Article, Pediatrics

Age variability in pediatric injuries from falls

Unlabelled imagePediatric injuries fr”>American Journal of Emergency Medicine (2012) 30, 1457-1460

Original Contribution

Age variability in pediatric injuries from falls?,??

Purnima Unni MPHa,?, Matthew Ryan Locklair MDb,

Stephen E. Morrow MDa, Cristina Estrada MDb

aDepartment of Pediatric Surgery, Trauma Program, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville,

TN 37232, USA

bDepartment of Pediatrics, Pediatric Emergency Medicine, Monroe Carell Jr., Children’s Hospital at Vanderbilt, Nashville, TN 37232, USA

Received 6 November 2011; revised 28 November 2011; accepted 2 December 2011

Abstract

Objective: The objective of this study is to examine the nature and circumstances surrounding pediatric fall- related injuries for specific age groups and their implications for age-appropriate Injury prevention efforts. Methods: This is a retrospective analysis of data (October 2006 to April 2009) from the trauma registry of a level 1 pediatric trauma center. Inclusion criteria are patients admitted because of fall-related injury younger than 15 years (n = 675). Injury mechanism specifics were obtained from medical records.

Results: Falls were the leading cause of admissions and accounted for 37% of all cases during this period. Most pediatric fall-related injuries (73%) occurred between 1 and 9 years of age. Although infants accounted for only 8% of fall injuries, a greater proportion of these children were more severely injured. The mean Injury Severity Score for infants was significantly greater than the overall average (P b .001). Causes of fall injuries vary by age and have been discussed.

Conclusions: The high incidence of PEdiatric fall injuries warrants dedicated injury prevention education. Injury prevention efforts need to be age appropriate in terms of focus, target audience, and setting. Recommendations for injury prevention are discussed.

Introduction

Falls are the most common cause of unintentional injuries among children. Each year, approximately 2.8 million children had an initial emergency department (ED) visit for injuries from a fall [1]. Previous studies on pediatric falls have addressed specific types of falls, such as falls from balconies [2], windows [3,4], and falls in bathtubs [5]. There is limited research on understanding patterns of fall injuries that may exist across

? No grant or funds were used for this article.

?? Presented at Annual Meeting of the American Public Health Association (Poster), November 2010.

* Corresponding author. Tel.: +1 615 936 8222; fax: +1 615 936 1046.

E-mail address: [email protected] (P. Unni).

different age groups. This article provides a systematic exami- nation of pediatric falls and their variations by age.

As children go through development stages, their exposure to and interaction with hazardous situations vary [6]. This research would identify leading causes of pediatric fall injuries by age. Knowledge of these causes would be useful in deve- loping age-specific fall injury prevention efforts. Fall injury prevention typically does not often receive the same prece- dence as other injuries. It is often bundled with home safety education [7]. Studies have suggested that parents and care- givers may be unable to assimilate large amounts of diverse and often complicated information pertaining to injury pre- vention. Therefore, simple, well-targeted interventions would likely prove most effective [7-9]. Although pediatric falls have lower mortality compared with motor vehicle crashes,

0735-6757/$ – see front matter. doi:10.1016/j.ajem.2011.12.001

drowning, and burns, they are nevertheless significant in terms of physical, emotional, and financial consequences and mandate focused injury prevention initiatives.

Methods

A retrospective analysis of data from the trauma registry of a level 1 pediatric trauma center between October 2006 and April 2009 was done. Only patients younger than 15 years, admitted because of fall-related injury (E-codes E880-E888, principal diagnosis, International Classification of Diseases, Ninth Revision Code, 2010) were included. Injuries from bicycles (E826), sports (E917), and child abuse (E967) were not included. Medical charts for these patients were examined to gain a better understanding of circum- stances and causes of the falls.

Age classifications used by the Centers for Disease Control and Prevention were used: younger than 1 year, 1 to 4 years, 5 to 9 years, and 10 to 14 years [1]. The key variables examined were age, sex, injury severity (measured by Injury Severity Score [ISS]), external cause of injury (E-code), injury site, and circumstances under which injuries were sustained. SPSS v19.0 (SPSS, Chicago, IL) was used to analyze the data. Statistical analysis included the ?2 test for categorical data and proportions and the t test for differences of means. P b .05 was used for level of significance. Human studies approval was granted by the Vanderbilt University’s institutional review board.

Results

For the 31-month period, falls were the leading cause of injuries for all age groups. The 675 hospitalizations from falls accounted for 37% of all cases in the trauma registry. Most patients (81%) were younger than 10 years. There were no fatalities from falls. The length of hospitalization ranged from 1 to 19 days with a mean of 1.5 days (interquartile range, 1-2 days). Patient characteristics are described in Table 1.

Table 1 Characteristics for patients hospitalized because of fall-related injuries

The main sites for injury from falls were in and around homes (56%); playground, including skate parks (21%); and schools (7%). Most falls in school occurred at the playground.

Injury Severity Score and age

The median ISS was 9.00. Table 2 shows the distribution of ISS by age. Most injuries were of moderate severity, except for those in the younger-than-1-year group, which were significantly more severe (?2, P b .001). One-way analysis of variance showed that the mean ISS of the youngest children was significantly greater than the mean ISS of the other groups (11.27 vs 9.17, P b .001).

External causes of injury (E-codes) and age

Table 3 shows the distribution of causes of fall injuries by age. Overall, the most common cause of fall was fall from one level to another (E884.9). There are significant variations across different age groups. Fall from furniture was the leading cause of injury for 1- to 4-year olds, whereas fall from playground equipment was the leading cause for 5- to 9-year olds. Interestingly, fall from one level to another was the leading cause for infants as well as the oldest group in this data set. To get a better idea of these causes, individual patient charts were examined.

Examination of charts

Infants (younger than 1 year)

Infants accounted for the least number (8%) of pediatric fall-related hospitalizations (Table 3). However, in this data set, among infants, fall was the leading cause of hospital- izations (38%, n = 56). Most falls resulted from the infant slipping out of a parent’s, sibling’s, or caregiver’s arms (46%). This typically happened when the person carrying the infant slipped or fell. Children 6 months or younger were especially susceptible to such falls. The other major fall type in this group was from furniture, such as beds and couches (29%). Unattended older infants (N6 months) who could crawl comprised most of the patients in this category. Remaining cases involved falls from a countertop or kitchen table (16%). In some of these cases, the child was in an infant carrier that was left unattended and unsecured on the countertop or a flat surface such as a clothes dryer.

Table 2 Injury severity score by age

n = 675

Sex

Female

297 (44%)

Male

378 (56%)

Race/ethnicity

White

501 (74%)

Black

86 (13%)

Hispanic

63 (9%)

Other

25 (4%)

Age

b1 y

56 (8%)

1-4 y

232 (34%)

5-9 y

262 (39%)

10-14 y

125 (19%)

(October 2006 to April 2009).

ISS

b1 y 1-4

y 5-9

y 10-14 y

Mild (b9)

12 (21%) 27

(12%) 31

(12%) 29 (23%)

Moderate

22 (39%) 190

(82%) 224

(86%) 77 (62%)

(9-15)

Severe

22 (39%) 14

(6%) 7

(3%) 19 (15%)

(N15)

Total

56 (100%) 232

(100%) 262

(100%) 125 (100%)

E-code

Cause of injury

b1 y

1-4

y

5-9

y

10-14 y

Total

% of all falls

E884.9

Fall from one level to another

28

44

75

31

175

26%

(tree, haystack, stationary

vehicle, embankment)

E884.0

Fall from playground equipment

0

38

84

9

131

19%

E884.2, E884.4,

Fall from furniture (including chair,

18

54

30

1

106

16%

E884.5

bed, other furniture)

E885.9

Fall from slipping and tripping

0

32

24

16

72

11%

E880.9

Fall from stairs

4

16

5

5

30

4%

E885.2

Fall from skateboard

0

1

4

22

27

4%

Other

Other

6

47

40

41

134

20%

Total

56 (8%)

232

(34%)

262

(39%)

125

(19%)

675

(100%)

100

1 to 4 years

Table 3 External causes of fall injuries by age

More than one third (34%, n = 232) of fall injuries were from this age group (Table 3). The leading causes of injuries were falls from furniture (23%), playground equipment (18%), and slipping or tripping (17%). Falls from one level to another comprised 19% of fall injuries in this group (Table 3). These included falls from trampolines, windows, decks, and toy vehicles. Falls from slipping or tripping accounted for 14% of cases. There is some variability by age in the occurrence of injuries. Falls from furniture, slipping, or tripping were more frequent among the younger (1- and 2-year-old) children. Injuries sustained at the playground and caused by falls from stairs were more common among 3- and 4-year olds.

5 to 9 years

This group accounted for most number of fall-related hospitalizations (39%). Almost a third of these injuries were caused by falls from playground equipment. Monkey bars and slides were the most common playground equipment involved. Falls from furniture (12%) and falls caused by tripping or slipping (12%) were the other leading causes of fall injuries. Falls from one level to another was the second most frequent cause of injury (Table 3). However, this classification included a variety of causes such as falls from trees, carts, trampolines, deck, and windows. Falls associated with rough and tumble play (8%) typical of this age group were also present.

10 to 14 years

Approximately 19% of fall hospitalizations were from this group (Table 3). The leading cause of injury was falls from skateboards (24%). Skateboard injuries were more common among the older male children. Other causes were falls from trampolines and falls due to slipping or tripping. These injuries were more common for the Younger children in this age group.

The 3 leading causes of fall-related injuries for the different age groups are shown in Table 4.

Discussion

Falls are the leading cause of pediatric injuries. However, injury prevention efforts often do not reflect the significance

of this problem. Research suggests that mothers perceived that society viewed falls by children as normative and that there was little expectation for parents to prevent them [10]. However, most fall-related injuries are preventable.

With a few exceptions [11,12], studies on pediatric falls have focused on specific types of falls [2-5] rather than injury patterns in different age groups. Falls are likely to be influenced substantially by developmental stage [13]. The data captured in the trauma registry are informative about the main causes of fall-related injuries. However, in many cases, it fails to convey specific information that would be helpful in guiding injury prevention efforts. For instance, the leading cause (E-code) of fall injuries was E884.9–fall from one level to another (tree, haystack, stationary vehicle, embank- ment). This code covers a variety of causes and may not reveal differences by age. For infants, injuries were incurred when the infant slipped from a caregiver’s arms, whereas for 1- to 4-year olds, injuries may have been caused by fall from a stationary toy vehicle or trampoline.

This retrospective review of data of pediatric patients admitted because of injuries from falls identifies specific causes of fall injuries by age group. This enables more targeted fall prevention efforts [6]. Injury prevention experts note the need to provide developmentally relevant counsel- ing. They also suggest restricting the number of topics for

Table 4 Leading causes of fall-related injuries by age Age Leading causes of injuries from falls

b1 y Falls from slipping out of caregiver’s arms (47%) Falls from beds and couches (40%)

Falls from a countertop (13%)

1-4 y Falls from furniture–beds, chairs, couches (23%) Falls from playground equipment (18%)

Falls due to slipping/tripping (17%)

5-9 y Falls from playground equipment (32%) Falls from beds and couches (12%) Falls due to slipping/tripping (12%)

10-14 y Falls from skateboarding (24%) Falls from trampoline (12%)

Falls due to slipping/tripping (11%)

injury Prevention counseling to less than 3 to take into account time constraints as well as inability of parents to absorb information in a limited period [14].

Implications

Infants experience a disproportionate share of severe injuries when compared with older children who are hospitalized from injuries sustained in a fall (Table 2). For infants younger than 6 months, the most frequent cause of injury was fall from caregiver’s arms. In many of these cases, the caregiver slipped or tripped inside the house. There were also several cases of the infant slipping out of a sibling’s arms. Injury prevention initiatives should emphasize the importance of maintaining uncluttered homes to help prevent adults from tripping [15,16] and care when siblings handle the infant. Parents must be taught to avoid placing their child’s car seat or bouncy chair on countertops and tables [17]. As infants grow older and become more mobile, it is important to keep them off of beds or couches while unattended. Proper use of safety restraints for bouncy chairs, carriers, and high chairs should be emphasized [17].

For 1- to 4-year olds, active supervision is essential because of their independent mobility. Parents should be encouraged never to leave their children unattended on beds and other furniture, playground equipment, and trampolines. Experts have stressed on 3 dimensions of active supervision, PAC: proximity, attention, and continuity [18]. Parents should be encouraged to use safety devices such as bedrails, safety straps for high chairs, gates for stairs, and window guards.

In the 5- to 9-year age group, injury prevention efforts should focus on safe behavior while using playground equipment such as monkey bars and slides, bunk beds, and daily activities. Many injuries were also attributed to slipping or tripping. Tips on making the home environment safe from tripping and slipping hazards should be provided. Education efforts should target elementary school teachers besides parents because many of these injuries occurred at school playgrounds. Focusing on teachers in communicating safe behavior in other areas has been shown to be effective [19]. For the 10- to 14-year olds, the focus should be on skateboarding and trampolines. Both these activities are inherently dangerous. Injuries in skateboarding can be minimized by the use of helmets and protective padding. Skateboarders should also be reminded to skate in safe areas such as skate parks. Known trampoline risks that can be minimized include simultaneous use by multiple children, absence of safety nets and spotters, and hard surfaces

adjacent to the trampoline [20,21].

Limitations

The data analyzed in the study were limited to injuries that required hospitalizations at 1 hospital. Patients treated and released by the ED are not included. Therefore, this data set is skewed to more severe injuries.

Conclusions

The circumstances of pediatric falls vary by age. It is important to look beyond E-codes to gain a better understanding of the causes of injuries from falls in children. Our study findings suggest that interventions to prevent injuries from falls should receive priority and be targeted by age group.

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