH wards or ED duringthe study period using administrative data obtained fromBCCH. BCCH administrative data included postal code,sex, age, length of stay and hospitalization status. StatisticsCanada’s Postal Code Conversion File Plus was used to as-sign neighbourhood income quintiles.The HRQoL of study participants at baseline and follow-up points was measured using parent response to PedsQL™.The relationship between PedsQL™ score at each time pointand demographic and injury related variables was exploredusing bivariable linear regression. To determine the propor-tion of children who continued to have depressed HRQoLscores relative to baseline, the “prevalence of outstandingimpact”, on overall HRQoL as well as the physical and psy-chosocial domains independently at each time point, wasdefined as having a score that was at least 1 standard de-viation of the baseline mean below the individual’s baselinescore. The relationship between the prevalence of outstand-ing impact on HRQoL and injury severity was explored byinvestigating the relationship between “prevalence of im-paired HRQoL” and hospitalization status and PaedCTASscores using chi-square or Fisher’s exact tests, as appro-priate. A Bonferroni correction was applied to determinethe alpha used for statistical significance to account formultiple comparisons.Bivariable associations between demographic and in-jury related variables were investigated with chi squaretests for categorical comparisons and t-tests or ANOVAfor continuous (age) variables. If variables were identi-fied to be potentially collinear (p < 0.10) the variable witha stronger crude relationship with recovery in HRQoLover time was brought forward for model building.Bivariable generalized estimating equation (GEE) modelsusing an exchangeable covariance matrix were built toexplore the crude impact of demographic and injury re-lated variables on HRQoL. To explore the impact of in-dependent variables on recovery overtime an interactionterm with time was included in all models. For the pur-pose of model building PaedCTAS scores were collapsedinto 3 categories, PaedCTAS 1 and 2, 3 and 4 and 5, be-cause there were not enough cases in the highest andlowest categories. A multivariable GEE model was builtincluding all variables identified to be statistically orconceptually important. The model was run with all ob-servations in the analytic sample (n = 204). Finally, aSchneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 5 of 11sensitivity analysis was run to assess the impact of exclu-sions due to missing data on our results. The meanHRQoL scores for the analytic sample at each time pointwere compared to the mean scores of the entire popula-tion of children who returned any data over the studyperiod and no clinically or statistically significant diffe-rences were identified (results not shown).ResultsStudy populationAfter exclusions there were 256 baseline surveys; ofthose individuals 204 returned at least one follow-upsurvey, making up the analytic sample. Table 1 providesdemographic and injury information for study partici-pants included in the analytic sample and a comparisonof participants with complete data to those lost tofollow-up. The analytic sample was not statistically sig-nificantly different than the sample of children whoreturned a baseline survey on any of the demographic ofinjury related variables collected (results not shown).Also, the analytic sample was not statistically differentthan the broader population of all injured children basedon sex or age, however the children in our sample hadhigher odds of being hospitalized (a result of purposefulsampling) and lower odds of being in the lowest 2 in-come quintiles relative to all injured children presentingat the hospital during the study period (Table 2).The mean age of analytic sample was 7.9 years, 62.3 %were male, and 89 % of respondents indicated English wasthe primary, or one of the primary languages spoken athome. Almost 30 % of participants were hospitalized fortheir injuries. The median length of stay for children whowere hospitalized was 2.7 days, ranging from < 1 day to43 days, with 40 % being hospitalized for 2 days or less.The majority of children included in this study were pre-viously healthy with 87 % of parents indicating that theirchild had zero days of ill health in the four weeks prece-ding the injury. Most parents indicated their child wasparticipating in leisure/entertainment activities (32 %), orsports/exercise either at school or at a club/gym (31 %) atthe time of injury.Table 3 presents HRQoL for participants based onPedsQL™ summary scores as reported by parents at eachtime point stratified by demographic and injury-relatedvariables. The mean baseline total HRQoL score (repre-senting pre-injury health) of participants was 90.66 (95 %CI (89.4, 91.9)). At one month the mean total health scoredropped to 77.8 (95 % CI (75.2, 80.4)), by four months thismean returned to almost that of pre injury status (90.3(88.9, 91.8)) and by 12 months the mean score was equalto pre injury status (91.3 (89.8, 92.8)). None of the demo-graphic or injury related variables were statistically signifi-cantly associated with baseline or twelve month HRQoLsummary scores. At one-month post injury having beenhospitalized, having a lower PaedCTAS score and beingover the age of 8 were all significantly associated withlower HRQoL summary scores (p < 0.001 due to Bonfer-roni correction). These relationships were no longer evi-dent at four months post injury, except for age.At 12 months post injury the prevalence of outstan-ding impact on total HRQoL was 8 %, 10 % and 9 % forthe total summary score, physical and psychosocial do-mains respectively (Table 4). No injury or demographicvariables were associated with the prevalence of out-standing HRQoL impact overall at 12 months.Table 5 presents the results of the GEE model examin-ing predictors of HRQoL over time (from 1-12 months)the QICu of the model with only time was 98 146 andthe model with all covariates the QICu was 72 322. Themodel demonstrates that the only significant modifiersof HRQoL recovery following injury, after controlling forbaseline HRQoL, were age and hospitalization status.Children who were hospitalized had a steeper slope torecovery as demonstrated by the fact that despite havinglower HRQoL at one month post injury relative to chil-dren who were not hospitalized, HRQoL for both hospi-talized and un-hospitalized children returned to baselineby four months post injury (Fig. 2). The parameter estimatefor the adjusted model from Table 5 for the hospitalizationand time interaction term can be interpreted as follows:during the time from 1-12 months post injury, in a onemonth period the average change in HRQoL score for chil-dren who were not hospitalized was 0.93 points less thanchildren who were hospitalized controlling for baselineHRQoL, age, sex and PaedCTAS. Likewise, relative to chil-dren who were one year younger, older children experi-enced a 0.07 point greater increase in their HRQoL scorein a month period, or the slope of HRQoL over time forchildren who were one year older was found to be 0.07steeper than that of younger children.Although injury severity, as measured by hospitalization,increased the rate of recovery, it did not impact the stateof recovery (a child’s HRQoL score at a given timepoint)beyond one month post injury. The mean HRQoL scorefor children who were hospitalized was significantly lowerthan those who presented to ED at one month post injury(65.9 vs 82.6, p <0.001) however this difference was nolonger evident at four or 12 months (Table 3). Likewisechildren with lower PaedCTAS scores had significantlylower HRQoL scores one month post injury, a differencethat again disappeared by four and 12 months. Whenbroken down into psychosocial and physical componentsof HRQoL however, we found that a greater proportionof children who were hospitalized continued to havediminished scores for the physical component of theHRQoL measurement through to 12 months post in-jury (16.7 % of hospitalized children vs 7.6 % of chil-dren presenting to ED, p = 0.05) although there was notSchneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 6 of 11Table 1 Baseline characteristicsa significant difference in the psychosocial domain ofHRQoL at four or 12 months between these two groups(Table 4).AttritionTotal n = 204 12 Month ComBaseline HRQoLMean (SD) 90.7 (±8.9) 91.3 (±8.3)Hospitalization Status n (%)Emergency Department 144 (70.6) 108 (72.5)Hospitalized 60 (29.4) 41 (27.5)Length of Stay (days)Median (25 %, 75 %) 2.7 (1.5, 6.8) 2.5 (1.5, 5.0)Range 0.2 – 43.4 0.2 – 14.9Sex n (%)Male 127 (62.3) 96 (64.4)Female 77 (37.7) 53 (35.6)Age (years)Median (25 %, 75 %) 7.1 (3.6, 11.7) 7.3 (3.7, 11.9)Range 0.1 - 16.9 0.3 – 16.9Age Category n (%)0 – 5 years 84 (41.2) 62 (41.6)6 – 10 year 66 (32.4) 46 (30.9)11 -16 years 54 (26.5) 41 (27.5)PaedCTAS n (%)1 (requires resuscitation) 11 (5.4) 8 (5.4)2 38 (18.6) 28 (18.8)3 43 (21.1) 30 (20.1)4 104 (51.0) 76 (51.0)5 (non-urgent) 8 (3.9) 7 (4.7)Income Quintile n (%)1 (lowest income quintile) 25 (12.3) 12 (8.1)2 25 (12.3) 16 (10.7)3 43 (21.1) 37 (24.8)4 39 (19.1) 28 (18.8)5 (highest income quintile) 72 (35.3) 56 (37.6)Injury TypeHead injury 18 (8.8) 12 (8.1)Lower extremity fracture 25 (12.3) 15 (10.1)Major trauma 16 (7.8) 13 (8.8)Minor external injury 77 (37.7) 57 (38.5)Upper extremity fracture 49 (24.0) 41 (27.7)Otherb 18 (9) 10 (6.8)Missing 1 (0.5) 1 (1.0)aOR from logistic regression, odds of returning 12 month surveybCategories with cell size < 5 were collapsed into, other this category includes Majoorgan injury, Spinal fractureDiscussionIn accordance with previous work [13, 25], we found thatmost children’s summary HRQoL score had returned toplete n = 149 Lost to Follow-Up n = 55 ORa (95 % CI)89.0 (±10.3) 1.0 (0.9, 1.1)35 (66.0) 0.7 (0.4, 1.4)20 (34.0)3.8 (1.8, 10.6) 0.9 (0.8, 1.0)0.2 – 43.431 (56.4) 1.4 (0.7, 2.6)24 (43.6) Ref6.8 (3.0, 11.6) 1.0 (0.9, 1.1)0.1 – 16.622 (40.0) 0.9 (0.4, 2.0)20 (36.4) 0.7 (0.3, 1.6)13 (23.6) Ref3 (5.5) 0.4 (0.0, 4.6)10 (18.2) 0.4 (0.0, 3.7)13 (23.6) 0.3 (0.0, 3.0)28 (50.9) 0.4 (0.0, 3.3)1 (1.8) Ref13 (23.6) 0.3 (0.1, 0.7)9 (16.4) 0.5 (0.2, 1.4)6 (10.9) 1.8 (0.6, 4.9)11 (20.0) 0.7 (0.3, 1.8)16 (29.1) Ref6 (11.3) 1.2 (0.3, 4.9)10 (18.9) 0.9 (0.3, 3.3)3 (5.7) 2.6 (0.5, 13.0)20 (37.7) 1.7 (0.6, 5.3)8 (15.1) 3.1 (0.9, 10.9)6 (11.3) Ref2 (2.3)r Burn, Hand or foot amputation, Head Trauma, Ingestion/chocking, InternalSchneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 7 of 11within one standard deviation of baseline by fourmonths post injury. Hospitalization status and age werethe only variables associated with a significant changein the rate of recovery, with children who were admit-ted and older children having a faster rate (steeperslope) to recovery relative to those who were seen inthe ED and younger children. This finding demon-strates that children with greater impact on HRQoL atone month post injury (those hospitalized and olderchildren) recover at an accelerated rate and by fourmonths post injury there is no difference in HRQoLimpact relative to their ED and younger peers. Hospi-Table 2 Study population compared to all children presentingto hospital with injury during study periodStudy population All injuries OR (95 % CI)Sex n (%)Male 127 (62.3) 8156 (58.3) refFemale 77 (37.8) 5825 (41.7) 1.2 (0.9, 1.6)Income Quintile n (%)1(lowest income quintile) 25 (12.3) 2,744 (19.8) 0.4 (0.3, 0.7)2 25 (12.3) 2,598 (18.8) 0.4 (0.3, 0.7)3 43 (21.1) 2,607 (18.9) 0.8 (0.5, 1.1)4 39 (19.1) 2,586 (18.9) 0.7 (0.5, 1.0)5(hightest income quintile) 72 (35.3) 3,305 (23.9) refHospitalized n (%)ED 144 (70.6) 12,419 (88.8) refAdmitted 60 (29.4) 1,562 (11.2) 3.3 (2.4, 4.5)Age (Mean ± SD)(range 0 – < 17 years)7.87 ± 4.67 7.32 ± 5.02 1.0 (1.0. 1.1)talized children may have experienced a greater impacton HRQoL at one month relative to children seen inthe ED due to time away from school/peers, and injur-ies that resulted in a greater impact on activities ofdaily living. Older children (those > 5 years of age) mayhave experienced a greater impact on HRQoL at onemonth post injury as they are more independent rela-tive to younger children in activities of daily living andleisure activities. Thus, their injuries may have resultedin a greater loss of independence.Our findings are consistent with the findings of theUK burden of injury multicenter study that recruitedalmost 300 hundred participants under 18 years ofage. They found that admission status and injury se-verity were the only variables associated with recoveryat one month post injury among 5-17 year olds, andthat 91 % of participants had recovered by 12 monthspost injury [25]. In addition, Polinder et al., reportedthat less than 10 % of their study population of injuredchildren 5-14 years had residual disability after ninemonths with girls and hospitalized children havinghigher odds of longer lasting disability [13]. Further, a2012 systematic review on studies of children who havesuffered traumatic brain injuries found that the odds ofexperiencing poor Quality of Life increased with moresevere injuries (assessment time points ranged fromthree months to five years) [26]. However, even amongchildren with TBI, a recent study found that by18 months post injury parent ratings of children’sHRQoL returned to the normal range for most children,regardless of injury severity [27].In the current study, at four and 12 months a higherproportion of hospitalized children, relative to their un-admitted counterparts, still had physical HRQoL scoresthat were at least one standard deviation lower thantheir baseline score while their total and psychosocialscores were on par with baseline. PaedsCTAS did nothave a significant impact on recovery despite being ameasure of severity. It is possible this result is due to thefact that although PaedsCTAS has been found to be asso-ciated with physical recovery, no relationship with psycho-social recovery has been observed [19]. Future analysiswill explore predictors of physical and psychosocial func-tioning independently. The utility of providing targeted re-habilitation support, such as occupational and physicaltherapy, throughout recovery to injured children whowere hospitalized to help diminish this impact could beinvestigated in future research.Variables that could be used to predict and protectthe subset of children at high risk of long-term or moreserious impact, outside of lengthy hospitalization andpossibly severe traumatic brain injury [28, 29] have notbeen consistently demonstrated across studies. Somestudies have found that children involved in motor ve-hicle accidents [30] and burn victims [31] can havemore psychological and/or longer lasting sequalae rela-tive to other injuries; the sample size of children withthese mechanisms of injury in the current study wastoo small to investigate this further.Our findings can inform the debate regarding thetradeoff between the benefits of a physically activelifestyle versus potential impacts on HRQoL resultingfrom childhood injuries [32–38]. Among our sample,63 % were engaged in leisure/physical activity at thetime of their injury, highlighting the high incidence ofthese injuries. Our data did not include informationon exposure time, however, a systematic review calcu-lated that the injury incidence rate during leisure/physical activity was between 0.15-0.27 medicallyattended injuries per 1,000 h of physical activity, indi-cating that while they may be prevalent, they are rela-tively rare when accounting for exposure [39]. Inthose relatively rare cases when injury does occur, ourfindings suggest that most children recuperate quickly,with HRQoL comparable to pre-injury levels by four-months post-injury.pthmp =7778p =8273Schneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 8 of 11Table 3 PedsQL total health score, parent report at each follow-uBaseline One Monn mean sd nSex p = 0.31Male 127 90.2 9.2 113Female 77 91.5 8.3 72Age Category p = 0.580 - 5 84 91.3 8.5 746 -10 66 89.8 9.5 63The limitations of this study should be noted ininterpreting the findings. Despite our best efforts, thestudy sample represents 30 % of the eligible popula-tion that was approached for study participation. Ourresponse rates appear to be lower than other compar-able longitudinal injury studies of children attendingan ED or admitted to hospital for an injury. For ex-ample, Polinder et al.’s pediatric study had a responserate of 43 % [13], while Lyons et al.’s study of injuredchildren and adults had a participation rate of 66 %[25, 40]. However, when we compared the studypopulation to the broader population of children pre-senting at BCCH with an injury, we found that our11-16 54 90.7 8.8 48 76Hospitalization Status p = 0.77 p <ED 144 90.5 8.9 132 82Hospitalized 60 90.9 8.9 53 65PaedCTAS p = 0.15 p <1 (resuscitation required) 11 85.4 12.4 10 652 38 91.1 8.6 33 683 43 91.7 8.2 40 784 104 90.3 8.9 94 825 (non-urgent) 8 95.2 4.3 8 82Income Quintile p = 0.12 p =1 (lowest income quintile) 25 90.2 9.5 21 732 25 88.3 11.7 23 743 43 93 6.9 38 834 39 88.6 9.4 35 755 (highest income quintile) 72 91.4 8.1 68 77Injury p = 0.89 p <Head injury 18 91.4 6.7 17 89Lower extremity fracture 25 92.9 9.2 22 58Major trauma 16 89.0 11.6 15 65Minor external injury 77 90.8 9.4 67 84Upper extremity fracture 49 89.6 8.5 46 77Other* 16 90.7 6.9 15 74aVariable ranges from 0-100 with 100 representing perfect health; minimal clinically*P values for differences in mean PedsQL scores across variables (within time points) frompointa,*Four Months Twelve Monthsean sd n mean sd n mean sd0.82 p = 0.47 p = 0.44.6 17.5 106 89.9 9.7 103 90.8 9.8.2 18.6 63 91 9.6 58 92.1 9.50.005 p = 0.003 p = 0.22.8 16.0 65 92.4 7.9 62 92.2 9.6.0 18.7 52 86.6 11.4 46 89.6 10.7sample matched all injured children, with the excep-tion of income with our study population having asignificantly lower proportion of individuals from thelowest two income quintiles. It is possible that beingfrom a lower income bracket could be associated witha detrimental impact on HRQoL recovery, which maynot have been captured in this study due to smallsample size. The influence of income was not exam-ined in Polinder et al. and Lyons et al.’s research,thus limiting our understanding of this issue. Oursensitivity analysis indicated no significant differencesin HRQoL over time resulting from excluding partici-pants due to missing data..5 17.9 41 91.3 8.5 41 92.9 7.20.001 p = 0.71 p = 0.82.6 14.8 126 90.2 10.1 113 91.4 9.2.9 19.6 43 90.8 8.4 48 91 10.80.001 p = 0.72 p = 0.87.8 17 9 88 9.4 7 90.7 12.2 19.9 30 90.1 8.5 33 91 9.118.3 34 89.8 9.2 34 92.2 8.715.9 90 90.5 10.5 79 91.3 9.711.8 6 95 4.8 8 88.1 14.30.16 p = 0.44 p = 0.27.9 21.1 18 89 9.9 13 93 9.3.8 18.6 20 87.4 10.2 18 88.2 10.6.9 17.6 37 92.3 9.6 38 92.6 10.9.6 17.5 31 90.8 10.8 33 89.1 10.8.8 16.5 63 90.2 8.9 59 92.2 7.60.001 p = 0.99 p = 0.95.3 8.2 15 91.4 6.4 12 93.6 5.9.6 19.9 16 88.7 9.4 15 90.2 10.2.5 21.2 13 90.0 9.8 13 90.0 11.2.8 15.3 60 89.2 11.6 57 91.3 10.9.9 12.2 41 91.5 8.8 41 92.6 7.3.8 16.9 11 90.6 5.9 10 92.0 9.1important difference is a 4 point changebivariable linear regression, < 0.001 considered significant with Bonferroni correctionTable 4 Prevalence of impaired HRQoL (as defined > 1 standard deviation of baseline mean below baseline score) by injury severityOne Month Four Months Twelve MonthsTotal Physical Psycho-social Total Physical Psycho-social Total Physical Psycho-socialFull population n (%)90 (44.1) 113 (55.4) 58 (28.4) 23 (11.3) 28 (13.7) 18 (8.8) 13 (6.4) 16 (7.8) 15 (7.4)Hospitalization Status n (%)p < 0.001 p = 0.001 p < 0.001 p = 0.91 p = 0.03 p = 0.21 p = 0.87 p = 0.05 p = 0.83ED 49 (34.0) 69 (47.9) 30 (20.8) 16 (11.1) 15 (10.4) 15 (10.4) 11 (7.6) 11 (7.6) 13 (9.0)Hospitalized 41 (68.3) 44 (73.3) 28 (46.7) 7 (11.7) 13 (21.7) 3 (5.0) 5 (8.3) 10 (16.7) 6 (10.0)PaedCTAS n (%)p = 0.06 p = 0.18 p = 0.03 p = 0.84 p = 0.14 p = 0.85 p = 0.12 p = 0.11 p = 0.041 (resuscitation required) 7 (63.6) 7 (63.6) 6 (54.5) 1 (9.1) 2 (18.2) 1 (9.1) 0 (0.0) 0 (0.0) 1 (9.1)2 21 (55.3) 26 (68.4) 15 (39.5) 6 (15.8) 9 (23.7) 2 (5.3) 5 (13.2) 7 (18.4) 5 (13.2)3 21 (48.8) 24 (55.8) 13 (30.2) 5 (11.6) 7 (16.3) 4 (9.3) 1 (2.3) 2 (4.7) 1 (2.3)4 36 (34.6) 50 (48.1) 21 (20.2) 10 (9.6) 9 (8.7) 10 (9.6) 8 (7.7) 10 (9.6) 9 (8.7)5 (non-urgent) 5 (62.5) 6 (75.0) 3 (37.5) 1 (12.5) 1 (12.5) 1 (12.5) 2 (25.0) 2 (25.0) 3 (37.5)*p values comparing prevalence of impaired HRQoL across groups from chi square test or Fisher’s where cell size < 5; < 0.001 considered significant withBonferroni correctionSchneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 9 of 11We were successful in sampling a breadth of injuriesand over-sampling injuries that required hospitalization.As with any longitudinal research, there was attritionover the course of this study. Those lost to follow-uphad a lower mean baseline HRQoL score relative tothose who completed the study period; however, this dif-ference was less than the minimal clinically importantdifference of 4.5 points [41]. Finally, baseline health priorTable 5 PedsQl Total score at 1, 4 and 12 months using GeneralizedTime only Model (95 % CI)Intercept 81.47 (79.37, 83.56)Time in months 0.99 (0.79, 1.19)Baseline HRQoLTime*BaselineHospitalization StatusTime*Hospitalization (ref = hosp)Age (yrs)Time*AgeSex (ref = Female)Time*SexPaedCTAS 1&2PaedCTAS 3PaedCTAS 4&5Time*CTAS3Time*PaedCTAS 4&5a“Crude” models include the covariate, time and the interaction between time andbAdjusted for all other variables in table including interaction termsto injury was based on a retrospective measure and it ispossible that parents under- or over-represented childhealth prior to injury. It has been suggested that baselinemeasures collected at recruitment are more appropriatethan healthy population norms for the purpose of deter-mining the impact of injury on HRQoL in an adultpopulation [42]. No study, to our knowledge, has exam-ined this in a pediatric population.Estimating EquationCrude Estimatea (95 % CI) Adjusted Estimateb (95 % CI)34.53 (17.88, 51.17)0.54 (–1.37, 2.46)0.52 (0.24, 0.79) 0.53 (0.29, 0.77)0.01 (–0.01, 0.03) 0.01 (–0.01, 0.03)13.65 (8.38, 18.93) 11.95 (5.59, 18.30)–1.17 (–1.67, –0.68) –0.93 (–1.58, –0.29)–1.03 (–1.46, –0.59) –0.93 (–1.32, –0.54)0.07 (0.03, 0.12) 0.07 (0.04, 0.11)–0.41 (–5.06, 4.25) 2.63 (–1.25, 6.5)–0.10 (–0.53, 0.33) –0.29 (–0.67, 0.10)Reference7.51 (0.54, 14.49) –0.59 (–8.33, 7.16)11.87 (6.24, 17.51) 2.29 (–4.56, 9.16)–0.61 (–1.25, 0.02) –0.02 (–0.73, 0.69)–1.07 (–1.58, –056) –0.36 (–1.03, 0.32)the covariateoSchneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 10 of 11ConclusionsThis study examined the longitudinal recovery of childrenin the year following injury. Our findings indicate thatvery few injuries have a long lasting impact on children’sHRQoL, demonstrating children’s resilience to physicaltrauma. This research contributes to, and expands uponthe current literature on recovery from childhood injuryby including a wide age-range of children, looking at alonger time period post-injury, and using a pediatrictool to measure HRQoL. Older and hospitalized chil-dren experienced greater short-term impact to HRQoLand a steeper slope to recovery. On average, hospitalizedchildren continued to experience greater impact to thephysical domain of their HRQoL throughout the year post-injury. On-going rehabilitation support should be consid-ered as a mechanism to reduce physical sequalae. Overall,the rapid recovery trajectory for most injuries encourageschildren’s participation in active healthy lifestyles.AcknowledgementsFig. 2 GEE estimates for injuries requiring hospitalization vs ED visit*.*Holding all other variables in model constant as: female; PaedCTAS of 190.7 (mean of population)The authors would like to extend their gratitude and acknowledgements toall study participants and study team members for their time and energyspent on this project.Salary support for authors was provided by the BCCH (MB, JB) and by aMichael Smith Foundation for Health Research Scholar Award (MB).FundingThis study was funded by the Canadian Institutes of Health Research (Grant #TIR-104028), as well as the Michael Smith Foundation for Health Research.The funders had no role in study design, data collection and analysis, decisionto publish, or preparation of the manuscript.Availability of data and materialThe datasets generated during and/or analyzed during the current study areavailable from the corresponding author on reasonable request.Authors’ contributionsAS was involved with data collection, designed and carried out statistical analyses,drafted the initial manuscript and approved the final manuscript as submitted. MBconceptualized and designed the study, oversaw data collection, reviewed andrevised the manuscript and approved the final manuscript as submitted. CM wasinvolved with study conceptualization and design, reviewed and revised themanuscript and approved the final manuscript as submitted. JB was involved withdeveloping the analysis plan, reviewed and revised the manuscript andapproved the final manuscript as submitted. SK, TI, and EZ were involved withstudy implementation, data collection, reviewed and revised the manuscriptand approved the final manuscript as submitted.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateThis study was reviewed and approved by the University of British Columbia/Children’s and Women’s Health Centre of British Columbia Research EthicsBoard, reference number H09-01627. Informed and written consents wereobtained from parents of all agreed participating children and assent fromall participating children aged 7 and older. Participants were informed abouttheir freedom from refusal and any decision which they may take would notaffect their healthcare services. Anonymity and confidentiality were maintainedthroughout the research process.Author details1School of Population & Public Health, University of British Columbia,Vancouver, BC, Canada. 2British Columbia Injury Research & Prevention Unit,F508 – 4480 Oak Street, Vancouver, BC V6H 3 V4, Canada. 3British ColumbiaChildren’s Hospital, Vancouver, BC, Canada. 4Department of Pediatrics,University of British Columbia, Vancouver, BC, Canada. 5Vaccine Evaluationr 2; 7.1 years of age (median age of population) and baseline PedsQl ofCenter, BC Children’s Hospital, Vancouver, Canada.Received: 10 December 2015 Accepted: 18 August 2016References1. Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Rahman AKMF,Rivara F, Bartolomeos K. World Report on Child Injury Prevention. Geneva:World Health Organization Press; 2008.2. Centers for Disease Control and Prevention. National Center for InjuryPrevention and Control. National Action Plan for Child Injury Prevention.Atlanta: CDC, NCIPC; 2012.3. Grad FP. Preable to the Constitution of the World Health Organization. B WorldHealth Organ. 2002;80:981–84.4. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life.Ann Intern Med. 1993;118:622–9.5. Patrick D, Erickson P. Assessing health-related quality of life for clinical decision-making. In: Walker SR, Rosser RM, editors. Quality of Life Assessment: Key Issuesin the 1990s. Dordrecht: Springer Netherlands; 1993. p. 11–64.6. Kenardy JA, Spence SH, Macleod AC. Screening for posttraumatic stressdisorder in children after accidental injury. Pediatrics. 2006;118:1002–9.7. March S, Kenardy JA, Cobham VE, Nixon RDV, McDermott B, De Young A.Feasibility of a Screening Program for At-Risk Children Following AccidentalInjury. J Trauma Stress. 2015;28:34–40.Choquette L, Chorney D, Collyer C, Herrington S, Janson K, Janssen I, LaroucheR, Pickett W, Power M, Sandseter EBH, Simon B, Brussoni M. Position Statementon Active Outdoor Play. Int J Environ Res Public Health. 2015;12:6475–505.38. Brussoni M, Gibbons R, Gray C, Ishikawa T, Sandseter EBH, Bienenstock A,Chabot G, Fuselli P, Herrington S, Janssen I, Pickett W, Power M, Stanger N,Sampson M, Tremblay MS. What is the Relationship between Risky OutdoorPlay and Health in Children? A Systematic Review. Int J Environ Res PublicHealth. 2015;12:6423–54.39. Nauta J, Martin-Diener E, Martin BW, van Mechelen W, Verhagen E. Injuryrisk during different physical activity behaviours in children: a systematicreview with bias assessment. Sports Med. 2015;45:327–36.40. Lyons RA, Kendrick D, Towner EM, Christie N, Macey S, Coupland C, GabbeBJ, UK Burden of Injuries Study Group. Measuring the population burden ofinjuries–implications for global and national estimates: a multi-centreprospective UK longitudinal study. PLoS Med. 2011;8, e1001140.41. Varni JW, Burwinkle TM. The PedsQL as a patient-reported outcome inchildren and adolescents with Attention-Deficit/Hyperactivity Disorder: apopulation-based study. Health Qual Life Outcomes. 2006;4:26–36.42. Watson WL, Ozanne-Smith J, Richardson J. Retrospective baselinemeasurement of self-reported health status and health-related quality of lifeSchneeberg et al. Health and Quality of Life Outcomes  (2016) 14:120 Page 11 of 118. Kassam-Adams N, Bakker A, Marsac ML, Fein JA, Winston FK. TraumaticStress, Depression, and Recovery. Pediatr Emerg Care. 2015;1.9. Polinder S, Haagsma JA, Belt E, Lyons RA, Erasmus V, Lund J, Van Beeck EF.A systematic review of studies measuring health-related quality of life ofgeneral injury populations. BMC Public Health. 2010;10:783.10. van Beeck Larson CF, Lyons RA, Meerding W, Mulder S, Essink-Bot M. EF.Guidelines for the conduction of follow up studies measuring injury-relateddisability. J Trauma. 2007;62:534–550.11. Polinder S, Haagsma JA, Toet H, van Beeck EF. Epidemiological burden ofminor, major and fatal trauma in a national injury pyramid. Br J Surg. 2012;99 (Suppl 1):121.12. Aitken ME, Tilford JM, Barrett KW, Parker JG, Simpson P, Landgraf J, RobbinsJM. Health Status of Children After Admission for Injury. Pediatrics. 2002;110:337–42.13. Polinder S, Meerding WJ, Toet H, Mulder S, Essink-Bot M-L, van Beeck EF.Prevalence and prognostic factors of disability after childhood injury.Pediatrics. 2005;116:e810–7.14. Davey TM, Aitken LM, Kassulke D, Bellamy N, Ambrose J, Gee T, Clark M.Long-term outcomes of seriously injured children: a study using the ChildHealth Questionnaire. J Paediatr Child Health. 2005;41:278–83.15. Desai AD, Zhou C, Stanford S, Haaland W, Varni JW, Mangione-Smith RM.Validity and responsiveness of the pediatric quality of life inventory(PedsQL) 4.0 generic core scales in the pediatric inpatient setting. JAMAPediatr. 2014;168:1114–21.16. Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of thePediatric Quality of Life Inventory version 4.0 generic core scales in healthyand patient populations. Med Care. 2001;39:800–12.17. Kruse S, Schneeberg A, Brussoni M. Construct validity and impact of modeof administration of the PedsQL™ among a pediatric injury population.Health Qual Life Outcomes. 2014;12:168.18. Gouin S, Gravel J, Amre DK, Bergeron S. Evaluation of the Paediatric CanadianTriage and Acuity Scale in a pediatric ED. Am J Emerg Med. 2005;23:243–7.19. Yates M, Ishikawa T, Schneeberg A, Brussoni M. Pediatric Canadian Triageand Acuity Scale (PasedsCTAS) as a Measure of Injury Severity. Int J EnvironRes Public Heal. 2016;13.20. Statistics Canada. Postal Code Conversion File Plus PCCF+ Version 5 F User’sGuide. Ottawa: Minister of Industry. Statistics Canada Catalogue no 82-E0086-XDB; 2010.21. Varni JW, Seid M, Knight TS, Uzark K, Szer IS. The PedsQLTM 4.0 GenericCore Scales: Sensitivity, Responsiveness, and Impact on Clinical Decision-Making. J Behav Med. 2002;25:175–93.22. Willis Gabbe BJ, Butt W, Cameron PA. CD. Assessing outcomes in paediatrictrauma populations. Inj Int J Care Inj. 2006;37:1185–96.23. Janssens L, Gorter JW, Ketelaar M, Kramer WLM, Holtslag HR. Health-relatedquality-of-life measures for long-term follow-up in children after majortrauma. Qual Life Res. 2008;17:701–13.24. Varni JW, Burwinkle TM, Seid M, Skarr D. The PedsQL 4.0 as a pediatricpopulation health measure: feasibility, reliability, and validity. Ambul Pediatr.2003;3:329–41.25. Kendrick D, Vinogradova Y, Coupland C, Mulvaney CA, Christie N, Lyons RA,Towner EL. Recovery from injury: the UK burden of injury multicentrelongitudinal study. Inj Prev. 2013;19:370–81.26. Battista A Di, Soo C, Catroppa C, Anderson V. Quality of Life in Children andAdolescents Post-TBI: A Systematic Review and Meta-Analysis. J Neurotraum.2012;29:1717–27.27. Brown EA, Kenardy J, Chandler B, Anderson V, McKinlay L, Le Brocque R.Parent-Reported Health-Related Quality of Life in Children With TraumaticBrain Injury: A Prospective Study. J Pediatr Psychol. 2016;41:244–55.28. Stancin T, Drotar D, Taylor HG, Yeates KO, Wade SL, Minich NM. Health-Related Quality of Life of Children and Adolescents After Traumatic BrainInjury. Pediatrics. 2002;109:e34.29. McCarthy ML, MacKenzie EJ, Durbin DR, Aitken ME, Jaffe KM, Paidas CN,Slomine BS, Dorsch AM, Christensen JR, Ding R. Health-related quality of lifeduring the first year after traumatic brain injury. Arch Pediatr Adolesc Med.2006;160:252–60.30. Winston FK, Kassam-Adams N, Vivarelli-O’Neill C, Ford J, Newman E, Baxt C,Stafford P, Cnaan A. Acute Stress Disorder Symptoms in Children and TheirParents After Pediatric Traffic Injury. Pediatrics. 2002;109:e90.31. van Baar ME, Polinder S, Essink-Bot ML, van Loey NEE, Oen IMMH, Dokter J,Boxma H, van Beeck EF. Quality of life after burns in childhood (5-15 years):children experience substantial problems. Burns. 2011;37:930–8.versus population norms in the evaluation of post-injury losses. Inj Prev.2007;13:45–50.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services Submit your next manuscript to BioMed Central and we will help you at every step:32. Langley J, Cryer C. A consideration of severity is sufficient to focus ourprevention efforts. Inj Prev. 2012;18:73–4.33. Brussoni M, Brunelle S, Pike I, Sandseter EBH, Herrington S, Turner H, Belair S,Logan L, Fuselli P, Ball DJ. Can child injury prevention include healthy riskpromotion? Inj Prev. 2014;21:344-47.34. Rivara F. Counterpoint: minor injuries may not be all that minor. Inj Prev.2011;17:149–50.35. Brussoni M, Olsen LL, Pike I, Sleet D. Risky play and children’s safety:Balancing priorities for optimal child development. Int J Environ Res PublicHealth. 2012;9:3134–8.36. Molcho M, Pickett W. Some thoughts about “acceptable” and “non-acceptable”childhood injuries. Inj Prev. 2011;17:147–8.37. Tremblay MS, Gray C, Babcock S, Barnes J, Bradstreet CC, Carr D, Chabot G,•  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submit

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