Symposium on Injuries and Injury Prevention
Falls in Children and Youth L. K. Garrettson, MD.,* and Susan S. Gallagher, M.P.H.t
STUDY OF FALLS BY THE THREE INJURY PREVENTION DEMONSTRATION PROJECTS Humpty Dumpty sat on a wall Humpty Dumpty had a great fall All the king's horses and all the king's men Couldn't put Humpty together again.
The frequency of falls in childhood and the advantages of prevention over treatment and rehabilitation long have been recognized in myth and in fact. Yet the wide diversity of situations in which children fall and the range of severity of resulting injuries have proven barriers to developing comprehensive, effective intervention programs. The purpose of this article is to provide the clinician with a review of the literature on falls and their prevention, and to present the experiences of three federally funded Injury Prevention Demonstration Projects with this important type of injury. Epidemiology Falls are the fourth leading cause of death from external trauma in all ages in the United States. 5 Death certificate analysis by the National Safety Council indicates that falls in children rank fourth behind motor vehicle trauma, fires, and drowning.! In New York City, falls are the third leading cause of traumatic death in children under 13 years. 48 In England and Wales, fall-related death has declined from third to fourth in the age group 10 to 14 between 1961 and 1979. In younger ages, deaths from falls have declined in frequency but remain fourth behind the same three leading causes of trauma in the United States. 49 Death rates from trauma in Masachusetts have been studied,19 and falls were found to be the fifth most frequent cause of traumatic death. At a rate of one per 100,000 per year in San Diego County, falls did not lead to a single head injury death in children 0 to 14 in 1978, although head
Professor of Pediatrics and Pharmacy/Pharmaceutics, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia tDirector, Statewide Childhood Injury Prevention Program, Massachusetts Department of Public Health, Boston, Massachusetts
Pediatric Clinics of North America-Vol. 32, No.1, February 1985
GARRETTSON AND SUSAN S. GALLAGHER
injuries killed 44 children in that age range that year. If falls kill 1 per 100,000 per year, and half are related to head injury, a county the size of San Diego (population 1.8 million with 384,000 age 14 and under) may not experience deaths in a given year. Therefore, while important, mortality from falls should be seen as an uncommon event. Morbidity from falls is large. Falls are the most frequent cause of injury bringing patients of all ages to the emergency department, 5 and this is true for children as well. 20, 36, 42 In a study where patients were identified as being injured in the home, falls were the most frequent injury in that population. 3 Age is the most consistent variable defining differences in fall rates, with the highest incidence occurring in early childhood and the elderly.2, 17, 20 The studies in Virginia and San Diego showed the incidence of falls was highest at younger ages and declined with age. Massachusetts data confirms this. Table 1 indicates that the rate of falls peaks in the toddler period for both sexes. Data from Virginia21 show a low rate of significant injury in children one to five who are brought to the emergency room. In Toronto,23 a bimodal peak was noted in fall victims admitted for head trauma with peaks occurring before one year and in seven to eight year olds. A bimodal distribution in age-related fall death was found in Brooklyn,48 with the second peak occurring in adolescence. Falls have been found to be more frequent among boys,2, 31, 36, 37, 42 and the injury ratio of boys to girls living in urban areas increases with age. s, 48 Between the age of one and four, the sex difference is small,26 and below the age of one there is little difference. Table 1 shows rates for both sexes in Massachusetts. Although the Massachusetts data also shows a higher rate of falls among boys, the sex ratio actually decreased with age. However, the Massachusetts study also includes data on children living in nonurban environments and excludes falls related to sports and bicycles. The rate of falls by socioeconomic class has been studied. Kravitz studied falls in the home for children under one year and found the frequency higher in clinic than private office patients. 33 Window falls in New York City are skewed to the lowest income group.43 Falls appear to be more prevalent among the poor. Deficiencies in the environment, which include aging or deteriorating housing and play areas, can explain these differences. Falls have been found to occur half as frequently in surburban and rural areas (65 per 10,000) in contrast to urban areas (134 per 10,000) in Massachusetts (Table 1). This is true for all age groups. Table 1.
Annual Fall* Injury Rates per lO,OOOt
0-19 0-5 6-12 13-19
134.07 240.10 92.13 96.30
65.02 130.70 43.18 47.25
99.54 185.40 67.66 71.78
*Includes all non-sports/non-bicycle related falls. tSources: Massachusetts SeIPp, September 1, 1979-August 30, 1982.
FALLS IN CHILDREN AND YOUTH
Race as a determinant of fall rate has been assessed. Manheimer36 found whites at the highest risk with blacks lower and Orientals lowest. In Brooklyn,48 the fall rate for blacks was higher than Hispanics and both were markedly higher than that for whites. In Virginia, standard morbidity ratios show the rate of falls in blacks significantly higher than whites at all ages except adolescent girls. The two large inner city hospitals, serving a largely black and indigent population, accounted for 15.8 per cent of all visits in the study, but 31.3 per cent of visits in children under one. Whether this represents a difference in injury rate, emergency department use patterns, or caretaker anxiety could not be discerned. An emergency department use pattern dependent on physician availability has been postulated. n Falls do not occur uniformly throughout the day. Studies of head injury, where falls are a major cause of the injury, have shown a peak rate between noon and early evening. n , 25, 26, 43 In Virginia, the peak time for an emergency department visit is between 6 and 8 P.M., although the occurrence of falls rises steadily throughout the day. The frequency of falls by month varies among studies. KlonofFll found falls in young children more frequent in spring and early summer. In Virginia, there was little monthly variability. Spiegel found that 70 per cent of window falls in New York City occurred in June, July, and August. 43 A summertime peak in incidence mirrors the seasonal pattern seen for all trauma in children. 24 What Children Fall From Table 2 lists what children aged 0 to 5 years in Massachusetts fell from in receiving injuries that took them to the emergency room or led to an admission. 15 The list does not select for the injury received. The home is a dangerous environment for toddlers. Injuries from stairs and steps predominate, while beds, tables, and chairs are also common injury vehicles. Only two children fell off roofs; both were admitted. Eight infants fell from changing tables and four were admitted. In Virginia, only children who fell and hit their head were studied (Table 3). Stairs are the most common location, furniture and adult beds and changing tables also were prominent. In this study, the records of only 773 of 4500 cases identified the surface from which the child fell. In a Canadian Study of 880 hospitalized head injuries in childhood, two thirds resulted from falls. Falls from bicycles predominated (19 per cent) while furniture, stairs, play, and sports were also common causes. Falls from heights, such as from windows, roofs, balconies, and trees, accounted for only 9 per cent.23 In studies a,ddressing falls from heights, the windows of the patient's domicile account for nearly all injuries. S, 12 Older children and adolescents fall more often from trees, roofs, and ladders. The Contact Surface In one fourth of cases in Virginia the impact surface was recorded (Table 4). Concrete or asphalt is associated with more injuries than other surfaces. Concrete is recognized as one of the most unforgiving surfaces. 40
L. K. GARRETTSON AND SUSAN S. GALLAGHER
Table 2. The Relationship Between Those Fall Victims Treated and Released and Those Admitted According to the Suiface Fallen From For Ages 0 to 5* PRODUCT
Housing Structures Stairs and steps Walls Doors and doorways Floors Porches Bathtubs and showers Windows Roofs Others
196 24 24 20 8 8 8 0 48
16 1 1 1 3 1 0 2 0
Household Furniture Beds Tables Chairs and stools Television and stereos Sofas High chairs Desks, chests, and bureaus Baby changing tables Cribs Others
96 96 84 32 24 20 12 8 8 20
7 2 3 0 1 0 0 4 1 0
Other Household Toys Ladders Others
32 4 80
0 1 0
Miscellaneous N onhousehold Playground equipment Baby carriages and strollers Bicycles and tricycles Grocery carts Others
60 48 16 8 32
2 5 1 1 1
No Product Reported Total
*Source: SCIPP Injury Surveillance System, Massachusetts, 1 year data, September 1, 1980--August 31, 1981. tEmergency visits are estimated from a 25% sample.
In the analysis of a series of 43 head injuries following falls from 10 feet or more, Cummins and Potter reasoned that the contact surface was more important than the height of the fall; victims that hit hard ground or concrete had greater injury than those who hit grass even though the heights of the falls were similar.l2 Injuries Sustained as the Result of Falls Velcek classified children under 13 who died from a fall according to the injury sustained and whether they arrived at the emergency depart-
FALLS IN CHILDREN AND YOUTH
What Children Fell From In Head Injuries*
1 2 3 4 5 6
Stairs Furniture Adult bed/Changing table Tree Bike Window Ladder Infant seat Roof
328 215 136 34 23 21 8 6 2
42 28 18 4 3 3 1 1
*Source: Extracted E.R. charts VA.
ment alive. 48 Head and neck trauma was the cause of death in 56 per cent and multiple trauma in 37 per cent of these cases. Assuming that the head was involved in many or all of the multiple trauma cases, it can be reasoned that head trauma is present in the great majority of falls causing death. In a series of head trauma deaths, Jamison and Kaye found that four of 14 deaths resulted from falls. The remainder were all automobile-related injuries. 26 The extent of the head injury was a common determinant in death from falls. There is little data on prolonged or debilitating injury follOWing falls other than those resulting in injury to the head. Jamison and Kaye reported on two victims of falls; one was left with a low IQ and hyperactivity, and the other with hemiparesis. 26 In a series of 160 severe head injuries from all causes (68 patients under 20), Becker found that mortality increased steadily with age. 7 Twelve per cent of the youngest group were left severely handicapped or vegetative; this was the highest figure for any age group. This pattern was not found by Bruce, who concluded that the child recovered more completely than the adult for the degree of acute injury. 10 The frequency, diagnosis, and Significance of skull fracture has been written about many times. g ,35 Controversies often center on less serious injuries, and, therefore, even when not stated, it can be assumed that falls have been the leading cause of injury. This literature is beyond the scope of this article. However, one aspect of the problem was amplified by the Table 4. RANK
1 2 3 4 5 6
What Children Hit Their Head On*
Furniture Concrete/Asphalt Brick Metal Object Rock Recreational Equip. *Source: Extracted charts VA.
49 32 7 6 5 1
59 50 14
GARRETTSON AND SUSAN S. GALLAGHER
studies presented here. The Virginia group observed a higher skull fracture rate in infants under the age of 1 year than at any other age. The increase of this injury in infants was seen by Boulis, 9 where the fracture frequency was five times the frequency for children 1 to 4 years. Leonidas,35 finding the same, has proposed skull films for all patients under one year of age who have a history of head trauma. Epilepsy has been associated with head injury. Jennet has suggested that both local and diffuse cerebral injury must be present before an injury becomes highly epileptogenic. 28 Falls from bunk beds may be a particularly important hazard for those with nocturnal seizures. 41 Falls leading to head trauma can lead to school problems. 32 School-age children had a higher incidence of complaints reported by parents one year after head trauma than did preschool children. The occurrence of headaches was the most common complaint. Otlwr problems included impaired concentration, learning difficulties, irritability, personality changes, dizzy spells, and visual or auditory impairment. The presence of this postconcussion syndrome 13 has not been included in most studies of morbidity resulting from falls. Acute injury from falls to parts other than the cranium and brain has been reported by several authors.3, 8, 9, 22, 23, 33, 48 In the Massachusetts study of 4767 falls 20 38 per cent of falls resulted in a laceration, 38 per cent in sprains, 14 per cent in a nonskull fracture, and 8 per cent in intracranial injuries. Only 3.3 per cent of all fall injuries required admission to the hospital. In Virginia, lacerations also were the most common injury, occurring in nearly 50 per cent of the cases. Below the age of one, the laceration rate was lower than at older ages. Only 7 per cent of the entire group had an altered level of consciousness on arrival at the hospital; the occurrence of a laceration defined a group that had only a two per cent likelihood of altered level of consciousness. X-rays identified those with potential injury to other parts. The child under one had the highest frequency of skull x-rays and fractures, but few had other radiographic studies. The child over 12 had the highest frequency of studies for non-CNS injury. It is the opinion of these reviewers that the true morbidity resulting from falls is underestimated. A striking finding in Virginia is the large number of children for whom no serious injury was found. Helfer reported 85 cases in which children had fallen out of a bed or crib and were brought to the emergency department for care. 22 There was only one with a skull fracture, and none had significant intracranial injury. It appears that a fall leading to bump of the head is viewed as a serious event by parents. This is due possibly to the widespread belief of the potential for death or prolonged illness from falls. Prevention of Fall Injury By Legislation and Regulation. Limiting the number of falls by environmental modification should be a rewarding area for our effort. Public building codes have been improved gradually to mandate design changes for child safety. Codes covering domestic safety, when enforced, have the potential for reducing childhood falls. As the stairway stands out in our
FALLS IN CHILDREN AND YOUTH
studies as an area of frequent injury, resolution of problems found there should be beneficial. The Massachusetts project included a housing inspection component. 18 Inspectors found violations and enforced compliance. Stairwells, handrailings, balusters, and spindels were noted as not meeting code in more than 30 per cent of urban homes. Many homes also contained stairs in poor repair or unilluminated stairways. Physicians in other states may find this a fruitful lead to follow. By Devices. Gates on stairways effectively prevent falls. Light, collapsable gates are common and readily available. Gates with accordion tops have been associated with strangulation, so other designs should be recommended. Gates become particularly important if a toddler uses a walker above the ground floor of a dwelling,3O yet more than 30 per cent of homes with young children in Massachusetts did not have toddler gates. Falls down stairways are also a risk for the elderly. As the populations of both age groups at risk increase, the routine installation of sturdy gates in the construction of all house and apartment stairs should be considered. Falls from windows are often lethal or devastating. 8 Window guards can remove this threat. 43 These devices should be mandated in areas with high rise apartments. Planting garden beds close to buildings to cushion falls has been proposed,12 The surface of playgrounds has been addressed by several authors. Technical information on surface materials is available. 40, 45, 46, 50 Concrete, asphalt, and brick have no place around playground equipment. Appropriate surfacing must be installed in all new playgrounds and a program of upgrading existing playgrounds should be developed in all communities. The New York State Playground Injury Prevention Demonstration Project16 addressed this problem through (1) playground equipment inspection surveys; (2) information and education seminars for those involved in purchase, installation, maintenance, and supervision of public playgrounds; and (3) a public information campaign via media assistance. Results of an evaluation indicated an increase in knowledge for playground personnel, a significant reduction in hard surfaces beneath playground equipment, a 42 per cent reduction in equipment hazards, and a 22 per cent reduction in playground-related injuries at two hospitals. Helmets may limit head and neck injury for bicycle riders and equestrians. In the last 10 years, devices have been marketed for both groups. Their use is to be encouraged on an individual and group basis, particularly where competition is involved. Studies are required to document the efficacy of helmets for these groups; the efficacy of helmets in motorcycle riding has been reviewed. 14 By Behavior Modification. Kravitz34 has shown that physician counselling of parents of small infants can reduce the incidence of falls. Specific topics for discussion, in addition to the gates and window guards mentioned above, are both cribs and changing tables. 47 These pieces of furniture appear frequently in epidemiologic studies, and prevention efforts directed at them are cheaply and easily accomplished. Falling out of cribs occurs when the infant begins to stand and climb. The mattress level must be adjusted at an age-appropriate time. When
GARRETTSON AND SUSAN S. GALLAGHER
climbing begins, items such as pillows and large stuffed toys must be excluded from the crib to prevent their use as ladders over the crib side. 34 , 47 The changing table was a leading contributor to falls in the Kravitz33 and Virginia studies. Kravitz proposed that they be redesigned with sides that curve up. However, it can be reasoned that a piece of furniture with such a short useful life and such injury potential should be eliminated altogether. As cloth diapers become infrequently used, the changing table's function for diaper storage diminishes. Infants can be safely and efficiently changed on the floor. Infants never fall off the floor. Reducing the Cost of Falls The Virginia study clearly showed an excessive use of emergency departments for insignificant head injury. Small town and suburban hospitals had the highest rate of visits for head bumps and for insignificant injury. It is not known how many patients tried to contact their private physicians, but the peak incidence came at a time when physician's offices are usually closed and a message must be left and call-back awaited. Education in basic assessment of the child who has bumped his head may allay the fears of parents so that they will await telephone advice when that is appropriate. In Virginia, a hotline number was developed to offer such counsel to parents who had no primary care provider. Protocols were developed with consultation from pediatricians, pediatric neurologists, and pediatric neurosurgeons. This service was similar to that of others38, 44 but was limited to head injury and burns. The service became used as soon as advertised. Over half of the callers could be followed at home, and no late referrals have occurred to date. The safety and acceptability of this form of care needs further study. Similar services have been incorporated by others into general pediatric phone protocols, and guidelines for advice are readily available. Conclusion Falls are common, particularly in infants and toddlers, and adolescents engaged in sports. Some prevention efforts directed at specific fall types have proved effective. Counselling by physicians has been shown to be effective in some situations. Physicians may be able to improve both the behavior of parents and the physical environment of the home by this counsel. Where extreme hazards exist, physical barriers must be the primary strategy. This may require both public education and legislation. Ordinances intended to reduce falls need enforcement, and physicians may recognize and report this need. Changing the design and underlying surface of the play environment of children has great potential for decreasing injury from falls. All physicians caring for children need to have a head injury protocol for their patients. This should include advice that will prevent the excessive use of emergency facilities when insignificant injury has occurred. Efforts directed by the knowledge of injury epidemiology reviewed in this article and expanding on the successful programs cited have great potential to reduce the morbidity of injuries resulting from falls.
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32. Klonoff, H.: Head injuries in children: Predisposing factors, accident conditions, accident proneness and sequelae. Am. J. Public Health, 61:2405, 1971. 33. Kravitz, H., Driessen, G., Gomberg, R., et al.: Accidental falls from elevated surfaces in infants from birth to one year of age. Pediatrics, 44:869, 1969. 34. Kravitz, H., and Grove, M.: Prevention of accidental falls in infancy by counseling mothers. Illinois Med. J., 143:570, 1973. 35. Leonidas, J. C., Ting, W., Binkiewicz, A.: Mild head trauma in children: When is a roentgenogram necessary. Pediatrics, 69:139, 1982. 36. Mannheimer, D. I., Dewey, J., Mellinger, G. D., et al.: 50,000 child-years of accidental injuries. Public Health Rep., 81:519-533, 1966. 37. Matheny, A. P., Brown, A. M., and Wilson, R. S.: Behavioral antecedents of accidental injuries in early childhood: A study of twins. J. Pediatr., 79:122, 1971. 38. Perrin, E. C., and Goodman, H. C.: Telephone management of acute pediatric illnesses. N. Engl. J. Med., 298:130, 1978. 40. Reichelderfer, T. E., Overbach, A., and Greensher, J.: Unsafe playgrounds. Pediatrics, 64:962, 1979. 41. Riley, T. L., and Brannon, W. L.: Bunk beds and the person with epilepsy. J.A.M.A., 242(25):2761, 1979. 42. Sibert, J. R., Maddocks, G. B., and Brown, B. M.: Childhood accidents-An endemic of epidemic proportions. Arch. Dis. Child., 56:225, 1981. 43. Spiegel, C. N., and Lindaman, F. C.: Children can't fly: A program to prevent childhood morbidity and mortality from window falls. Am. J. Public Health, 67:1143, 1977. 44. Strasser, P. H., Levy, J. C., Lamb, G. A., et al.: Controlled clinical trial of pediatric telephone protocols. Pediatrics, 64:553, 1979. 45. U.S. Consumer Product Safety Commission. A Handbook for Public Playground Safety. Vol. 1. General Guidelines for New and Existing Playgrounds. Washington, D.C.: U.S. Govt. Printing Office, 1981. 46. U.S. Consumer Product Safety Commission. A Handbook for Public Playground Safety. Vol. 2. Technical Guidelines for Equipment and Surfacing. Washington, D.C.: U.S. Govt. Printing Office, 1981. 47. U.S. Consumer Product Safety Commission: Product safety fact sheet no. 20. Infant falls. 1978. 48. Velcek, F. T., Weiss, A., DiMaio, D., et al.: Traumatic death in urban children. J. Pediatr. Surg., 12:375, 1977. 49. Wells, N.: OHE Briefing: accidents in childhood. Office of Health Economics, London, 1981. 50. Werner, P.: Playground injuries and voluntary product standards for home and public playgrounds. Pediatrics, 69:18-20, 1982. Department of Pediatrics Virginia Commonwealth University Richmond, Virginia 23298