Preschool injuries in child care centers: Nursing strategies for prevention

ORIGINAL ARTICLE

PreschoolInjuries in Child Care Centers: Nursing Strategiesfor Prevention Margaret

Smith

& Mary

Ulione,

Dooling,

PhD, MSN,

RN, RN

are the most frequent cause of preschool child death and disability in this country Approximately

one in every five

children will receive an injury that requires medical attention. The five leading causes of death for children 0 to 4 years of age are homicide, fire and burns, drowning,

motor vehicle occu-

pancy accidents, and motor vehicle pedestrian accidents (Ray & Yuwiler, 1994). Other than homicide all of these injuries are unintentional

or accidental injuries and are amenable to pre-

vention. Most injuries do not result in death but in disability ‘cusses the-problem of injuries in child care centers in general and “discusses injury prevention strategies the nurse can share with the child care provider. Educational resources are included to help the child care providers assess and monitor their own center’s injury risk. J Pediatr Health Care (1997). I I, 11 l-l 16.

May/June

1997

or dis-

comfort of some kind. The medical expenditures

for injuries

Margaret Smith Ulione is the Director of the Post MSN Practitioner College of Nursing at the Universiv of Missouri St. Louis.

Professor at Barnes

Mary Dooling

is a Child Care Health Consultant

Program and a Clinical

at Pedi Health Works

in St. Louis, Missouri.

Reprint requests: Margaret Smith Ulione, PhD, RN, Barnes College of Nursing, 8001 Natural Bridge Rd., St. Louis, MO 63121. Copyright

Q 1997 by the National Association

0891-5245/97/$5.00

of Pediatric Norse Associates

University

of Missouri

St. Louis,

& Practitioners.

+ 0 25/l/76904

111

ORIGINAL ARTICLE

incur an enormous drain on the health care system (Rice & Max, 1996). Although nonfatal unintentional injury statistics are difficult to interpret, it appears that the most common injuries for the preschool age child are falls, strikes by objects, cutting and piercing injuries, burns, poisonings, foreign body aspiration, bites, and motor vehicle injuries (Bourguet & McArtor, 1989; Widome 1991). Several variables influence a child’s injury risk. These variables include the child’s age, stage of cognitive and motor development, and everyday environment. Although child care providers are often well versed in child development principles and how they affect education, they are sometimes unaware how these principles affect a child’s injury risk. Nurses can prevent childhood injuries in child development centers by first educating the child care providers about injury prevention and then by teaching them how to assess for and monitor injury risks in their own centers. This education will help child care providers ensure a safe environment for children. The purpose of this article is to present general injury epidemiologic information for the nurse to use with child care providers and to provide strategies the nurse can use to empower child care providers to assess and monitor the injury risk in their centers. Age and Developmental Considerations Developmentall infants and toddlers are driven to actively explore their environment. Their gross motor skills, however, are still developing, resulting in tripping and falling over objects and their own feet. Add to this the toddler’s impulsive behavior and inability to understand the consequenties of his or her actions, and you have an injury waiting to happen. It is no surprise

1 12

Volume

11 Number

3

U!ione & Dooling

then that infants and toddlers have the highest rates of injuries during childhood (Zuckerman & Duby, 1985). Preschool children are in the developmental stage of preoperational thinking (Freiberg, 1992). Preschool age children are very egocentric; in other words, they think only of themselves. For example, many injuries result from egocentric peer struggles “. . . that block belongs to ME.” Preschoolers also believe that inanimate objects are capable of human feelings and actions. For example, a 4-year-old child who runs out in front of a car will believe that the car would stop because it would not want to hurt someone. l’relogical thinking means that preschool age children do not fully understand cause-andeffect relationships, so they really cannot think about the consequences of their actions. They are also very curious and will “get into everything” to explore their worlds. These characteristics put preschoolers at risk for hjury. Characteristics

of Injury Risk

The concept of “injury proneness” is controversial (Bijur, StewartBrown, & Butler, 1986). Although the type of temperament a child has does not necessarily predict his or her injury proneness, some children may be more susceptible to injury than others. Nyman (1987) studied children who had been hospitalized for injuries and found that those children were characterized by negative mood, high intensity of responses, persistence, a high level of activity, and a negative reaction to new situations. Similarly at risk are boys, because they are injured twice as often as ‘girls, and children who are characterized as aggressive or overactive on standardized rating scales (Bijur et al., 1986; Elardo, Solomons, & Snider, 1987). Knowing the characteristics that are associated with increased tijury will help the child

care provider to identify children who may be more at risk for tijury than others. Injuries in Child Development Centers Few research studies have examined the epidemiology of injuries in child development centers. Chang, Lugg, and Nebedum (1989) studied the injury incidence in children 2 to 5 years of age in a California school district. These researchers collected data on 423 injury incidences that resulted in a total of 500 reported injuries. Consistent with injury epidemiology, boys sustained more injuries than girls, and most injuries were minor; medical attention was recommended in only 12.8% of the injuries. The leading types of tijuries were contusions, 238 (47.6%), lacerations, 115 (23.0%), abrasions, 54 (lO.B%), and other injuries, 32 (6.4%). The greatest numbec of injuries (56%) occurred in late morning from 9:00 AM to noon. Half (50.1%) of the injury events occurred during outdoor activity, and more than half (53.7%) of the injuries involved a consumer product. In these cases playground equipment was involved in 62.3% of the incidents. Although Chang’s research is some of the most complete on the epidemiology of child care tijuries, no data on infants and toddlers are included. Lee and Bass (1990) analyzed 103 accident report forms in a ‘university daycare center. They found that infants had the lowest number of injuries, toddlers second, and 3- to 5-year-olds the most. The most frequent injury for the 3- to 5-yearolds was a scratch, cut, or abrasion (30%), which occurred during running, fighting, or horseplay. The playground was the site for most of these injuries. Ulione (1994) measured the accidental injury rates of 35 children in a university child development center with both direct observation

JOURNAL

OF PEDIATRIC

HEALTH

CARE

ORIGINAL

ARTICLE

and review of the injury report forms. The most frequent injury (60%) was a bump or abrasion. The injuries were caused by product equipment in 30% of the cases, by conflicts between children in 30% of the cases, and were self-inflicted in the remaining 40% of the cases. Consistent with injury epidemiology, boys were injured more frequently than girls, and most of the hjuries occurred in late morning. Child care providers recognize the need for injury prevention information to adequately supervise preschoolers. Nelson and Hendricks (1988) conducted a study to determine the level of and need for health education in child care settings in Alabama. The 100 child care program directors surveyed perceived their greatest needs for educational resources were in the areas of poisoning, falls, fire safety, iirst aid, dental health, nutrition, exercise, and hygiene. They responded that the greatest barriers to health education were lack of educational resources, time, and money. Practice Implications Clinical practice with child care programs and current research indicate that initial education issues focus on common injuries such as falls, biting, pedestrian injuries, and playground hjuries (National Committee for Injury Prevention and Control, 1989; Ray & Yuwiler, 1994). This list is, of course, not complete but addresses issues that are of most concern for child care providers. Because these are topics of interest to the child care providers, they are a good starting point for a child health care consultant’s injury prevention curriculum and practice. Falls Falls are the most common tijuries for both children and staff in child development centers. A typical fall for a child or staff member

JOURNAL OF PEDIATRIC HEALTH CARE

Ulione

BOX

1

CHILD

TO

PREVENT

supervise

prevent

the children

them

dangerous

from

diatily

from and

until

Furniture

imme-

access

to the

the floor

is dry.

objects

not be placed

should

under

in a manner

that

windows

allows

easy

to the window.

Stairways

should

that

into

the floor

limit

or other

access

to

getting

situations.

spills

area

Playground Equipment

FALLS

Closely

Clean

provider in Box 1 will help prevent falls before they happen.

CARE

PROVIDERTIPS

match

have

handrails

the child’s

the child

should

grip,

and

be frequently

cautioned

to go slowly

on the

stairs.

stairs

should

be

rugs,

debris,

The

well Avoid

lit. scatter

cluttered

on the floor

of traffic;

blocks

semienclosed furniture

should

be in a Secure

could

fall or be

from

a crib

over.

Remove

a child

the crib level

sides

use them

to climb

preschoolers provider

Keep

so the child

safe behaviors

everything

when

are at the nipple

of the child.

a minimum Model

or toys in areas

space. that

pulled

will a child

& Dooling

toys

to

can’t

out. because try to copy care

does!

is caused by slipping on spilled liquid in the center. There are other types of common falls for preschoolers. Many falls occur from climbing on top of objects such as a table or from tripping over something such as blocks. Younger children who are still napping in a crib may fall out while trying to climb out of it. Although most falls are minor, they account for a large number of injuries and deaths each year (Rivara, DiGuiseppi, Thompson & Calonge, 1989). Educational tips for the child care

Playground equipment is a common cause of injury in the preschool age child (Chang et al., 1989; Lee & Bass, 1990). Many of these injuries are falls from the equipment, resulting in broken bones, abrasions, and bumps. Unfortunately almost 50% of child care centers do not have impact-absorbing surfaces under their playground equipment (Centers for Disease Control and Prevention, 1988). The issues related to surfacing such as type and depth of surfacing needed to prevent injuries are complicated but are well documented in the literature (Caring for Our Children, 1992; Daugs &Z Fukui, 1988) and through the U.S. Consumer Product Safety Commission. Additional tips for safe playground play are found in Box 2. Pedestrian Injuries (Pick-up and Drop-off) Pedestrian injuries are a problem in general in the population of young children. This type of injury is the fifth most common cause of death for children 0 to 4 years of age and the second most common cause of death for children 5 to 9 years of age (Ray & Yuwiler, 1994). There is not much research on pedestrian injuries in child care centers; however, our own research and practice tells us this is a safety issue for child care providers (Ulione, & Donovan, in press). Children get excited and parents can be preoccupied or tired when picking up or dropping off children at child care settings. Combine these circumstances with the fact that young children think if they see the car, the car sees them, and the potential for a pedestrian tijury results. Educational tips to use while teaching child care providers about pedestrian injuries are found in Box 3.

May/June

1997

1 1 ?J

ID?~ORIGINAL Wi

ARTICLE

Ulione & Dooling

BOX 2 CHILD CARE

BOX 3 EDUCATIONAL

BOX 4 STRATEGIES FOR

PROVIDER TIPS TO PREVENT PLAYGROUND INJURIES

TIPS FOR PEDESTRIAN SAFETY

HANDLING

All areas of the playground should be visible at all times. Children should be closely monitored on the playground site by a child care provider. Climbing equipment and swings should be set in concrete footing at least 6 inches below ground surface. All pieces of playground equipment should be designed specifically for the body dimension of the preschooler; that is, use anthropometry to eliminate hazards. Similarly, make sure the apparatus matches the appropriate activity for the age group that is using it. Since late morning is the time of day preschoolers are most likely to be injured, before lunch is not a good time to try the children out on an unfamiliar piece of equipment. Check the playground every day for hazards such as trash or foreign matter, loose or wobbly equipment, sharp or protruding surfaces in the play equipment, or inadequate surfacing. Teach children safe play in the playground and indoors.

Human Bites Children younger than 3 years of age frequently bite. Initially, biting in a child approximately 1 year of age is a chance discovery at a time when teething and mouthing are normal behaviors. Later, children may use biting in stressful situations because they have not yet mastered language skills to express anger and frustration (Schmitt, 1992; Solomons & Elardo, 1989). Crowding can invite biting.

1 14

Volume

11 Number

3

The center staff, parents, and children should be aware of the designated plan for safe pickup and drop-off. The plan should clearly spell out safe drop-off and pick-up points and pedestrian crosswalks in the vicinity of the center. Child should be supervised by an adult while boarding and exiting all vehicles. Buckle children into the seat restraint after boarding, clear of the path of vehicle while exiting. Teach children car and traffic safety, especially before a field trip.

Crowded environments, in which one child is literally on top of another, can greatly frustrate toddlers who are just beginning to learn the social skills of sharing, taking turns, etc. (Dershewitz, 1993). Biting can trigger an emotional response for both child care providers and parents. Providers frequently express frustration at children who repeatedly bite; providers say that when biting starts with one child, it can become contagious and more children start to bite. The strategies in Box 4 will help prevent or eliminate this problem. Education and Assessment Child development centers are an obvious focal point to direct injury prevention services and other health promotion strategies (National Committee for Injury Prevention and Control, 1989). Despite this fact, few child development centers consult a nurse or nurse practitioner.

BITERS

Establish the ground rule that biting is not allowed. If a child bites, tell him or her firmly “No biting, biting hurts,” and temporarily remove him or her from the setting. Providers, parents and children should know the way this will be handled. Note the time of day and activity when biting occurs. It may fit a pattern, occurring, for example, during transition from one activity to another, or just before meal and nap time when kids are particularly tired and hungry. Look at the environment. Is there enough space to allow children to parallel play and access toys? Check your state and local licensing requirements for space. Provide outlets for expressing anger. Have punch bags, soft, squishy toys, and punching toys. Help children to identify and give a name to their feelings. Offer care and nurturing to the child who has been bitten, “That hurts.” If the skin is broken, apply first aid. Provide little attention to the biter. ,

The role of the nurse consultant is to educate the child care providers about injuries and injury prevention in early childhood educational settings and then to empower them to continually assess and monitor the injury risks in their particular center. To this end a nurse consultant should schedule an initial assessment visit. On an initial visit the nurse consultant reviews the policies and procedures of the center to make sure that the center has policies related to illness inclusion or exclusion, child abuse, emer-

JOURNAL

OF PEDIATRIC

HEALTH

CARE

ORIGINAL ARTICLE

Ulione & Dooling

BOX 5 RESOURCES Injury Prevention Works (IPW) 135 Glen Argyle Rd. Baltimore, MD 21212 Injury prevention works (IPW) is a nonprofit educational clearinghouse for playground safety information. They seek out and develop materials that are of use to those involved in designing, maintaining, and renovating playgrounds and those involved in advocating for safe playgrounds in community and school settings. U.S. Consumer Product Safety Commission (CPSC) Washington, D.C. 20207 Handbook for Public Playground Safety (free) This handbook contains voluntary safety recommendations for playground equipment and surfacing and recommendations for the layout, installation, and maintenance of playground equipment. The CPSC has numerous fact sheets and information of a variety of injury topics such as crib safety. American Academy of Pediatrics TIPP: The Injury Prevention Program Department of Publications 141 Northwest Point Blvd. P.O. Box 927 Elk GroveVilLage, IL 60009-9016 A Guide to Safety Counseling in Office Practice ($5.00) TIPP targets the most frequent and severe injuries at each developmental stage from birth to 12 years of age. TIPP materials include schedules of recommended minimal safety counseling and handouts providing detailed information about specific injuries. The guide includes safety surveys, counseling guidelines, and safety slips. National Association for the Education of Young Children Healthy Young Children: A Manual for Programs, 1995 1509 I 6th St., N.W. Washington, D.C. 20036-2460 I-800-424-2460

A comprehensive guide for health and safety. Topics include promoting health in programs for young children, healthful environments, safety and first aid, preventive health care, nutrition, special health needs, and managing illness.

gency medical care, and first aid. Each center should also have an injury report or incident report form that is complete enough to help the center determine its injury

JOURNALOFPEDIATRICHEALTHCARE

Maternal Child Health Bureau Health Resources and Services Administration, US PHS Department of Health and Human Services Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs One copy free from: National Maternal and Child Health Clearinghouse 2070 Chain Bridge Rd., Suite 450 Vienna, VA 22182-2536 This comprehensive volume of standards for out of home programs was developed in conjunction with the American Public Health Association and the American Academy of Pediatrics. In addition to general information on standards for child care programs, this volume includes standards on nutrition, infectious diseases, children with special needs, and facilities requirements. American

Automobile

Association

IOOOAAADr.

Heathrow, FL 32746-5063 The above address will give you information on teaching passenger safety to children. In addition, your local office has a catalog of films and videotapes that you can borrow free of charge. The videos are in the areas of school bus, bicycle and pedestrian safety, driver education, and highway safety. Children’s Safety Network (CSN) National Center for Education in Maternal and Child Health (NCEMCH) 2000 15th Sweet North, Suite 701 Arlington, VA 22201-2617 The Children’s Safety Network is a network of technical assistance centers working to assist state and other injury prevention agencies combat the public health threat facing children and adolescents today. . . injury and violence. CSN provides information and technical assistance to facilitate the development of new injury and violence prevention programs and to improve existing efforts to prevent injury and violence.

profile. The information in a good injury or accident report form includes facts about the injury itself such as what body part was injured, the day and time of the

injury, and any treatment. Any contributing factors should be included such as where the injury occurred and what equipment and other people were involved. If the

May/June 1997

1 15

ORIGINAL

ARTICLE

center does not have a good report form, examples can be found in Shapiro-Kendrick, Kaufmann, & Messenger’s (1995) book “Healthy Young Children. U If the center has been using a good injury report form, the nurse reviews past injury report forms with the child care provider to determine the center’s injury profile. An injury profile is an individualized needs assessment for injury prevention based on the injuries that have happened at the center. After the center’s profile is completed, the nurse develops specific injury prevention strategies and teaches the providers how to continually assess the center for injury hazards. For example, if blocks are often out in the open where they can be tripped over by staff and students, the strategy may be to offer block play in a semienclosed area. As a consultant the nurse can assist the child care providers by identifying appropriate resources for the center. There are a multitude of excellent resources the nurse can introduce to the child care provider to help him or her become knowledgeable about injury prevention. As an educational tool there are some excellent checklists available for assessing a center such as the one found in Kennedy and Kuhns’ book, &L&/Z Practices Assessment. Most of these resources are either low or no cost; the key is to access them (See Resources in Box 5). Educating child care providers and helping them access and use injury prevention resources is a major role for the nurse involved in child care. In addition, the nurse can continue to provide on-site consultations related to risk prevention and additional educational classes for parents and children.

116

Volume

11 Number

3

Prevention is the key to decreasing injury disability and death in this country. Primary care health providers can be in the forefront to decrease injuries through education and practice as child care health consultants.

Child

injury

in

American

S., & Butler,

behavior 11,966

and

Caring

children.

for

grams

(1992).

Daugs,

moting

in

care

pro-

in

chilcenters.

pro-

guide for

City,

of Health. pediatric

H.C.,

& Snider,

of accidents

American

K. (1992). approach.

Bartlett

Publishers.

B.C.

of Orfho-

development:

Boston:

Jones

A and

in Maternal

of age in

care

settings.

84,1011-1016. Instructionsfor

Philadelphia:

chtldren

Kaufmann,

(1995).

R.

Healthy

Washington,

Association

pediatric

W.B. Saunders.

A., KI?

&

young

D,C.:

National

for the Education H.C.,

injuries

of Young

hood Research Ulione,

& Elardo,

R. (1989).

at a day care center. M.S.

Quarterly,

(1994).

MS.,

Bile Child-

promotion

in a child raw

and

development

data.

& Donovan, in project

health.

Early

4,89-96.

Health

prevention

E. (in

head stark

press).

Improving

Issues in Comprehensive

Pediatric

Nursing. M.D.

(1991).

Pediatric

the

practitioner,

vention

for

Problems

in Pediatrics,

Zuckerman,

B.S.,

Developmental

for Education

Risk of injury

5 years

home

B.D. (1992).

Widome,

Kennedy C., & Kuhns, C. (1995). Health practices assessment. Arlington, VA National Child

versus

center. Unpublished

at a day

Journal

Human

Health,

C., Thompson,

N. (1989).

less than

care

Schmitt,

Ulione,

57,60-65.

l&span

Center

to children

Nursing

care center. Freiberg,

F.P., DiGuiseppi,

injury

PA.: J.B. Lippincott

An analysis

of Public

Children.

Playground

safety. Salt Lake

R., Solomons,

psychinty,

Rivara,

Solomons,

R.A. (1993). Ambulatoy

(1987).

Annotation: in the United

Journal

Shapiro-Kendrick,

Company Elardo,

San Diego,

Network.

of injuries

American

patients.

A.

preschool

day-care

care. Philadelphia,

Child and ado-

databook. W. (1996).

cost

Pediatrics,

United

& Nebedum,

Department

hospitaliza-

26,398~404.

Safety

& Max

Messenger,

A curriculum

UR Utah

58,

temperament,

J. (1994).

injury

R.S., & Calonge,

and Mortality

F. (1988).

playground

Dershewitz,

and

injuries

among

& Fukui,

perspectives:

D.P., States.

83,272-277.

D.D.,

care

Health,

and

Pediatric,

Children’s

of

in the

M.M.,

enrolled

Pediatrics,

(1988).

in child

Infant

& Yuwiler,

Journal

and Prevention.

Morbidity

Injuries

C.M.

accidents,

The high

143,125-126.

A., Lugg,

dren

Rice,

Guide-

child

children

Report,

(1989).

(1989).

health

Playground-related

Weekly

Oxford

86,14-15.

National

Control

1983-1987.

York

of School

(1987).

lescent fatal

day

States, Chang,

G.

childhood

in

American

out-of-home

preschool-age

prevention:

New

needs

Journa/

factors

standards:

for Disease

(1988).

R.E. Risk

performance

lines

injury

& Hendricks,

education

Ray, L.U.,

143,556-559.

for our children:

Centers

G.D.,

tion. Clinical

children.

& McArtor,

ojchildren,

safety

Press.

programs.

accidental

preschool

injuries:

preschool Diseases

University

CA

C.C.,

Prevention

the challenge.

Health

140,487-492. Unintentional

for Injury (1989).

Meeting Nelson,

N.

ofDiseases ofChildren,

]ournal

Bourguet,

Control.

Nyman,

l?E., Stewart-Brown, (1986).

Committee

and

& Dooling

360-364.

REFERENCES Bijur,

National

Ulione

vention. America,

&

injury

pre-

Current

429468. Duby,

J.C.

approach Pediatric

to injury

Clinics

of

(1985). preNorth

32,17-29.

and

Health.

Lee, E.J., & Bass, C. (1990). dents

in a university

Joxmal

of Pediatric

Healfh

Survey day

care

of accicenter.

Care, 4,18-23.

JOURNAL

OF PEDIATRIC

HEALTH

CARE