Chapter 7 - For The Safety of Canadian Children And Youth

Chapter 7

Fall-related Injuries

Laura, 11 months old, is a happy explorer. One morning in March, she is in the kitchen with her mother, "cruising" around, holding on to the cupboards. She slips at the door leading to the basement and falls down five or six steps. Though Laura's mother remembers having closed the door, it may have been left open by another child. Laura is brought to the emergency room, where she is placed under observation for a concussion.

Based on CHIRPP.

MORTALITY AND HOSPITALIZATION PROFILE^{1, 2}

by Robert Choinière and Danielle Dorval, Direction de la santé publique de Montréal-Centre, Québec

This chapter covers only unintentional falls. This section discusses all types of falls,³ including injuries due to falls on stairs, from buildings and during sports and recreation activities.

MAGNITUDE OF THE PROBLEM
During the period 1990-1992, falls led to an annual mean of 26 deaths and approximately 21,000 hospitalizations⁴ among Canadians under the age of 20 (Table 1). There were about 800 hospitalizations for every death. While falls accounted for a small proportion of injury-related deaths in the under-20 age group, they were the major cause of injuries leading to hospitalization. For children and youth as a whole, more than one-quarter of injury-related hospitalizations were for falls (see Chapter 1, Methodological Considerations and Overall Profile of Mortality, Hospitalizations and Emergency Room Visits).

AGE AND SEX
In children and youth under the age of 15, the hospitalization rates for falls varied little from one age group to another and were higher than the rate for 15-19-year-olds. In 5-9-year-old children, fall-related injuries accounted for more than 40% of injury-related hospitalizations. In all age groups, falls caused more deaths and hospitalizations in boys than girls. The deaths were mainly among 15-19-year-old boys and boys under the age of one.

PROVINCES AND TERRITORIES^{5, 6}
Hospitalizations for falls showed a clear trend by province of residence. In eastern Canada, the rates were below the Canadian average while, in western Canada, they were above average. Because the number of deaths due to falls was low, no comparison could be made between the different provinces.

HISTORICAL TRENDS
Death and hospitalization rates for falls have declined in recent years. The death rate fell by approximately 70% from 1975 to 1992, while the hospitalization rate has fallen by 15% since 1984 (Figure 1).

CIRCUMSTANCES, NATURE OF INJURIES AND OPPORTUNITIES FOR ACTION

by Yvonne Robitaille, Direction de la santé publique de Montréal-Centre, Québec

INTRODUCTION
In Canada, as in other parts of the world (1), falls are the leading cause of injury-related hospitalization among children and youth. This is not a recent phenomenon. The high incidence of fall-related injuries is not surprising, because they can occur anywhere and at almost any time, simply because of the force of gravity. No one can escape Newton's law.

The International Classification of Diseases (ICD), 9th revision, which is used to code causes of death and hospitalization, lists some of the circumstances of falls (Table 2). Falls from playground equipment, falls on stairs, falls during sports activities, falls from a chair or bed and falls from a building account for 40% of hospitalizations for falls. The other circumstances are miscellaneous or unspecified.

Fall-related injuries show up with great frequency in studies of injury-related medical consultations (2). If the rate of fall-related emergency room visits calculated for the state of Massachusetts a few years ago (1) is transposed to Canada, the result is that an estimated 600,000 children and youths under the age of 20 visit emergency rooms in Canadian hospitals every year as a result of falls.

CIRCUMSTANCES ACCORDING TO CHIRPP DATA
In 1993, hospitals participating in the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP)⁷ reported 39,877 emergency room visits following a fall in children and youth under the age of 20, or 45.2% of all cases recorded in the system for this age group. These falls⁸ occurred in a range of environments (Table 3).

Some of these falls are analyzed in other chapters.⁹ The following sections focus on the causes and circumstances of 29,146 cases of falls not covered in the other chapters, or 73.1% of falls (Table 3). The 29,146 cases of falls analyzed in this chapter make up one-third of all injury cases recorded in CHIRPP, as shown in Table 4.

As with hospitalizations, emergency room visits following falls were more frequent in boys (55.7%) than in girls (44.3%). The boy:girl ratio did not, however, increase with age (Table 5).

Location
The percentage of falls occurring in the home declined as children grew older, and falls in educational, sports and recreation, and road environments gradually became more frequent (Table 5).

According to CHIRPP data, almost all falls in infants (children under the age of one) occurred at home (92.3%); detailed analysis shows that the majority occurred in living areas and bedrooms (65.8%) or in the kitchen (14.4%).

In 1-4-year-old children, the home was still the prime location for falls (82.9%). Other locations included not only educational environments (most often day care centres) but also commercial environments. Although children do not spend much time in the latter, these locations are not designed to accommodate their urge to explore. After reaching school age, children spend less time at home. Nonetheless, half of all falls (51.8%) in the 5-9-year-old age group occurred at home. These children fell less frequently in living areas and bedrooms than younger children, but new locations began to appear: garages and back yards (17.3%). One-quarter of falls occurred at school (26.8%), most of these in the school yard or on the playground (18.8%).

In 10-14-year-olds, falls occurred with increasing frequency at school and in other locations. In 15-19-year-olds, falls occurred less frequently in educational environments (19.8%) and more frequently in road environments (20.3%).

Activity and Product Involved
Children and youth were most often injured in falls when playing, or while walking or running¹⁰ (Table 5). In the youngest children, falls also occurred when the child was sitting or sleeping.

CHIRPP data identify the situations in which falls occur along with the products involved. Table 6 shows the elements and products most frequently mentioned in descriptions of the circumstances of a fall, and their rank in terms of frequency for each age group. To assess the rank of each element or product, we calculated the percentage of each category among all CHIRPP falls, regardless of the youth's activity. The total included falls covered in other chapters (e.g., from bicycles or from playground equipment). It was found that 11.3% of all falls among 15-19-year-olds were related to stairs. Stairs, furniture in general (beds and chairs in particular), and ice during winter are the elements or products most frequently associated with falls. A few particularities by age group are noteworthy.

Children under the Age of One

Among infants, the products most frequently involved in falls were beds, chairs and furniture (including changing tables), stairs, walkers and strollers (Table 6).

Infants fell off beds or cribs while playing, sleeping or trying to get out of them. In almost one-third of falls from a bed, an adult's bed was involved. The written comments (verbatim) in CHIRPP are revealing: "nursing in bed, mom and baby fell asleep, baby rolled out onto carpeted floor." Falls from high chairs or child seats were also frequent: "sitting in baby seat on top of washing machine, fell off onto floor, hit head."

In another fairly frequent scenario, infants slid out of their seats while being carried by a parent, or were dropped when an adult tripped. After beds and chairs, changing tables were the type of furniture from which infants fell most frequently.

In this age group, many falls also occurred on stairs (21.4%). The infant fell while trying to go up or down the stairs or tumbled down the stairs in a walker, or the person carrying the infant fell on the stairs and dropped him or her: "climbing stairs, brother picked her up and both fell down the stairs." In about 9% of all falls recorded in CHIRPP for this age group, the infant was in a walker, which suggests that in 1993 walkers were still a safety problem for young children. In almost nine cases out of ten, falls related to walkers occurred on stairs. Only one-quarter of stroller falls occurred on stairs.

1-4-Year-Old Children

Table 6 shows that stairs were mentioned in 13% of cases of falls in 1-4-year-old children: "fell down basement stairs, landed on concrete floor." In another frequently encountered situation, children tripped while running or playing and fell onto sharp or hard objects such as the corner of a coffee table, a marble fireplace, or a cement basement floor. They also tripped and hurt themselves on objects in their hands or mouths: "playing with a comb, fell with the comb in his nose." In this age group, children fell in seemingly innocuous situations. Falls from a window or balcony were rare, but usually caused serious injuries: "playing on balcony, slid between rails, landed on concrete." When windows were involved, typically, the child climbed up on a piece of furniture or leaned onto a screen that gave way: "sister left window open by her bed, fell from second floor onto snowy ground."

5-9-Year-Old Children

Falls that led to injuries in 5-9-year-old children occurred during play or when the child was walking or running. Stairs still represented a hazard for children in this age group, who tended to fall when in a hurry to ascend or descend (Table 6). In another seemingly innocuous situation, children were injured on ice while playing in the school yard or sliding on the sidewalk. In bedrooms, there were many cases of falls from bunk beds during sleep or play, and several cases of children who were jumping on a bed and hit a piece of furniture as they fell. There were also injuries in this age group caused by falls from poorly enclosed balconies.

10-19-Year-Old Youth

Stairs were mentioned in 7.8% of all falls in 10-14-year-olds and 11.3% of falls in 15-19-year-olds recorded in CHIRPP. In the great majority of cases, the youth was going downstairs. The other falls occurred when the youth fell on ice in the school yard or on the sidewalk, was perched on some kind of structure, such as a window or balcony, or tripped while playing.

NATURE OF INJURIES AND TREATMENT ACCORDING TO CHIRPP DATA

Falls produced injuries that varied in nature and severity according to age group. The head and neck were the body part most frequently affected (48.8%), followed by the upper limbs (26.5%) and the lower limbs (17.7%) (Table 7). Minor head injuries or concussions were especially frequent in infants. In children under the age of five, two-thirds of injuries were to the head or neck, with this percentage falling to about 15% in youth aged 10 and over. Fractures or dislocations occurred with great frequency in 5-14-year-old children and youth (Table 5). Sprains accounted for more than one-quarter (27.8%) of injuries to 15-19-year-olds.

In more than half of cases of falls for which medical treatment was sought, only minor treatment or advice was required (Table 5). The other side of the story, however, is that falls occurred frequently. In 1993, 12,257 cases involving falls required medical treatment with follow-up or hospitalization, accounting for 13.9% of the 88,312 cases of injury recorded in CHIRPP, for all circumstances of injury combined. The key issue regarding falls is their high number, and the main challenge is their diversity.

OPPORTUNITIES FOR ACTION

Research Priorities

Falls constitute the second leading cause of head injuries, after transport (3). While the consequences of serious head injuries on children's cognitive and behavioural functions have been quite well described, the consequences of minor head injuries¹¹ are not well understood. Some authors report problems with memory, language and spatial orientation several months after the event in children and adolescents with minor head injuries (4). Other studies have found no such sequelae (5). A number of authors take the view that sequelae still present one year after a fall warrant more elaborate longitudinal studies (6,7). Because falls occur so frequently, even a small percentage of serious cases represents a large number of fall-related injuries. If even minor head injuries were found to have medium- and long-term consequences, there would be reason enough to greatly intensify current efforts to prevent fall-related injuries in children and youth.

Improve knowledge of the long-term consequences of concussions and minor head injuries due to falls (research groups, head injury prevention organizations).

Health professionals do not consider walkers to be of any benefit to child development (this is the position of the Ordre des physiothérapeutes du Québec, 1995) (8). There is no longer any question that walker-related injuries are a serious problem (9). In Canada, the manufacture of walkers has been subject to voluntary standards since 1989, at which time Canadian manufacturers chose to stop producing them. Nonetheless, they are still in use. According to 1993 CHIRPP data, approximately 9% of all fall-related injuries in infants involved a walker. Walkers continue to be produced in the United States (US). Any strategy to reduce the number of walkers in use would require knowledge of the percentage of parents who use walkers (second-hand or purchased in the US), how they acquired them, and how much they know about the hazards of using them.

Study trends in injuries associated with walkers in Canada over the past 10 years, including how and why parents use them, and conduct a cost-benefit study of a campaign to stop the use of walkers, and distribute information about the associated hazards (research groups, health professionals, consumers' associations).

Preventive Measures

Events involving children falling out of windows or off balconies are rare, but the injuries that result are usually severe (10) and even fatal (11). Canadian data do not provide a good picture of the magnitude of the problem, because there is no specific code for such injuries in the ICD. Between 1990 and 1992, falls from or out of a building or other structure (E882) were responsible for 7 deaths and 634 hospitalizations in children and youth under the age of 20. An undetermined number of these hospitalizations were attributable to a fall from a window or balcony. While windows in houses usually have screens, these are not designed to withstand the weight of a child leaning against them. A well-known American study (12) shows that installing window guards in high-rise apartments of families with young children (under the age of 11) in New York substantially reduced hospitalizations for such falls. In Canada, fire exit regulations make installing permanent grilles on residential windows a problem. The National Building Code of Canada, 1995 (NBC) stipulates that, in homes, windows with sills 50 millimetres or less (about 18 inches) from the floor must be protected by a guard¹² or by a mechanism capable of limiting the window opening to less than 10 cm (4 inches) to prevent children from sliding through (13).

The NBC also requires guards for balconies, exterior landings, mezzanines and accessible roofs. However, no protection is required for other windows that children can reach, and screens give the illusion of protection, although they cannot withstand lateral loads. A number of provinces, territories and municipalities have their own building standards, which are generally more stringent than the NBC. Although we need to improve our knowledge of falls from windows or balconies as a cause of hospitalizations, there is also a need to take action.

a) Promote compliance with the National Building Code of Canada, 1995 as a minimum standard with respect to access to low windows in residential buildings (municipal inspections during construction, professional groups such as architects' associations); b) inform the public of safety criteria for different types of windows so that all windows accessible to children can gradually be fitted with a mechanism that limits how far they can be opened by a child (architects, consumers' associations, engineers); and c) encourage the removal from beneath windows of any object that children can climb on, to render windows inaccessible to them (parents, health professionals).

Young children just learning to walk are not the only ones injured on stairs; adolescents, adults and seniors are also vulnerable. For greater safety on stairs, the steps must be visible and deep enough so that the foot rests comfortably on them, and the stairway must have handrails of appropriate shape and height to make them easy to grip (Jake Pauls, Consulting Services in Building Use and Safety, personal communication, 1996) (14). Specific standards have been developed to reduce the risk of falls on stairs in public places and private homes. The same standards are suitable for adults and children, which makes the application of the "universal design" concept appropriate. The NBC is extremely explicit about the dimensions of stairs, steps, handrails and guardrails (section 9.8). It is likely that a substantial percentage of dwellings built before the NBC standards were established do not currently meet those standards.

Because all young children require constant supervision, a number of authors recommend that a gate be installed at the top and bottom of every staircase (15). Until recently, the requirements of the NBC were less stringent for basements, so parents had to be especially vigilant. In addition to adequate handrails and guardrails, one option to consider is covering cement floors with thick carpeting.

a) Promote stairway safety in homes by ensuring compliance with the National Building Code of Canada, 1995 in new and renovated buildings (building contractors, architects, etc.); b) promote the concept of universal design in stairways (architects, builders, health professionals); c) encourage and facilitate the use of gates to bar access to stairs by children under the age of 18 months (health professionals, designers, parents); d) promote the covering of surfaces at the foot of stairs such as ceramic tile and cement with reasonably energy-absorbing surfaces (parents).

Falls from heights of less than one metre sometimes lead to very severe injuries (11). Counselling by primary care physicians is recognized as an effective way of improving parents' knowledge and behaviour with respect to safety (16). Some authors have shown that a home visit by a health professional can increase new parents' knowledge about the risk of injury, and also minimize hazards in the home (17,18). Postnatal visits are a good opportunity for this type of action. The role of non-health professionals, who can be specially trained to make these visits, should be studied and expanded.

Make new parents aware that fall-related injuries can occur because of hazards in the home environment, including beds, changing tables, furniture with sharp corners and ceramic tile floors; suggest ways of improving safety in the home, especially for preschoolers (health professionals, public health organizations).

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1. For more detailed information concerning methodology and data sources, see Chapter 1, Mortality and Hospitalizations section.

2. Mortality and hospitalization data are from Statistics Canada and represent annual averages. Mortality analysis covers three-year periods from January 1, 1951, to December 31, 1992. Hospitalization analysis covers two-year periods spanning April 1, 1982, to March 31, 1992.

3. International Classification of Diseases (ICD), 9th revision, codes E880 to E888: Accidental Falls. Falls into water with drowning, falls into flames, falls onto piercing, pointed or sharp objects and transport-related falls are excluded.

4. Estimated number of hospitalizations for all of Canada from the rate observed in the eight provinces that compile data on E codes (circumstances surrounding injuries).

5. In this section, the discussion will focus only on those regions with a death rate or a hospitalization rate that presents a statistically significant difference with respect to the observed Canadian rate.

6. In geographic and temporal comparisons, allowance must be made for the fact that hospitalization data undergo many distortions due to factors other than health. These factors include the availability as well as physical and financial accessibility of treatment, administrative decisions limiting the number of hospital stays, and the specialization of certain hospitals (see Chapter 1, Methodological Considerations and Overall Profile of Mortality, Hospitalizations and Emergency Room Visits).

7. For more detailed information concerning CHIRPP methodology, see Chapter 1, Visits to Hospital Emergency Rooms section.

8. In the following sections, the term "falls" is used for all fall-related injuries.

9. Falls from bicycles are included in Chapter 5, Bicycle Injuries; falls from playground equipment are covered in Chapter 12, Playground Equipment Injuries; and falls that occur during other sports and recreation activities are covered in Chapter 14, Other Sports and Recreation Activity Injuries.

10. Walking and running are included in the personal activity category.

11. Minor head injuries as defined by the Glasgow Coma Scale (GCS): 13 to 15.

12. These guards must be at least 900 millimetres high, or about 35 inches (National Building Code of Canada, 1995, Articles 9.7.1.6 and 9.8.8).

BIBLIOGRAPHY

1. GALLAGHER, S.S., K. FINISON, B. GUYER and S. GOODENOUGH. 1984. "The incidence of injuries among 87,000 Massachusetts children and adolescents: Results of the 1980-81 statewide childhood injury prevention program surveillance system." American Journal of Public Health, 74, 1340-1347.
2. SCHEIDT, P.C., Y. HAREL, A.C. TRUMBLE, D.H. JONES, M.D. OVERPECK and P.E. BIJUR. 1995. "The epidemiology of non-fatal injuries among US children and youth." American Journal of Public Health, 85(7), 932-938.
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13. CANADIAN COMMISSION ON BUILDING AND FIRE CODES. 1995. National Building Code of Canada, 1995. Ottawa, Ont.: National Research Council of Canada. 571 p.
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