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Injury Prevention With Young Children
The greatest risk to children’s health is not cancer, heart disease, or any other form of illness. The leading killer of children (ages 1–19) in the United States is injury. In a single year, close to 4,500 children under age 15 lose their lives, and 5 million require emergency medical care because of injuries. Children under age 4 are particularly at risk. For this age group the most common causes of death are drowning, motor vehicle accidents, suffocation, and fire/burns. Injury is the fifth leading cause of death for infants; suffocation accounts for the majority of these deaths.
In the past, unintentional injury was thought to be due to “accidents.” This term is no longer used in the field of injury prevention because it implies that injury is a random, unpredictable event. In fact, the large majority of childhood injuries can be predicted and prevented. Moreover, the majority of unintentional injuries occur in the home, making parents critical in the prevention of such injuries. Behavior therapists have traditionally advocated three levels of intervention for parents in preventing injuries among young children:
- Change the child’s surroundings/environment (i.e., safety proofing);
- Change the parent’s behavior, typically by supervising the child more closely;
- As a last resort, change the child’s behavior, typically by teaching the child safety rules.
The best way to protect children from injuries is to use a combination of environmental barriers and close supervision. Safety proofing an environment dramatically reduces the risk of injury for young children. However, it is often difficult to fully anticipate a child’s risk-taking behavior. Research has shown that injuries often occur when children engage in behavior that is unexpected or unusual for them. Thus, close supervision is an important addition to safety proofing the environment. When safety proofing an environment isn’t possible (e.g., at someone else’s home, in a public place), close supervision is critical. Supervision should increase with the level of hazard present in the environment. For example, close supervision is critical around any body of water.
Parents or teachers can also increase children’s safety skills by teaching safety rules; such teaching should begin early in life and continue throughout childhood. However, children under the age of 5 should never be made responsible for their own safety behavior. Children can behave in ways that are unpredictable, and it is risky to rely on their memory of safety rules or their compliance with such rules.
Ways to prevent some of the leading causes of fatal injury to children are discussed below.
Drowning is the most frequent cause of death in children under age 4. Drowning in swimming pools is common, but children can drown in any body of water, from an ocean to an irrigation ditch. Indoor drowning in seemingly harmless situations also occurs. Being left alone even for a few moments in the bath (even in an infant bathtub) can result in an infant drowning. Other sources of water such as toilets or buckets are hazardous when crawling infants grab them when standing and then tumble forward.
There is no substitute for nonstop, vigilant supervision when a child is in or near water, either in the bath or by a backyard wading pool. Tragedies can occur when a parent answers the telephone or goes to the door for only a moment. Letting the bell ring or taking the child in a towel with you is the only safe alternative. No amount of experience or swimming lessons will make a small child safe in the water without adult supervision.
Fencing around pools that cannot be readily opened by children has been shown to reduce drowning. A complete fence, rather than one side of the house opening onto a three-sided fence, is necessary to protect children in the home. Inflatable toys may lure children toward the water without protecting them and thus should never be left in the pool. Safety-approved flotation devices should be worn by all members of a boating group, especially small children. Latches for toilet lids can be purchased, and buckets can be emptied between uses or placed out of reach.
A five-gallon bucket is particularly risky because it tends not to tip when a child falls into it. Such buckets might well be avoided entirely by parents of small children. Finally, bathtubs should be drained immediately after use.
The second leading cause of death for small children is automobile crashes. Properly used restraints can reduce serious injury by up to 70%. A child riding on a lap is not protected but is at double risk: Not only is it physically impossible for the parent to keep the child from being thrown into the windshield and dashboard, but if the adult is unbelted, the force of the adult’s body may crush the child. Keeping a child in an approved car seat during every car ride is the simplest and easiest way to keep a young child safe. Children at this age are less likely to be injured as pedestrians than are older children, as parents correctly recognize that young children cannot cross streets safely in the absence of an adult. However, toddlers are more likely than older children to wander into the street or driveway; and, because toddlers are small, drivers are more likely to back over them when leaving a garage or driveway. Prevention Strategies
Infant and child car seats reduce fatal injuries by up to 71%. Children should ride in rear-facing car seats from infancy until age 2, or until they have reached the maximum height and weight restrictions for the seat. After age 2, children should be seated in a forward-facing car seat with a 5-point harness. It is central to the child’s safety that the correct seat for the child’s body weight be used. The National Highway and Traffic Administration and Safe Kids USA both have helpful information about choosing a car seat online:
Once the correct car seat is chosen, it is also important that the seat is used properly. Caregivers should ensure that the seat belt is correctly routed around the car seat, and that straps are adjusted to the child’s body (e.g., shoulder straps should not be slipped off and lap straps should go across the thighs, not the abdomen).
Children should not wear winter coats or snow suits in the car seat; it is okay to place a coat or a blanket over the child once they’re buckled in. Car seats should only be used for 6 years, and any seats that have been involved in a car accident should be replaced.
The National Highway and Traffic Administration has online tutorials and videos to help guide parents in car seat installation, see http://www.safercar.gov/parents/CarSeats/How-To-Install-Car-Seats.htm. Another good way to ensure that car seats are installed properly is to get them checked by a certified car seat technician. Local fire stations can often provide information about seat checking locations, and the website http://www.seatcheck.org has a search engine that can be used to locate local technicians. Caregivers can also call 1-888-SEAT-CHECK. Finally, new car seats should be registered with the manufacturer so that consumers can be notified in case of recalls.
Parents should have a rule that the car does not move until the child is secured in a safety seat. Children have been killed as their car pulled out of a driveway and the child slipped out of the door. Most children who have been in a safety seat from birth may never protest using the restraint. Others may undo their restraint if not supervised. Firmness, as well as contingent reward (receiving a reward for correct behavior) for use and sufficient entertaining attention when the child remains in the restraint helps. Research has shown that children are better behaved in the car when wearing safety restraints. Parents are also less likely to be distracted by a child in a restraint.
Parents can also keep their children (and others’ children, too) safe by not driving after drinking alcohol, when very tired, or when taking medication that limits judgment or reaction time. When anyone is entering or leaving a driveway, picking the child up or holding his or her hand is a sensible strategy.
Most fatal burns come from house fires. Flame burns occur when a child’s clothing is exposed to a flame. Scald burns from hot liquids occur at much lower temperatures and more quickly in infants and toddlers than in older children and adults. Scalds can occur from plain tap water, from hot water vaporizers, or from hot food on the stove or beverages at the table.
When formula is heated in the microwave, the container can feel only warm when the liquid inside is actually hot enough to burn infants’ or toddlers’ airway sufficiently to make them swell shut. Carelessly extinguished cigarettes or cigarette lighters can also burn toddlers who are fascinated by glowing or shiny objects.
All homes should be equipped with several smoke detectors (especially the kitchen and bedrooms) with batteries that are checked frequently. Selecting an anniversary such as New Year’s Day or daylight savings time to sound the smoke alarm makes it easier to remember. Outside windows in rooms where infants and toddlers sleep should be specially marked to alert firefighters.
Children’s clothing, especially sleepwear, should be close-fitting or flame-retardant. Setting the thermometer on the family water heater to 120°–125° F is an important method of eliminating scald burns from the tap water. Putting guards on the stove front can protect small exploring hands from touching a hot pan. Hot-water vaporizers should never be used with children; cool-mist vaporizers are just as effective. Food or liquid heated in a microwave should be stirred well and sampled by an adult before it is given to a child. Parents should not allow young children to remove hot food from the microwave; hot liquids may spill out of containers and burn a child. Parents should test carefully to ensure bath water is only tepid prior to putting a child in the bath. Or, bathtub thermometers are available to help ensure that the temperature is in the correct range; this is especially important for infants.
Because small children reach and grab for things, hot beverages should never be consumed or placed near a small child. Cooking should be done away from children, and pot handles should be turned in so that the pot cannot be overturned. Matches, lighters, and lighted cigarettes should never be left where a child can reach them. In case of a house fire, parents should have an escape route planned from each room in the house and should exit low (below the smoke) and immediately with their child at the first sign of a fire.
Poisoning deaths are partially prevented by child-resistant packaging, limits on the amount of medication in a single container, reductions of some toxic chemicals (e.g., lead), and improved poison control centers. However, poisonings from beauty products, cleaning products, solvents, and medications continue to occur. Laundry detergent pods are particularly problematic because they are colorful and can be mistaken by children to be candy. If children bite into these pods, the pressurized liquid will squirt into their mouth and down their throat.
Before an infant can crawl, all poisonous materials should be placed out of reach or should be locked up. The safest approach is to put them both out of reach and lock them up. Cabinet and drawer latches can be used to secure such materials. Medications for both humans and pets should be stored in child-resistant containers in a locked cabinet. It’s important not to rely on child-resistant packaging because sometimes children are able to open these, or adults may fail to close them properly. Any vitamins and herbs should be similarly stored. Flavored children’s medications (e.g., cough syrups) are particularly likely to be swallowed if left where the child can find them. In addition to all bathroom and kitchen cleaners, substances such as drain cleaners, petroleum products, cosmetics, plant fertilizers, and turpentine should be rounded up and safely stored.
Many poisonings occur from a mother’s or grandmother’s purse, which might contain cosmetics and medications; if these are kept in a purse, they should be placed in child-resistant containers and be safely stored. Supervision of crawling infants and toddlers is also essential in any new location where toxic materials such as cigarettes, pesticides, or poisonous plants might be available. During the first 18 months of life, mouthing objects is one important way a child explores the world, and older toddlers still taste interesting-looking objects.
Knowing the poison-control center number in an emergency and having syrup of ipecac in the house to induce vomiting (only if so instructed) can also prevent a serious consequence should a poisoning occur.
Choking and Suffocation
There are several types of everyday materials that can cause a child to choke. Choking can occur with common foods; foods that most often cause choking include soft, pliable foods such as hot dogs or grapes and hard, slick, round foods such as candies or nuts. Similarly, adult medications, pieces of balloons, foreign objects from toys or from off the floor can block a child’s airway.
Strangulation can occur when the cord holding a baby’s pacifier or the cord from window blinds wraps around the child’s neck or when a child’s head is wedged in between slats of a crib or a gate large enough to allow the child’s head to pass through.
Children can suffocate in small refrigerators, under mechanically powered garage doors, or in old trunks. A common cause of fatal suffocation for infants involves sleep location and positioning.
Any object large enough for a child to crawl into (e.g., empty freezer/refrigerator) is a hazard that should be locked shut or removed. Infants and toddlers should not wear anything around their neck, such as pacifiers with strings or necklaces. Similarly, the loop from blinds is also a potential hazard that can be removed by simply clipping the loop above the child’s reach.
Selection of foods that do not pose a risk or making risky foods harmless (i.e., slicing hot dogs lengthwise, cutting grapes into pieces, buying flat candy rather than round) will help avoid injury. Infants and small children can choke on adult-sized medications such as aspirin tablets; only liquids should be given to infants and liquids or chewable medications to toddlers after they have teeth. Anything that can fit inside the width of a toilet paper roll is a choking hazard for young children.
The warning with some toys, “Not recommended for children under age 3,” should be taken seriously. These toys may have small parts that could choke an infant. Similarly, common household objects, such as a thimble, or outdoor objects, such as pebbles, can choke a young child. An area must be swept clear of any small objects or constant vigilance with a crawling or toddling child is necessary. Automatic garage-door openers need to be checked periodically to ensure that the door maintains sufficient sensitivity to reverse itself quickly should it encounter any object blocking its closure.
Finally, the risk of infant suffocation can be significantly reduced by following the American Academy of Pediatrics recommendations for infant safe sleep (https://www.healthychildren.org/English/agesstages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx). Such guidelines specify that infants should always (even for naps) sleep alone, on their back, and on a firm flat surface (e.g., in a crib or pack and play). Although it can be tempting to allow babies to sleep in bed with adults, their airways can easily be blocked by blankets or pillows. Infants lack the strength and motor control to free themselves from such hazards. Moreover, other people or animals on a sleep surface may accidentally block an infant’s airway. When placed on a flat sleep surface, nothing should be in the sleep surface with the infant—any objects also pose a suffocation hazard.
Infants can be placed in swaddle sacks for warmth, but should not be placed to sleep with any blankets or pillows. Also, infants should not be allowed to sleep in any infant-soothing devices with harnesses (e.g., infant swings). Infants have died in such devices; once asleep, their head can fall forward and block their airway. It’s okay for infants to sleep in car seats when the seats are in the car or compatible stroller because the angle of the car seat keeps their head in a safe position; however, infants should not be allowed to sleep in a car seat outside of the car or stroller.
There are many other dangers to a small child within the home (e.g., firearm injury, electrocution) and outside the home (e.g., tricycle injuries, animal bites). In general, environmental barriers between the child and the hazard, removal of the hazard when possible, and the use of consistent parental supervision are most important. As children grow, their knowledge and use of safety skills should be repeatedly tested before parental supervision is reduced.
Once safety becomes a habit, it becomes easy to change one’s lifestyle. Altering one’s environment and behavior to promote safety can become second nature.
Because injury continues to be the leading cause of death in the U.S. (up to age 40), what better legacy to leave a child than a healthy respect for hazards that result in injury and the knowledge and motivation to ensure safety at each stage in development?