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Professionals involved in efforts to promote health in child populations are faced with a growing challenge. Children in many societies are burdened with the disease consequences of overweight and obesity, in part related to physical inactivity.1–3 Prevalence rates of childhood obesity have been increasing since the 1980s,4 5 and their known consequences include reduced quality of life, increased rates of chronic disease and associated healthcare costs, and early mortality.6–10 Obvious solutions to this problem include the promotion of physical activity via sports and active recreational opportunities. Such strategies can lead to reductions in risk for chronic disease which in turn lead to gains in health status that carry forward from childhood into the adult years.11–15
The same health professions that are charged with the responsibility of promoting physical activity in child populations are also faced with the reality of its negative health consequences. Injury related to childhood physical activity can occasionally lead to death or ongoing disability.16 Physical activity injuries are also a leading reason why children present to the emergency department and other acute care settings for urgent medical care.16–21
The obvious benefits (reduced obesity) and risks (increased injury) of childhood physical activity set the stage for a debate within the health promotion disciplines—one that requires thought and compromise. Physical activity specialists often argue that injury is an inevitable side effect of a healthy, active lifestyle. Hence, some injuries should be accepted.22 Injury control professionals typically offer the perspective that childhood injuries by definition are inherently bad, irrespective of their origins.16 Such positions seem to be opposed to one another, and occasionally pit one side of our profession against the other.22 23 We have recently been asking ourselves if there room for compromise in this debate.
More anecdotally, our research groups have occasionally struggled with this debate in more local settings. When faced by a physical activity-minded audience, we often hear arguments that the injury prevention world may be unintentionally working against progress in the physical activity world. This is attributable to the dominant paradigm in the injury control world that all childhood injuries, irrespective of their origins, are unacceptable.16 24 The basic argument raised is that efforts to prevent injuries may have a stifling effect on the engagement of children in healthy physical activity.25 Consistent with others, we hear that fears attributable to injury and perhaps even legal liability may be discouraging parents, teachers, and other responsible adults from promoting active lifestyles and their associated developmental benefits in child populations.25–33 While physical activity injuries to children are common, the vast majority are viewed as relatively minor and non-disabling in nature.16 17 It is sometimes difficult to respond to the arguments raised by our physical activity colleagues with balance and certainty. This is compounded by the fact >40% of children in many countries report experiencing at least one medically treated injury per year, most of which are sports related and most of which are quite minor in severity.34
Should society be aiming to prevent all minor injuries to children at the cost of limiting engagement in physical activity? Is our profession's basic mantra that ‘all injuries are predicable and hence preventable’ inadvertently causing harm?16 Has the time come for the injury prevention world to view certain childhood injury events in a different light, perhaps accepting that there is a threshold incidence for childhood physical activity injuries below which it might be difficult or even not sensible to concentrate our prevention efforts?22 Taken to the extreme and following the observations of others, is there even such as thing as an ‘acceptable injury’ in the context of the health and development of child populations?22 Indeed, such views are sometimes expressed by those promoting health associated with physical activity33 but not among researchers in our field.
Some organised thoughts about acceptable and non-acceptable childhood injuries
If one accepts the premise that there is such thing as an ‘acceptable injury’ for child populations, it is necessary to propose an operational definition. We suggest that this definition should be based on a classification that involves standard parameters used in the description of external causes of injury (intent, severity, activity, mechanism),35 as well as knowledge of whether known preventive measures were adhered to. Table 1 presents a possible matrix to assist in such a classification.
As per this matrix, any of the following are deemed non-acceptable: (1) intentional injuries; (2) severe or disabling injuries; (3) injuries occurring while involved in unhealthy, unnecessary, or abnormally risky behaviours; and (4) injuries that occurred while ignoring known preventive measures. However, injuries that are unintentional, occurring during a necessary or health generating activity, and that do not have long-term implications could be viewed as acceptable, after weighing the benefits of engagement in healthy activities with the risks for injury and trauma.
Identification of some types of childhood injury as more acceptable than others has implications for prevention efforts. First, professionals in the fields of health promotion and injury prevention should obviously continue to aim to provide safe contextual environments for sports and recreational activities in order to minimise harms, while bearing in mind that some injuries are still likely to occur. Second, some injuries will be accepted and tolerated as part of the healthy development of child populations.22 Third, questions available for injury prevention research could be expanded. Fears of injury and safety concerns could be studied in a quantitative manner as potential barriers for physical activity, as most existing studies of these topics are qualitative in nature.28 29 36 Methodological research could also be used to arrive at a consensus definition for an ‘acceptable injury’ for children and their health. The above matrix could be used as a basis for early discussions of this topic. Finally, once a definition is established, this would permit study of the causes and consequences of acceptable versus non-acceptable childhood injury outcomes, perhaps leading to new advances in aetiological research.
This commentary reviews the concept of an ‘acceptable injury’ within the child health field. We realise that this is a provocative idea that goes against the grain of much of our training as injury control professionals. Our commentary was not developed to create division within our profession. Rather, our hope is that this commentary and our proposed matrix will facilitate a discussion and debate of this issue, and will ultimately result in improved strategies to optimise the health of child populations.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.