Nursery Product-Related Injuries Treated in United States Emergency Departments

Discussion

On average, >66 000 nursery product–related injuries were treated in the US EDs annually from 1991 through 2011. Despite the significant decline in both the number and rate of nursery product–related injuries from 1991through 2003, primarily attributable to the decline in baby walker/jumper/exerciser-related injuries, both the number and rate of injuries increased significantly from 2003 through 2011. Part of this increase was driven by an increase in the number and rate of concussions/CHIs, which is likely attributable to multiple factors, including heightened awareness about concussions during recent years among parents, child caregivers, and health professionals. These findings agree with a recent study, which reported a >200% increase in traumatic brain injuries among children aged <5 years occurring in the home from 1991 to 2012.³² Further research is needed to better define the factors contributing to the observed increase in concussions/CHIs.

From 2009 to 2012, nursery products were the leading children’s product category recalled in the United States,^1–4 and it is estimated that up to 80% of recalled children’s products remain in consumer households after a recall.⁶ Since enactment of the Consumer Product Safety Improvement Act of 2008, which (among other requirements) mandated safety standards for all durable infant or toddler products,³³ product recalls have begun to decline.⁶ However, components of the law are continuing to be phased-in, and its effects on nursery product–related injuries is unlikely to be reflected in the results of the present study. Future research is warranted to assess the effects of this important consumer product legislation on nursery product–related injuries to children.

Given the success of interventions to prevent injuries associated with baby walkers, including strengthened safety standards and new safer product design,^18,20 similar efforts should be used to address injuries associated with other nursery products, especially the top contributors to pediatric morbidity in this study: baby carriers, cribs/mattresses, and strollers/carriages. Baby carriers were the leading source of nursery product–related injuries and hospital admissions. Baby carrier–related falls involving caregivers may lead to more severe injuries due to factors such as the caregiver falling on top of the child or propelling the child with additional momentum during a fall.³⁴ To reduce the likelihood of these injuries, caregivers should attempt to keep living spaces free of objects that pose a tripping hazard. Child caregivers using a carrier should minimize the use of stairs and refrain from carrying other objects while on the stairs, using the free hand to grasp the handrail.³⁵ Infants should be matched to carriers that are appropriate for their size and weight.³⁶

Nearly one-third of product failures were associated with baby carriers, which included instances of handle detachment and product collapse. Baby carrier seats, especially detachable car seats, should be carefully inspected before infant transport. Any supporting devices and carrier handles should be locked into position before moving an infant or child.³⁷ Carrier seats also pose an additional hazard of injuries due to unattended falls, which are associated with placement of seats on elevated surfaces.^34,38 Infants in carrier seats should always be secured using the safety harness straps provided, and carriers should be equipped with nonskid undersides. Caregivers should not place carrier seats on slippery surfaces, such as glass tables, or on soft surfaces, such as beds, where a tip over could lead to suffocation.³⁷

Cribs/mattresses were the second most common source of injury and were associated with the majority of nursery product–related fatalities. Previous literature provides evidence that cribs are a leading nursery product associated with infant mortality.^15,22,39 It is likely that sudden unexpected infant death accounted for many of these fatalities in our study as well as in others. Sleep environment hazards play a key role in infant injury, especially sudden unexpected infant death, and health care practitioners should counsel caregivers to not place bumper pads or soft objects, such as blankets or pillows, in the crib because of the risk of strangulation, entrapment, and suffocation.^36,37 Caregivers should only use the firm, snugly fitting mattress designed for their crib and never use supplemental mattresses, which may increase the risk of entrapment and suffocation.

Crib bumper pads have been marketed as protective barriers to reduce entrapment injuries, and some organizations, such as the Juvenile Products Manufacturers Association, maintain that bumper pads are safe.⁴⁰ However, multiple fatalities attributable to bumper pad–related suffocation or strangulation have been reported.^41,42 Since 2011, the American Academy of Pediatrics has recommended against bumper pad use due to the risk of injury.^43,44 The city of Chicago⁴⁵ and the state of Maryland⁴⁶ have taken these recommendations further, banning the sale of bumper pads. Despite these public policy efforts, bumper pads can still be found in Chicago,⁴⁷ and more needs to be done at the national level to limit the sale and use of crib bumper pads.

Strollers/carriages were the third-leading source of nursery product–related injuries. Tip overs and falls involving strollers have been described as the predominant mechanism of injury in the literature,^12,48,49 underscoring the need for caregivers to avoid taking strollers on stairs, hanging objects on stroller handles, and allowing other children to play with or hang onto a stroller while a child is inside.³⁶ These measures should be combined with safety belt use, which previous studies suggest is low among injured children.⁴⁹ In a report describing stroller-related injuries in Queensland, Australia, researchers noted that 8% of fall injuries were due to the stroller rolling away from the caregiver.⁴⁸ The injury risk from stroller-roll-away could be mitigated through the installation of a “dead man brake,” similar to those on airport trolleys. Manufacturers should be encouraged to place these conditional braking systems on child strollers and carriages.

Almost 90% of injuries occurred at home, and 80% of injuries were due to a fall. Therefore, prevention efforts should focus on fall prevention in the home setting. Strategies for preventing falls include the following: (1) use of products’ safety devices, such as a strap or harness; (2) appropriate adult supervision; and (3) proper assembly/installation and use of products, such as adjusting the mattress height in a crib to prevent a child from climbing out. We also found that young children were more likely to injure their head and neck or be diagnosed with a concussion/CHI, whereas older children were more likely to injure an upper extremity or be diagnosed with a laceration. This finding is most like due to children’s developmental changes and how this development specifically affects how they fall. Young children have disproportionately large heads, which provides a larger target for injury and also raises their center of gravity. These children tend to lead with their head when they fall and are unable to break their fall with their arms because of lack of coordination and strength. As they get older, they use their arms more effectively to protect their heads but have more upper extremity injuries as a result.³²

Several limitations exist in this study. The number of nursery product–related injuries was underestimated because only cases treated in EDs were included. Injuries treated in urgent care centers and other non-ED medical facilities are not captured by the NEISS. Fatalities are also underreported in the NEISS because prehospital deaths may not be transported to an ED, and fatal patient outcomes after hospital admission are not captured in the NEISS database. The findings of this study, therefore, may not be representative of all nursery product–related injuries. In addition, NEISS case narratives are limited by the amount of detail included in ED medical records. Narratives may not consistently provide information about injury mechanism, factors contributing to the injury event, and which product was primarily involved in the injury if multiple products were listed. Information regarding socioeconomic status was unavailable. It is possible that some of these injuries were the result of child maltreatment. Because multivariate analyses were not performed, our results do not reflect the potential influence of covariates on the relationships examined. Despite these limitations, the strength of this study lies in its use of a large, nationally representative sample over a period of 21 years that includes product-specific information.