Pediatrics

Sofa and bed-related pediatric trauma injuries treated in United States emergency departments

a b s t r a c t

Introduction: Children under the age of 5 years suffer from the highest rates of fall-related injuries. Caretakers often leave young children on sofas and beds, however, falling and rolling off these fixtures can lead to serious injury. We investigated the epidemiologic characteristics and trends of bed and sofa-related injuries among chil- dren aged <5 years treated in US emergency departments (EDs).

Methods: We conducted a retrospective analysis of data from the National Electronic Injury surveillance System from 2007 through 2021 using Sample weights to estimate national numbers and rates of bed and sofa-related injuries. Descriptive statistics and regression analyses were employed.

Results: An estimated 3,414,007 children aged <5 years were treated for bed and sofa-related injuries in emer- gency departments (EDs) in the United States from 2007 through 2021, averaging 115.2 injuries per 10,000 persons annually. Closed head injuries (30%) and lacerations (24%) comprised the majority of injuries. The primary location of injury was the head (71%) and upper extremity (17%). Children <1 year of age accounted for most injuries, with a 67% increase in incidence within the age group between 2007 and 2021 (p < 0.001). Fall- ing, jumping, and rolling off beds and sofas were the primary mechanisms of injury. The proportion of jumping injuries increased with age. Approximately 4% of all injuries required hospitalization. Children <1 year of age were 1.58 times more likely to be hospitalized after injury than all other age groups (p < 0.001).

Conclusion: Beds and sofas can be associated with injury among young children, especially infants. The annual rate of bed and sofa-related injuries among infants <1 year old is increasing, which underscores the need for in- creased Prevention efforts, including parental education and improved safety design, to decrease these injuries.

(C) 2023

  1. Background

unintentional falls are the most common cause of non-fatal injuries for children in the United States (US) [1]. Although deaths from these injuries are rare, they often lead to visits to the emergency department and, at times, hospitalization [2]. The injuries leading to Hospital visits can vary, but more severe injuries often include fractures and/or head trauma [1,3]. Among all children, those aged four years and younger suf- fer from the highest rate of fall-related injuries [4]. Falls account for the majority of all visits to the emergency department seen in children under one year of age [2].

* Corresponding author at: Medical School, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA.

E-mail address: [email protected] (R.H. Solaiman).

There are various causes of fall-related injuries. Prior literature has documented falls from beds, sofas, caretaker’s arms, windows, stair- ways, and playground equipment as common causes of pediatric injury [3,5,6]. Caregivers may assume beds and sofas are safe locations to place Younger children and leave them unattended. However, rolling off beds and sofas can lead to serious injury [3,5]. As these falls are plausible events among young children, bed and sofa-related fall scenarios are oc- casionally used to conceal child abuse [7]. We chose to analyze bed and sofa-related injuries among young children as these injuries are common, preventable injuries.

Our study retrospectively investigated the epidemiologic character- istics and national trends of bed and sofa-related injuries among chil- dren <5 years of age evaluated at US emergency departments during a 15-year period. To the best of our knowledge, this study is the first to use a nationally Representative sample to study bed and sofa- related injuries in the pediatric population.

https://doi.org/10.1016/j.ajem.2023.03.055

0735-6757/(C) 2023

  1. trends over time“>Methods
    1. Study design

We queried the National Electronic Injury Surveillance System database of the United States Consumer Product Safety Com- mission (CPSC) for all bed and sofa-related injuries between 2007 and 2021 among patients 4 years or younger. IRB approval was not required at our institution for this population-based, retrospective study with no site-specific or protected health information. The NEISS database pro- vides a nationally representative sample of US hospital emergency de- partments (EDs). The sample includes 100 hospital EDs nationwide stratified by hospital size and geographic location. ED visits are used to categorize the hospitals as follows: small (1-16,380 ED visits), me- dium (16,831-28,150 ED visits), large (28,151-41,130 ED visits), and very large (over 41,131 ED visits). Children’s hospitals are an additional hospital category with varying ED visits. The total NEISS sample includes 47 small, 13 medium, 9 large, 23 very large, and 8 children’s hospitals. Stratifying the sample by total ED visits allows for weighted sampling so that national estimates with sampling errors can be derived for doc- umented injuries [8]. We also assessed the US Census Bureau Interna- tional Database to determine the population of children under the age of 5 years during the study period to analyze Injury incidence per 10,000 children.

    1. Variables

ED visits for bed and sofa-related injuries in pediatric patients

<5 years of age were identified using NEISS product codes 679 (Sofas, Couches, Davenports, Divans, or Studio Couches), 4076 (Beds or Bedframes, Other or Not Specified), and 694 (Beds, Not Specified), and an age filter (<5). Patient demographics collected included patient

and characteristics of the injuries are summarized in Table 1. An in- depth look at injury incidence among children under the age of 2 years is shown in Table 2.

    1. Overall injury trends over time

We identified an 8% increase in national bed and sofa-related annual injuries from 2007 to 2021. When analyzing the injury incidence per 10,000 children, a statistically significant trend was not found for the entire study period but was found when analyzing from 2007 to 2019, prior to the COVID-19 pandemic (R2 = 0.56, p < 0.05) (Fig. 1). During the first six years of the study period, the annual incidence increased from 96 to 126 injured children per 10,000 children (31% increase). Over the following seven years of the study period, the annual incidence decreased from 126 to 121 injured children per 10,000 children (3% de- crease). During the COVID-19 pandemic (2019 to 2021), the annual in- cidence decreased from 121 to 101 injured children per 10,000 children (14% decrease).

When stratified by age, a 67% increase in injuries among children

<1 year old was identified from 2007 to 2021 (R2 = 0.84, p < 0.001). There was no statistically significant trend in children aged 1-4 years old. Fig. 2 shows the overall trend by age group from 2007 to 2021.

    1. Patterns in injury and hospitalization

Children <1 year of age at the time of injury accounted for 29.4% of injuries and 39.4% of hospitalizations among the included population. Children younger than 1 year of age were 1.58 times more likely to be

Table 1

Characteristics of Bed and Sofa-Related Injuries Among Children <5 Years Old Presenting to Emergency Departments, 2007-2021.

sex, age, and year of presentation. Patients were assessed in total and by five age groups (<1, 1, 2, 3, and 4 years). Data regarding each injury that was collected included anatomic injury location, diagnosis, location

Characteristics Number of Actual Cases

Weighted National Estimate

% of Weighted Cases

95% CI

(95% CI: 2,445,830-4,382,186) bed and sofa-related injuries in children

of incident, and disposition. The types of injury were identified by key- Total injuries

word analysis of case descriptions and were further classified as falling, Age, yrs

133,655

3,414,007

100.0%

2,445,830-4,382,186

rolling, jumping, or other. <1

39,274

978,737

28.7%

844,454-1,113,020

1

29,082

745,984

21.8%

643,635-848,333

2

27,483

712,760

20.9%

614,969-810,551

2.3. Statistical analysis 3

22,142

573,151

16.8%

494,515-651,787

4

15,674

403,377

11.8%

348,034-458,720

Both case numbers and national estimates are presented as reported Sex

by the CPSC and the provided sample weighting. Descriptive statistics Male

74,419

1,784,902

52.3%

1,574,998-1,994,806

were employed to characterize injury counts across study variables. In- Female

59,236

1,628,967

47.7%

1,437,400-1,820,534

Diagnosis

jury incidence per number of persons in the US population was further closed head injury

41,215

1,027,628

30.1%

906,779-1,148,477

calculated using US Census Bureau data. Linear regression analysis was (internal organ

performed to identify trends in bed and sofa-related injury by year. A injury)

line of best fit was determined for trends using a linear model. Bivariate Laceration

31,091

805,736

23.6%

695,189-916,283

Contusion/abrasion

18,724

504,418

14.8%

435,212-573,624

regression analysis was performed to calculate likelihood ratios of Fracture

18,674

448,782

13.2%

387,209-510,355

hospitalization after injury based on age. All statistical analyses were Dislocation

4680

121,144

3.6%

102,149-140,139

performed using Excel software (Microsoft, Redmond, WA, USA). Statis- Hematoma

3427

82,478

2.4%

67,929-97,027

tical significance was based on analyses of the number of samples and Concussion

1944

46,823

1.4%

37,646-56,000

not weighted estimates. Statistical significance was set at p < 0.05. Other

13,900

374,474

11.0%

323,096-424,852

body part injured

Head

92,548

2,406,519

70.5%

2,123,512-2,689,526

3. Results Upper extremity

23,739

578,726

17.0%

499,325-658,127

Lower extremity

9769

235,106

6.9%

198,241-271,971

Analysis of the NEISS database resulted in an estimate of 3,414,007 Neck

1258

32,711

1.0%

25,659-39,763

Other

6341

160,943

4.6%

135,707-186,179

aged 4 and younger between 2007 and 2021. There was an average of

Treated/released

126,167

3,233,637

94.7%

2,853,361-3,613,913

227,600 injuries per year and 114 injuries per 10,000 children annually.

Treated/transferred,

5109

123,685

3.6%

104,291-143,079

Children in this study sample presented to EDs in children’s hospitals

admitted or observed

Disposition

(48%) and non-age-specific hospitals (52%). Males accounted for the majority of injuries (52%). Closed head injuries and lacerations com- prised 30% and 24% of cases, respectively. The primary body part injured was the head or neck (70%) and the upper extremity (15%). Approxi- mately 4% of patients required hospitalization. General demographics

Left against medical 2180 51,670 1.5% 42,555-60,785 advice

Other 199 4921 0.2% 3474-6368

Type of product

Bed

92,861

2,353,411

69.1%

2,076,650-2,630,172

Sofa

40,794

1,054,938

30.9%

930,877-1,178,999

Table 2

Age of Children <2 Years Old with Bed and Sofa-Related Injuries Presenting to Emergency Departments, 2007-2021.

Age, months

Number of Actual Cases

Weighted National Estimate

% of Weighted Cases

95% CI

1

2876

59,807

3.5%

49,257-70,357

2

1850

42,214

2.5%

33,940-50,488

3

1829

44,259

2.6%

35,584-52,934

4

2608

62,199

3.7%

51,227-73,171

5

4202

103,450

6.1%

87,229-119,671

6

5221

128,355

7.6%

108,229-148,481

7

5378

130,272

7.7%

109,845-150,699

8

4986

121,004

7.2%

102,031-139,977

9

4175

105,178

6.2%

88,686-121,670

10

3375

80,252

4.7%

66,096-94,408

11

2774

67,117

4.0%

55,278-78,956

12

2981

64,862

3.8%

53,420-76,304

13

2281

55,996

3.3%

46,118-65,874

14

2375

62,298

3.7%

51,309-73,287

15

2316

57,500

3.4%

47,357-67,643

16

2389

63,111

3.7%

51,978-74,244

17

2456

65,001

3.8%

53,535-76,467

18

2411

64,396

3.8%

53,037-75,755

19

2369

62,218

3.7%

51,243-73,193

20

2469

63,399

3.7%

52,215-74,583

21

2357

64,285

3.8%

52,945-75,625

22

2413

64,452

3.8%

53,083-75,821

23

2266

60,608

3.6%

49,917-71,299

Total

68,357

1,692,233

100.0%

1,493,226-1,891,240

hospitalized after injury than children aged 1 year and older (95% CI: 1.49-1.69; p < 0.001). The primary mechanism for injury was by falling (68%), followed by jumping (17%) and rolling (9%) off beds and sofas. The proportion of injuries from jumping increased by 31% with increas- ing age from <1 year to 4 years, while the proportion of injuries from rolling decreased by 18% with increasing age from <1 year to 4 years. The mechanisms of injury stratified by age group are highlighted in Fig. 3.

Of the 4% of infants and children who required hospitalization, frac- tures (63%) and closed head injuries (20%) accounted for the majority of diagnoses. There were 17 infants or children identified with a concern for abuse or suspected abuse in the sample of 100 representative EDs (n = 133,656), which extrapolated to a national estimate of 113 possi- ble cases between 2007 and 2021- the majority of cases involved children <1 year of age (59%).

  1. Discussion

This study is the first to use a nationally representative sample to study bed and sofa-related injuries in the pediatric population. The key findings of our study are that injuries associated with beds and sofas are common among young children, a leading cause of trauma and hospitalization among infants (<1 years old), and dangerous due to a high prevalence of head injuries. Falling from beds and sofas was the primary movement mechanism associated with injury and is most common among the infant age group. Not only were infants suffering from the highest proportion of overall bed and sofa-related injuries (29%) and associated hospitalizations (39%) in the included population, but they were also more likely to be hospitalized than children aged be- tween one and five years (OR: 1.58). A closer look into injury incidence trends, injury characteristics, and injury scenarios from our study may help better inform preventative strategies for these injuries and aid pe- diatric emergency preparedness in clinical settings and at home.

Over 3.4 million injuries among children aged <5 years were identi-

fied in the study period; our analysis demonstrates several interesting trends. Though the incidence of bed and sofa-related injuries in children

<5 years old fluctuated over the 15-year period, we observed an in- crease in incidence between 2007 and 2012, followed by a decrease in incidence from 2012 to 2021. A similar pattern is seen in children pre- senting to US emergency departments for furniture and television tip- over injuries [9]. The steepest decrease in emergency department visits (14%) occurred between 2019 and 2020, corresponding with the COVID-19 pandemic. The apparent increase in the incidence of bed and sofa-related injuries presenting to US emergency departments from 2007 to 2012 is consistent with the national trend of increasing ED department utilization during this time period [10-12]. The sharp decline in ED visits observed from 2019 to 2021 in this study is consis- tent with a dramatic national decrease in all-cause pediatric emergency department visits during the early COVID-19 pandemic [13-15].

The demographic trends and injury characteristics observed in this study are consistent with those of existing studies on pediatric falls – especially regarding the localization of injuries to the head region and the increased incidence and severity of injuries in children below the age of one [16]. This pattern seems intuitive as our results indicate that falls are responsible for most of the bed and sofa-related injuries in children. In a 2018 study on the demographics and mechanisms of falls in children across a single state trauma registry, Chaudhary et al. found that falls from beds were the most common cause of furniture- related falls in this patient population [17]. The same study also noted

Image of Fig. 1

Fig. 1. Incidence Per 10,000 Persons of Bed and Sofa-Related Injuries in Children Under Age Five Between 2007 and 2019.

Image of Fig. 2

Fig. 2. National Estimates of Bed and Sofa-Related Injuries Categorized by Age Between 2007 and 2021.

increased incidence and severity of injuries in children <1 year of age, and that head injuries, such as intracranial hemorrhages and skull frac- tures, represented the majority of pediatric fall-related injuries. Our study supports these findings to hold true in a nationally representative sample. Similarly, Haarbaur-Krupa et al. found that the greatest propor- tion of fall-related brain injuries took place in children below the age of one; Orces and Orces identified an increasing trend in pediatric head and neck fractures between 2001 and 2015 [18,19]. While there was a high incidence of injuries among children under the age of one in our study, we observed a decreasing incidence in injury as age increased. In general, younger children are more vulnerable to unintentional furniture-related injuries given their limited strength and coordination [20]. This may explain why children under the age of one accounted for nearly 40% of hospitalizations from bed and sofa-related injuries in our

study period. Furthermore, the short stature of young children relative to the height of the fall may be associated with the observed increased risk of head and neck injuries. The high incidence of bed and sofa- related head and neck injuries in children under the age of 5 highlights the need for Preventative measures, as even mild and moderate head injuries in young children can have negative long-term functional and neurobehavioral consequences [21,22].

Falls from beds and sofas are common scenarios provided to conceal child abuse and neglect [23]. Given the high incidence of bed and sofa- related Pediatric injuries presenting to US emergency departments, it is vital that clinicians are able to distinguish between unintentional and abusive injuries. Both missed child abuse cases and wrong suspi- cions can have serious consequences. The results of our study suggest that bed and sofa-related injuries were used to conceal over 100

Image of Fig. 3

Fig. 3. Proportion of Bed and Sofa-Related Injuries Between 2007 and 2021 by Movement Type.

suspected or confirmed cases of child abuse nationally between 2007 and 2021. This is likely an underestimate, given the reportedly low de- tection rates of child abuse in Pediatric cases presenting to emergency departments [24]. Fortunately, studies have shown that effective emer- gency department Screening tools can substantially improve child abuse detection rates [24-26]. Several studies on injury potential in children attempt to aid clinicians in distinguishing between abusive and unin- tentional injuries by outlining specific details of the clinical history (e.g., mechanism of injury, type of impact surface, presence of bruises, presence of subarachnoid hemorrhage or other brain injury, mobility of the child at the time of injury, evidence of prior concurrent injury, etc.) that can be crucial in alerting clinicians suspected abuse [7,27]. By highlighting common injury characteristics of pediatric bed and sofa-related injuries, our study’s results inform the general expectations for the clinical presentation of such injuries, thereby making clinicians better equipped to recognize cases of Suspected child abuse.

There are several limitations to our study. The use of ED admissions as a metric of national medically attending injury incidence may result in underestimates, as patients may also present to outpatient clinics and urgent care centers. Additionally, all cases of abuse or suspected abuse may not have been documented in the database, as the reported details of each case can vary. Other factors potentially influencing the accuracy of our dataset include our reliance on estimated national Incidence rates based on database-provided weights, the potential for incomplete or incorrect documentation by ED personnel, and the absence of concomitant injuries being consistently recorded within the NEISS database.

Despite these limitations, our analysis reveals that bed and sofa- related incidents are an important source of injury to children under five years of age, highlighting the need for increased preven- tion efforts, and the importance of effective screening tools to identify cases of abuse. Potential prevention efforts include increas- ing caregiver education and improving safety design to reduce soft furniture injuries in young children [28]. Caregiver education, where the risks of placing children on beds, sofas, and other furniture are outlined, may serve as a simple and effective preventative mea- sure for soft furniture injuries. Medical practitioners should engage in education on home safety practices for young children on a regular basis to help inform caregivers. In particular, caregivers should avoid leaving small children unsupervised on beds and sofas because of the high risk of injury from falling or rolling off of these furniture items. Caregiver supervision is also essential in situations where small children may attempt to climb and jump from furniture or push other children (e.g., younger siblings) from a sofa or bed. Additional strategies to enhance safety can include placing beds and sofas over shock absorbing surfaces (rugs, carpets, etc.), installing guard rails on beds, increasing age recommendations for bunk beds, and includ- ing cautionary labels for parents on furniture items. While multiple robust studies and prevention efforts have been implemented for other sources of unintentional childhood injury (e.g., stairs, windows, baby carriers), research related to soft furniture-related injuries is lacking. Future studies should further explore the risk fac- tors for such injuries and investigate the efficacy of preventative strategies.

  1. Conclusion

Beds and sofas can be associated with injury among young children, especially infants, and oftentimes lead to head trauma. In this retrospec- tive national database study, we identified an increasing rate of bed and sofa-related injuries among infants <1 year old over a 15-year period. Increased prevention efforts, including caretaker education and im- proved safety design, as well as utilization of effective child abuse screening tools by clinicians, are necessary to decrease and better man- age these injuries.

Sources of support

No additional funding or support was received.

CRediT authorship contribution statement

Rafat H. Solaiman: Writing – review & editing, Writing – original draft, Validation, Methodology, Investigation, Formal analysis, Conceptualization. Sergio M. Navarro: Writing – review & editing, Writing – original draft, Methodology, Investigation, Data curation, Conceptualization. Eesha Irfanullah: Writing – review & editing, Writing – original draft, Investigation. Jilun Zhang: Writing – review & editing, Investigation. Marc Tompkins: Writing – review & editing, Supervision. James Harmon: Writing – review & editing, Supervision.

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