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Prevention of falls and fall-related injuries in children

Prevention of falls and fall-related injuries in children
Literature review current through: Jan 2024.
This topic last updated: Jan 03, 2023.

INTRODUCTION — This topic discusses the epidemiology, clinical features, and prevention of falls in children. Falls in adults are discussed separately. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in community-dwelling older persons" and "Falls: Prevention in nursing care facilities and the hospital setting".)

GENERAL EPIDEMIOLOGY — Unintentional falls are a leading cause of nonfatal injury in children younger than 14 years of age in the United States (table 1) [1] and account for 8 percent of fatal children's injuries worldwide [2]. Fall-related mortality in children has declined since 1987; nonetheless, in the United States in 2020, 100 unintentional fall-related deaths occurred in children age 0 to 19 years: 19 in children younger than age 0 to 4 years, 10 in children age 5 to 9 years, 18 in children age 10 to 14 years, and 53 in children between 15 and 19 years [3]. Males were more than three times as likely as females to die from fall-related injuries.

Emergency department and outpatient surveillance systems indicate that falls are one of the most common injuries requiring medical care and the most common nonfatal injury requiring hospitalization [4-6]. In 2020, nearly 1.4 million children age 0 to 19 were treated in emergency departments for unintentional fall-related injuries; 42 percent were age 0 to 4 years, 23 percent were age 5 to 9 years, 18 percent were age 10 to 14 years, and 17 percent were age 15 to 19 years [7].

In the pediatric age group, children younger than five years of age are at the greatest risk of incurring fall-related injury [1]. Falls are also the most frequent cause of any injury during infancy (an estimated 35.1 per 1000 infant-years) [8]. In newborns, hospital falls have been associated with mothers falling asleep while holding their infants during nighttime feeding [9,10]. The combination of curiosity, immature motor skills, and lack of judgment renders preschool children particularly susceptible to falling (eg, climbing on unstable furniture to obtain toys that are out of reach).

Falls by children occur mainly in the warmer months [11-13]. The location and mechanism of injuries caused by falls vary depending upon the age of the child. More than 80 percent of fall-related injuries in children younger than four years of age occur in the home; among children aged 5 to 14 years, approximately one-half of the injuries occur at home and one-quarter at school. Among infants, falling from furniture or stairs is an important mechanism [11,14,15]. The risk of falling from windows is greater for toddlers than for children of other ages [16,17]. Falling from playground equipment is a common mechanism for falls in older children [18,19].

Children from low-income families are more likely to be injured from falls due to lack of safety equipment (eg, window guards) or deteriorating housing [20-22]. Additional predisposing factors for fall injuries identified in case series include history of previous unintentional injury, neurologic disorder (eg, seizures, developmental delay, hyperactivity), documented neglect, and acute stressors (eg, recent move, illness, or job change) [23-26].

FALLS IN THE HOME

Falls from height — The severity of fall-related injuries is related to the height of the fall [23,27]. The mortality rate increases from 1 percent for falls from <15 feet (4.6 meters) to 2.4 percent for falls >15 feet (4.6 meters). [27,28]. The mortality rate for short falls (<5 feet [1.5 meters] in vertical height) for infants and young children is <0.48 deaths per year [29]. Head injury, orthopedic injury, and thoracic injury occur more commonly from high-level falls, whereas abdominal injury occurs more commonly from low-level falls in children [27]. In children, falls from heights usually occur from windows, balconies, and roofs. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation" and "Thoracic trauma in children: Initial stabilization and evaluation" and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization".)

Falls from windows

Epidemiology and clinical features – Compared with falls associated with other products, children are more likely to be severely injured or die from window-related falls [13,23,30]. Each year in the United States, approximately eight children younger than five years of age die from injuries related to falls from windows [31]. In addition, an estimated 3300 children younger than five years of age are treated in hospital emergency departments for injuries sustained by falling from windows [31]; 45 percent of the injuries are serious (eg, fractures, internal injury, concussion, intracranial hematoma, intracranial hemorrhage) [23]. Head injuries and fractures are the most common of the serious injuries [16,23].

Fatal injuries related to falls from windows are usually from the second story or higher; the mean height for fatal window-related fall injuries is five to six stories [23]. Serious or life-threatening injuries rarely are sustained in falls from less than 10 feet (3 meters) [32]. Thus, many trauma centers use "fall greater than 15 feet (4.6 meters)" as criteria for transport to a trauma center [33,34]. However, this criterion may be a poor predictor of major injury [27,35,36], particularly when no unrelated witnesses can corroborate the initial history [36].

Intentional injury should be considered in children with serious injuries from falls that were reported to be less than two stories and in all unwitnessed falls [32,33,36,37]. In one series of 61 patients who required hospital admission for falls from at least one story, approximately one-quarter of the falls were intentional: some children jumped to avoid beatings or fires, some were pushed, and some attempted suicide, although other methods of suicide are more common (in 2020, falls accounted for 177 suicides among individuals 12 to 24 years of age) [38,39]. (See "Physical child abuse: Recognition".)

Most deaths and hospitalizations related to falls from windows occur during the spring and summer months [16,23,25,40]. One author suggested a possible association between record-breaking temperatures and an increased incidence of pediatric falls from windows [41]. Children at increased risk for falling from windows are males, younger than five years, and playing unsupervised at the time of the fall [13,16,21,42-44]. Children living in apartment buildings are five times more likely to fall from a window than are children living in a house [23]. Falls from windows occur more often in urban areas with multilevel, low-income, poorly maintained housing [20,24,40,45]. The windows usually are in bedrooms or living rooms on the second or third story of apartment buildings or single-family homes; they typically are left open (with just a screen in place) [12]. Furniture often is placed under or near the open window.

Prevention – Window guards or stops can be used to prevent children from falling through the window opening. The maximum opening should be less than 4 inches (10 cm) because most children younger than six years can slip through a 6-inch (15.25 cm) opening, and none older than one year can pass through a 4-inch (10 cm) opening [23].

Two years after the introduction of an educational program and the provision of free, easily installed window guards to families with young children living in high-risk areas of New York City, mortality related to falls from windows was reduced by 50 percent (from 108 to 54 deaths per year) [40]. No child fell from a window equipped with a window guard. The success of the program in reducing fall-related injury and death persuaded the New York City Department of Health to require landlords to provide window guards in apartments that house children younger than 10 years of age [46]. Admissions to local hospitals for injuries related to falls from windows decreased by as much as 96 percent after the mandatory program was established [38].

The American Academy of Pediatrics Committee on Injury and Poison Prevention has issued a policy statement regarding falls from windows, roofs, and balconies [23]. Recommended strategies to prevent such falls include the installation of window guards or stops on all multistory housing; however, window guards or stops should not be permanently affixed because they may prevent escape in the case of a fire. [23]

Other important strategies to prevent falls from windows include the following [23]:

Open double-hung windows from the top only

Avoid the placement of furniture under or near windows

Close windows in rooms where children play

Supervise young children, particularly near open windows

Do not rely on window screens to prevent falls [47]

Plant shrubbery at the base of tall buildings to soften the impact surface

Other falls from height — In addition to falling from windows, children can fall from a variety of other heights, including rooftops, fire escapes, and balconies [20,23,40,48]. Falls from these locations typically occur in older males. Falls from stairs occur most frequently between the ages of 6 and 11 months [15,49].

The building codes in many communities require that railings be placed on balconies and fire escapes to prevent a child from passing through them [23]. National building codes for all newly constructed buildings specify that vertical railing bars must be placed no more than 4 inches (10 cm) apart, and most codes specify railing heights of 36 inches (91 cm). The retrofitting of older dwellings with railings would help to prevent additional falls from heights. In addition, the provision of safe ground-level playing areas may prevent children from playing in dangerous areas, such as fire escapes and roofs [20].

The use of stair gates in the home may prevent falls from stairs in young children. Meta-analyses have shown safety interventions that provide free or reduced-cost stair gates are effective in increasing stair gate use [50].

Falls in infant walkers

Epidemiology and clinical features – According to data from the National Electronic Injury Surveillance System (NEISS), an estimated 230,676 children <15 months of age were treated for infant walker-related injuries in United States emergency departments between 1990 and 2014 [51]. The median age was 8.2 months, 59 percent were male, and 98.8 percent of injuries occurred at home. Approximately 90 percent of children sustained an injury of the head or neck. Among the 4.5 percent who required hospitalization, approximately 38 percent had a skull fracture and 29 percent had closed head injury or concussion.

Most of the infant walker-related injuries were caused by a fall down stairs (74 percent) or falling out of the walker (15 percent) [51]. Approximately 3 percent of infant walker-related injuries occurred because the walker provided access to safety hazards (eg, hot beverages or surfaces, sharp objects) that would otherwise be out of reach (ie, "proximity mechanism"). Among the children with proximity mechanism infant walker-related injuries, 74 percent had burns and 14.5 percent were admitted for treatment of burns.

The number of emergency department visits in the United States for infant walker-related injuries in children <15 months of age decreased between 1990 and 2014 (from 20,650 to approximately 2000) [51]. The decrease in infant walker-related injuries is likely multifactorial (eg, mandatory safety standards, decreased infant walker use, increased use of stationary activity centers).

Prevention Use of infant walkers should be discouraged, and the American Academy of Pediatrics has called for a ban on the manufacture and sale of infant walkers in the United States [51]. Even with supervision, infant walkers remain unsafe because caretakers cannot respond quickly enough to prevent injuries [52].

Caregivers who choose to use infant walkers should be encouraged to purchase one that complies with the Consumer Product Safety Commission's 2010 safety standards. Safety standards for infant walkers in the United States include requiring the base of the walker to be greater than 36 inches (91 cm; the width of a typical doorway) and requiring the walker to have a braking mechanism to stop the walker's progression in the event that one or more of the walker's wheels dropped over the edge of a step [51]. In addition, there are detailed specifications for testing the braking mechanism and stipulations to prevent importation of walkers from foreign manufacturers who do not adhere to the standards. Infant walkers have been banned in Canada since 2004 [52].

Falls from infant carriers — According to the United States Consumer Product Safety Commission, in 2013, infant carriers/car seat carriers were associated with 66 percent of injuries in children younger than five years who were treated in emergency departments [53]. Many of these injuries were the result of falls. One study reported that 87 percent of the children that sustained an infant-carrier-related injury were not buckled into their seats when they fell [53]. Prevention of infant carrier falls should include family counseling and the use of warning labels. Infant seats and carriers should be placed on the floor, rather than on tables or counters.

Falls from furniture

Epidemiology and clinical features – Injuries related to nursery products and furniture occur commonly in children younger than five years of age, particularly those who are younger than one year [11,14,54,55]. Most of these injuries are caused by falls [11,54]. Falls from furniture are the most frequent type of fall among children between 3 and 47 months of age [49]. Falls from highchairs tend to occur when an unrestrained child tries to stand in the chair or when the chair tips over [56-58].

Severe injuries sustained in falls from less than 3 feet (0.9 meters) are extremely rare [20,29,37,59,60]. In one retrospective study, the hospital records of 207 children younger than six years of age with documented falls of 25 to 54 inches (64 to 137 cm) from cribs or beds were reviewed [61]. Only 15 percent of the children had visible trauma (contusions, minor lacerations); one child had a simple skull fracture, and one had a clavicle fracture; and none of the children had serious, multiple, visceral, or life-threatening injuries. The authors concluded that falling out of bed usually is a benign occurrence and that the history should be questioned in those children who present with severe injuries from a minor fall.

In another review of 85 children (66 of whom were younger than six years) presenting to a pediatric emergency department for injury sustained from falling from a bed or a top bunk, most were reported to have fallen out of bed while sleeping. Thirty-three sustained lacerations or soft-tissue injury to a limb, 25 had fractures, 27 had head injuries, and 14 required admission [62]. Twenty-two percent of the children who had significant injuries fell from the top bunk. The authors suggest that children younger than six years of age should not sleep in upper bunks.

The condition of the contact surface may influence the risk of injury in falls from less than 4 feet (1.2 meters). In simulations of feet-first free falls from low heights (≤47 inches [119 cm]) using a three-year-old test dummy, head injuries were more likely when the linoleum contact surface was dry than when it was wet [63].

Prevention – Recommendations to prevent furniture-related fall injuries include:

Using preinstalled restraints on high chairs and increasing high chair stability [56]

Keep highchairs away from tables or counters to prevent pushing over and tipping over

Never leaving babies alone on any furniture, even if they have not yet begun to roll over

Using guard rails on cribs and changing tables

Placing infant seats on the floor, rather than on tables or counters

Lowering the mattress in the crib as the infant learns to sit and pull to stand, and discontinuing the use of the crib when the top rails are less than three-quarters of the child's height

In addition, mandatory federal standards for bunk beds and any bed manufactured in the United States in which the underside foundation is more than 30 inches (76 cm) from the floor (effective since June 2000) include the following [64]:

The upper bunk must have guardrails on both sides; the wall-side rail must be continuous.

Openings in the upper bunk structure must be small enough to prevent the passage of a child's torso (less than 3.5 inches [9 cm]).

A label must be affixed to the bed that warns not to place children younger than six years of age on the upper bunk. Instructions that accompany the bed must contain the same information and warning.

Falls in the bathtub

Epidemiology and clinical features – Falls in the bath are the most common cause of bathtub-related injuries. In one review of 204 children (4 months to 16 years, mean age 3.1 years) who were treated for bathtub-related injuries, the following findings were noted [65]:

Lacerations were the most common injury (67 percent)

The head and face were involved in 68 percent of cases

Adult supervision was present in 85 percent of the injuries to children younger than five years of age

Prevention – Because adult supervision was present in most cases of bathtub falls, other passive methods of prevention, such as the addition of slip-resistant devices to increase surface friction, are recommended [65].

FALLS FROM PLAYGROUND EQUIPMENT

Epidemiology and clinical features – According to the Centers for Disease Control and Prevention, between 1990 and 2000, 147 children 14 years or younger died from playground-related injuries [66]. Of these deaths, 70 percent occurred in home locations, and 56 percent died from strangulation (eg, in ropes, cords, rope swings) [66,67].

Data from the emergency subset of the National Hospital Ambulatory Medical Care Survey indicate that an average of 153,425 children younger than 20 years of age in the United States visit emergency departments for injuries sustained in playground falls [68]. The rate of falls from playground equipment was greatest among five- to nine-year-olds. Playground falls were more likely to occur at school or day care compared with home, public, and other locations (40, 25, 9, and 15 percent, respectively) [68]. Another study found that being male and engaging in sports was also associated with falls that occurred at schools [69].

Falls from playground equipment, such as swings, climbing equipment, and slides, are the leading cause of playground injuries [66,70]. The activity most often associated with falls on home equipment was intentional jumping or dismounting from equipment, primarily swings. Most playground-related injuries involve falls to the undersurface, although some involve falls onto equipment resulting in straddle injuries. (See "Straddle injuries in children: Evaluation and management".)

Playground injuries in children younger than five years of age involve the head and face more often than in older children (49 versus 28 percent) [71]. Fractures, usually of the wrist, lower arm, and elbow, are the injuries most reported in all ages. In a cross-sectional study of 3184 emergency department visits for falls in children age 2 through 17 years, 64 percent of 151 falls from monkey bars resulted in fractures; the odds of a fracture after a fall from monkey bars was approximately three times that after any other type of fall [72]. (See "Evaluation and management of dental injuries in children" and "Nasal trauma and fractures in children and adolescents".)

The risk of incurring injury is related directly to the height of the equipment [73-75], with an increased rate of injury from falls from equipment that is more than 5 to 6 feet (1.5 to 1.8 meters) above ground [73,74,76,77]. The odds of a major fracture are almost four times greater when falling from a piece of playground equipment compared with a standing fall [78].

The risk of incurring injury also is related to the energy-absorbing potential of the undersurface, which can vary substantially depending upon its composition [75-77,79-83]. As an example, in one study of 930 children who presented to an urban pediatric emergency department for injuries related to falls from playground equipment, children were more likely to sustain a head injury or fracture when falling onto grass compared with sand (75 versus 61 percent, odds ratio 1.74, 95% CI 1.21-2.52) [84].

Safe playground surfaces include loose fill materials and synthetic rubber mats. Among loose fill materials, wood chips have better energy-absorbing potential than does sand or gravel [71,80]. The absorption potential is dependent upon the depth of the material [71]. Synthetic rubber mats also may have acceptable energy-absorbing potential [80], but the potential varies depending upon the manufacturer and the material from which the mat is made; individuals who wish to use synthetic mats as the undersurface should request data from the supplier to ensure that it is safe for the intended equipment [71].

Prevention – Strategies for preventing playground injuries have included adding energy-absorbing surfacing materials, decreasing the height of playground equipment, performing regular playground inspections, and supervising children on playgrounds.

Guidelines to ensure the safety of home playground equipment have been developed by the Consumer Product Safety Commission (CPSC) [85]. In addition, the CPSC handbook for public playground safety makes the following recommendations to prevent fall injuries [71]:

Avoid using asphalt, concrete, grass, and soil surfaces under playground equipment. Acceptable loose fill materials include shredded rubber; hardwood fiber, mulch, or chips; and fine sand. Loose fill materials should not be installed over existing hard surfaces.

Surfacing should be maintained at a depth of 12 inches (30.5 cm) and should extend a minimum of 6 feet (1.8 meters) in all directions around stationary equipment. Depending on the height of the equipment, surfacing may need to extend further than 6 feet (1.8 meters).

Play structures more than 30 inches (76 cm) high should be spaced at least 9 feet (2.75 meters) apart.

Continuous handrails extending the full length of the access should be provided on both sides of all stairways and stepladders.

Guardrails or protective barriers should be provided for all elevated surfaces; openings in guardrails should measure less than 3.5 inches (9 cm) and openings between ladder rungs should measure more than 9 inches (23 cm) to prevent entrapment injuries.

Hazardous hardware (eg, open "S" hooks, protruding bolt ends, sharp points, or edges) should be repaired, replaced, or removed.

Tripping hazards (eg, exposed concrete footings, tree stumps, and rocks) should be removed.

Play equipment and surfacing should be regularly checked to make sure they are in good condition.

Children on play equipment should be supervised at all times.

FALLS FROM SHOPPING CARTS

Epidemiology and clinical features – Each year in the United States, an average of approximately 24,100 children younger than 15 years are treated in emergency departments for shopping cart-related injuries [86]. Children are injured in shopping carts when they fall out or get pinched in the folding mechanism, or when the shopping carts tip over or strike against an object [87,88]. Shopping carts are prone to tipping over because they have a high center of gravity and a narrow wheel base.

Injuries caused by falls are the most common [86,89]. Most injuries occur when children stand up in the seat or the basket of the cart [90]. Head injuries account for between one-half and two-thirds of the injuries; between one-quarter and one-half of these are considered serious (eg, fracture, concussion) [90-92]. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation" and "Skull fractures in children: Clinical manifestations, diagnosis, and management".)

Prevention – The American Academy of Pediatrics (AAP) policy statement on shopping-cart-related injuries calls for clear and effective performance standards to prevent falls and tip-overs [93,94]. The AAP further advises caregivers to use other methods for transporting their children while shopping until safety standards for carts are implemented in the United States. If caregivers choose to use a shopping cart, they should follow CPSC recommendations to prevent injuries related to shopping carts [90]:

Children riding in the seat of the cart should wear a seatbelt

Children should not ride in the cart basket, stand in the cart, or climb on the sides of the cart

Adults should push shopping carts in which children are seated

Do not let a child push the cart with another child in it

Do not put infant carriers on top of the basket [95]

The use of infant seats and restraining belts may not prevent injuries related to shopping carts in children younger than one year of age because tip-over of shopping carts is an important mechanism of injury for this age group [88]. Some authors suggest that children should not be transported in shopping carts unless the carts have been redesigned to prevent tip-over (eg, with a wider wheel base and outrigger-type wheels) [88].

FALLS FROM THE CARGO AREA OF PICKUP TRUCKS

Epidemiology and clinical features – Although falls from pickup trucks are not a common occurrence, each year approximately 200 deaths occur to passengers in truck cargo areas; approximately one-half of these deaths occur in children [96-98]. Ejection from the cargo area is the most common cause of death and injury [99]. Enclosure of the cargo area (eg, with a camper shell) does not provide adequate protection from injury. In one study of 161 fatalities in occupants of cargo areas of pickup trucks, 16 percent of the victims were riding in enclosed cargo beds [100]. Occupants of the cargo area are more likely to sustain multiple and severe injuries than are occupants of the cab [96,101,102] and are eight times more likely to die in a collision than are restrained occupants in the cab of the truck [100]. Even without a collision, children could fall from cargo beds should rapid braking occur or if traveling on an uneven road surface [100,103,104].

Prevention – Cargo areas of pickup trucks are neither required nor designed to meet occupant safety standards because they are not intended for passenger use. However, 30 states and the District of Columbia have laws addressing the dangers of riding in the cargo area of pickup trucks; these laws are designed primarily to protect children [105]. The American Academy of Pediatrics Committee on Injury and Poison Prevention has issued the following recommendations regarding children in pickup trucks [96]:

Travel in the cargo area of pickup trucks should be prohibited; teenagers should agree that they will neither ride nor transport others in the cargo area of pickup trucks

Age-appropriate restraint devices should be used for travel within the cabs of pickup trucks

Trips should be planned in advance so that an appropriate seat position and restraint device are used for each passenger

Injuries that occur during travel in the cargo area should be recorded and reported appropriately [106]

Clinicians should advocate for more stringent and comprehensive state legislation that would prohibit any occupant from traveling in the cargo area of a pickup truck and urge law enforcement agencies to enforce laws related to occupant travel

FALLS DURING RECREATIONAL ACTIVITY

Epidemiology and clinical features — Children may be injured in falls during recreational activities, including inline skating and riding skateboards and nonmotorized scooters [107-109]. Data from the National Electronic Injury Surveillance System of the United States Consumer Product Safety Commission (CPSC) indicate that in 2021, 10,775 children under 15 years of age were treated in hospital emergency departments for injuries related to inline skating and 87,426for injuries related to skateboards, scooters, and hoverboards [110].

Injuries to inline skaters are particularly common for novice skaters, roller hockey players, and those who perform tricks. Most injuries occur because of loss of balance secondary to road defects or debris; being unable to stop; speeding out of control; or doing a trick [111]. The same probably is true for skateboard and scooter injuries. Two-thirds of inline skating-related injuries are fractures; the wrist is the most common site of injury, accounting for 37 percent of all injuries. Two cases of severe perineal lacerations have been reported in females whose legs were rapidly abducted (ie, a "splits" type maneuver) during a fall [112]. Death caused by injuries related to inline skating rarely occurs (36 deaths reported to the CPSC between 1992 and 1998) and usually is caused by collision with a motor vehicle [113].

Similar to inline skates, athletic shoes with a single removable wheel located in the heel (Heelys or inline gliders) are adding to the burden of injuries from falls [93,114-116]. Upper body orthopedic injuries are the most common injury associated with inline gliders.

Prevention — The use of protective equipment (eg, helmets, knee and elbow pads, and wrist guards) during these activities can prevent injury [111,117,118].

Inline skating — The effectiveness of various types of safety gear in preventing injury of inline skaters was evaluated in a case-control study [111]. The age- and sex-adjusted odds ratio (OR) for wrist injury in those not wearing wrist guards, compared with those who were, was 10.4 (95% CI 2.9-36.9); the OR for elbow injury in those who did not wear elbow pads (adjusted for the number of lessons skaters had had and whether they performed trick skating) was 9.5 (95% CI 2.6-34.4). Not wearing knee pads was associated with a nonsignificant increase in the risk of incurring knee injury (crude OR, 2.2; 95% CI 0.7-7.2). The effectiveness of helmets could not be assessed in this study. In a subsequent observational study, helmet use was associated with reduced risk of head injury in inline skaters age 1 to 16 years (adjusted OR 0.33, 95% CI 0.14-0.79) [117].

The American Academy of Pediatrics (AAP) Committees on Injury and Poison Prevention and Sports Medicine and Fitness make the following recommendations to prevent injury to children during inline skating activity [107,118]:

A helmet, wrist guards, knee pads, and elbow pads should be worn at all times. The helmet should meet applicable safety standards [119].

Novice skaters should practice on a rink before attempting to skate on a path or the street.

Skating should take place only on streets that are blocked off or closed to through-traffic (eg, dead end streets or cul-de-sacs).

Skating while holding onto a moving vehicle ("truck-surfing" or "skitching") should be prohibited for all skaters.

Skates should fit properly; the type of skate should be appropriate for the child's size, skill level, and purpose.

Skaters should learn to stop quickly and fall safely; receiving instruction by a teacher certified by the International Inline Skate Association is recommended.

Children with hearing or vision deficits and those with problems of large-muscle motor skill or balance should skate only in a protected environment.

State legislation that requires use of a helmet while skating should be encouraged; helmets are required for children and adolescent skaters in some states.

Skateboards/hoverboards — The AAP Committees on Injury and Poison Prevention and Sports Medicine and Fitness make the following recommendations to prevent injury to children during skateboarding [113,118]:

Children younger than five years of age should not be allowed to ride skateboards [113,120]. They are more susceptible to incurring injury because they have a high center of mass, immature skeletal development, an undeveloped neuromuscular system, and lack of judgment of their own skills and strength.

Children younger than 10 years of age should not use skateboards without close supervision by an adult or responsible adolescent [121].

Skateboards must never be ridden in or near traffic.

Children should never hold onto the side or rear of a moving vehicle while riding a skateboard ("skitching a ride").

All skateboarders should wear a helmet and other protective gear (including wrist guards, elbow pads, and knee pads) to prevent the occurrence or reduce the severity of injuries resulting from falls [122]. The helmet should meet applicable safety standards [119,123]. In an observational study, helmet use was associated with reduced risk of head injury in skateboarders 1 to 16 years (adjusted OR 0.33, 95% CI 0.23-0.46) [117].

Hoverboards are electric, self-balancing, two-wheeled boards that are similar to skateboards. They were not evaluated for safety before commercial release in 2015. Observational studies suggest that the types of injuries among hoverboard riders are similar to those among skateboard riders (eg, fractures, contusions, sprains, and/or strains) [124]. However, hoverboarders have more injuries to the wrist and skateboarders have more injuries to the ankles.

Studies of hoverboard safety and counseling for prevention of hoverboard injuries are limited. Nonetheless, given that a fall in the most common mechanism and the wrist is often injured [125], it is reasonable to suggest that children who use hoverboards wear helmets and wrist guards. Caregiver supervision is also suggested.

Scooters

Nonmotorized scooters – Nonmotorized scooters are becoming increasingly popular among young children. Falls are the most common cause of scooter-related injuries [117,126]. Head injuries occur most frequently when children fall forward or to the side after losing control of the scooter or colliding with another object [127]. Distal radial fractures are associated with holding onto the handle of the scooter while falling [128].

The AAP recommends that pediatric health care providers counsel caregivers regarding nonmotorized scooters according to the CPSC recommendations [113,129]:

Children younger than eight years of age should not ride scooters without close adult supervision

Children should not ride scooters in streets, in traffic, or at night

Children should wear helmets, knee pads, and elbow pads while using scooters

In an observational study, helmet use was associated with reduced risk of head injury in scooter riders age 1 to 16 years (adjusted OR 0.53, 95% CI 0.33-0.86) [117].

Electric scooters – Electric scooters (e-scooters, motorized scooters), which can reach speeds of up to 15 miles per hour, are increasingly popular and available in the United States. Regulations for e-scooter use vary locally but often require the rider to be ≥16 years of age and to wear a helmet. In some states, electric scooters cannot be ridden on sidewalks, increasing the risk of motor vehicle-related injuries [130].

In a one-year retrospective study, 249 patients were evaluated for e-scooter-related injuries; approximately 11 percent were <18 years of age and only 4.4 percent were wearing a helmet [131]. A fall was the most common mechanism of injury; head injuries (40 percent) and fractures (32 percent) were the most common types of injury. Although most of the injuries were minor, 6 percent of patients were admitted to the hospital.

Pending additional information regarding the safety of e-scooters and effectiveness of counseling and other interventions to prevent e-scooter-related injuries, we agree that riders of e-scooters should wear helmets and that children <16 years should not ride e-scooters [132]. Helmets should meet applicable safety standards [119].

Trampolines — The use of trampolines is discouraged by the AAP [133]. Trampolines pose a serious risk for falls, particularly when they are used on an uneven surface, which may result in an off-balance jump. In retrospective reviews, injuries to the head and/or neck account for 10 to 17 percent of trampoline-related injuries [134-136].

For families who choose to use trampolines, the AAP Council on Sports Medicine and Fitness makes the following recommendations to prevent injury [133]:

Children younger than six years of age should be prohibited from jumping on trampolines

Active adult supervision should occur with all other jumpers

Trampoline use should be limited to only one jumper at a time

Somersaults and flips should not be performed in a recreational setting

Caregivers should inspect trampolines for adequate placement and condition of padding

Trampolines should be placed on a level surface and away from trees or other hazards

Trampolines should be inspected before each use for worn or damaged parts and safety equipment such as netting and padding [137].

INJURY REPORTING — Full, accurate documentation of injury events, including the "who, what, when, where, why, and how" of the injury occurrence and whether protective equipment (eg, a safety helmet) was used, is an essential step in injury prevention [106]. Such information defines the extent of the problem and provides the basis for preventive counseling and development of possible prevention strategies.

The United States Consumer Product Safety Commission should be contacted for any injury or death involving consumer products

RESOURCES — Information on prevention of falls is available from the following organizations:

Safe Kids Worldwide

The American Academy of Pediatrics

The "MakeSafeHappen" smart phone application (available at https://makesafehappen.com) provides room-by-room safety tips for specific risk categories (eg, falls) and can be customized for various ages

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

Beyond the Basics topic (see "Patient education: Head injury in children and adolescents (Beyond the Basics)")

SUMMARY

Epidemiology – Unintentional falls are a leading cause of nonfatal injury in children younger than 19 years of age in the United States (table 1). The risk of fall-related injury is greater in children younger than five years than in older children and adolescents. (See 'General epidemiology' above.)

Falls from windows – The severity of fall-related injuries is related to the height of the fall. Intentional injury should be considered in children with unwitnessed falls and in children with serious injuries from falls that were reported to be from less than two stories. Window guards or stops can be used to prevent falls through open windows. (See 'Falls from height' above.)

Infant walkers – Most children younger than 15 months of age who sustain injuries related to infant walkers are injured by falling down stairs. (See 'Falls in infant walkers' above.)

Nursery products and furniture – Falls from furniture may be prevented through use of preinstalled restraints and guardrails; supervising infants who are placed on furniture (eg, changing tables, sofas, beds), even if the infant cannot roll over; not placing infant seats on tables or counters; and lowering the mattress in the crib once the infant can pull to stand. (See 'Falls from furniture' above.)

Playground equipment – Fractures, usually of the arm, are the most common injury related to falls from playground equipment. The risk of injury is related to the height of the equipment and the energy-absorbing potential of the undersurface. (See 'Falls from playground equipment' above.)

Shopping carts – Head injuries are the most common injury related to falls from shopping carts, which are prone to tipping over because they have a high center of gravity and a narrow wheel base. If caregivers choose to place their child in a shopping cart, the child should ride in the seat and wear a seat belt, and the cart should be pushed by an adult. (See 'Falls from shopping carts' above.)

Recreational activity – The use of protective equipment (eg, helmets, knee and elbow pads, and wrist guards) during inline skating, skate boarding, hoverboarding, and scooter riding can prevent fall-related injuries. (See 'Falls during recreational activity' above.)

Injury reporting – In the United States, injuries related to consumer products should be reported to the United States Consumer Product Safety Commission. (See 'Injury reporting' above.)

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Topic 2857 Version 25.0

References

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