Consumer product-related injuries to children

Monash University Accident Research Centre – Report #168 - 2000

Full report in .pdf format [1.9MB]

Authors: W. Watson, J. Ozanne-Smith & J. Lough

Abstract :

This research was undertaken to establish the role of consumer products in injuries to children to underpin an injury reduction program by the Consumer Affairs Division of the Commonwealth Department of Treasury.

National and Victorian data were analysed to identify the types of consumer products involved in unintentional injuries to children. Products were ranked by frequency of association for four levels of injury severity: deaths, hospital admissions and non-hospitalised cases. Injury Surveillance data from the U.S. Consumer Product Safety Commission was also examined for comparison.

In Australia in 1997, injuries to children aged 0-14 years led to a total of 347 deaths, about 58,000 hospitalisations and an estimated 576,000 non-hospitalised, medical attendances. In total, it is estimated that there were about 634,000 medically-treated child injuries in that year. Overall, 1 in 6 children in the population sustained an injury for which medical treatment was sought.

In terms of unintentional injury death, the priority areas within the scope of consumer product safety are drowning (swimming pools), mechanical asphyxiation (cots, strollers, bunk beds) and fires (matches and lighters). Priorities based on hospitalisations are more diverse with more causes involved. Falls emerge as a common issue in the under fives with falls from playground equipment featuring in the 5-9 year age group. Hospitalisation data also shows the importance of poisoning (medicines and household products) and burns and scalds (hot drinks, hot tap water) in the under fives and recreation and leisure injuries (bicycles, play ground equipment, skates, skateboards and trampolines) in the older age-groups.

Recommendations are made for general product safety and injury prevention strategies relating to individual products and causes. Key recommendations relate to general product safety, bunk beds, baby walkers and trampolines.

Executive Summary

AIMS & OBJECTIVES

The primary aim of this project was to undertake research into the role of consumer products in injuries to children (aged 0 to 14 years) in order to support a proposed injury reduction program in this area.

More specifically, the aims are:

1)    To undertake a review of recent Australian and international literature concerning injuries to children (0-14 years), and to thus identify the major causes of such injuries and the extent to which consumer products are involved.

2)    To identify and comment on major sources of injury data in Australia and overseas that can assist in exploring the links between consumer products and injury.

3)    To analyse available data to investigate:

  • The nature of injuries and what types of consumer products may be involved, and;
  • The ranking of occurrence and severity of injury by product type.

4)    To establish and comment on patterns and trends in injuries to children as a basis for injury prevention programs.

5)    Having regard to the consumer product safety responsibilities of Consumer Affairs, make recommendations on injury prevention measures to assist children.

METHODS

An overview of the numbers and rates of injury for children in Australia is reported for three mutually exclusive groups that broadly reflect the severity of injury : 1) injury resulting in death, 2) injury resulting in hospitalisation and 3) non-hospitalised injury requiring medical treatment (Emergency Department and General Practitioner attendances). These are presented by five-year age-group and gender. For each level of severity, numbers and rates of the major causes of injury (including identifiable products) are also presented.

National injury data for deaths and hospitalisations was provided by the Research Centre for Injury Studies (RCIS; formerly the National Injury Surveillance Unit) at Flinders University. Estimates of the number of non-hospitalised injuries were based on ratios of hospitalisations to Emergency Department presentations, using data from the Victorian Inpatient Minimum Dataset (VIMD) and the Victorian Emergency Minimum Dataset (VEMD), and applied to the national hospitalisation figures. The total estimate was then broken down into injury cause categories, age, and gender groups using the distributions in the 1996 VEMD presentations data.

An overall estimate of the number of general practitioner attendances by age and gender was also calculated. This was derived by applying the ratio of general practitioner attendances to Emergency Department presentations (1.1 : 1) used in previous studies (Watson & Ozanne-Smith, 1997). However, it was not considered appropriate to provide estimates of the numbers and rates of injury by cause for this group of injuries, given the small and geographically limited sample on which the estimate is based.

National non-fatal injury surveillance data was provide by the NCIS and comparison data from the US by the National Electronic Injury Surveillance System (NEISS) managed by the US Consumer Product Safety Commission.

A more comprehensive analysis of product-related injury data from the Victorian Coroner’s Facilitation System (VCFS) and the Victorian Injury Surveillance System (VISS) held at Monash University Accident Research Centre (MUARC) was undertaken to examine the involvement of products in unintentional deaths, hospitalisations and non-hospitalised injury at different ages (0 years, 1-4 years, 5-9 years and 10-14 years).

A search of the national and international literature relating to child injury was conducted and the results of the data analysis discussed in relation to the literature.

RESULTS

Magnitude of the problem

In Australia in 1997, injuries to children aged 0-14 years led to a total of 347 deaths, about 58,000 hospitalisations and an estimated 576,000 non-hospitalised, medical attendances at either hospital Emergency Department (274,104) or General Practitioners’ surgeries (301,514). In total, it is estimated that there are about 634,000 medically-treated child injuries in that year.

Overall, 1 in 6 children in the population sustained an injury for which medical treatment was sought. There were approximately 167 hospitalisations and 1,659 non-hospitalised medical attendances for every death (Figure 4.1).

Ratio of deaths, hospitalisations and medical attendances for injury in Australian children aged 0-14 years.

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Overview

A marked decrease in death rate with increasing age is apparent to 14 years with the drowning peak in 0-4 year olds an obvious problem requiring intervention. Children in the 0-4 year age group are more vulnerable to injury, and death from injury, than other age-groups. Hospitalised and non-hospitalised injury rates for this younger age group are higher than for other children (5 to 14 years). The injury death rate for 0-4 year-olds is twice that of 10-14 year-olds and almost three times that of 5-9 year-olds. In terms of unintentional injury death, the priority areas within the scope of general consumer product safety are drowning, mechanical asphyxiation and fires.

Priorities based on hospitalisations are more diverse, with more causes involved. Falls emerge as a common issue in the under five year olds, with falls from playground equipment featuring in the 5-9 year age group. Hospitalisation data also show the importance of poisoning and burns and scalds in the under five year olds, and sports and recreation injuries in the older age-groups.

The location of injury occurrence varies with age, with the home particularly prominent for 0-4 year olds, where it represents the site for 73 percent of injuries. As children mature, the home decreases in importance with other locations increasingly involved and a more diverse spread of injury locations noted in the 10-14 year age group. This pattern reflects the increasing amount of time spent outside the home with increasing age. When estimated hours of exposure are taken into account for school and home injuries in older children, it is found that the risk of injury is similar (Goss, 1992).

Injuries in the first year of life

Data from the Victorian Injury Surveillance System suggest that nursery furniture is associated with 23 percent of injuries in this age group that are presented to hospital Emergency Departments, with falls accounting for almost 80 percent of these injuries. The most common items of nursery furniture associated with injury in this age group are prams and strollers, high chairs, baby walkers, bouncinettes, change tables and cots. Cots and pram/strollers are associated with fatal injuries in this age group.

Baby walkers allow an increased mobility beyond the developmental stage of the infant that often leads them into hazardous situations, which can result in a fall or accessing of hazardous substances such as hot beverages on coffee tables

Falls from heights also occur when infants are left unattended on beds, tables, chairs and couches or when bouncinettes are placed on elevated surfaces such as bench tops.

Infants become increasingly mobile in the first year of life, allowing them to access a wide range of hazards. Their small size in relation to their environment results in frequent scalds from pulling hot liquids down onto themselves from coffee tables or benches. They also access and frequently mouth a range of hazardous substances (e.g. cigarettes and medications) and objects left within their reach (e.g. coins).

Injuries to children aged 1-4 years

Drowning is the major cause of death in this age group with the majority occurring in backyard swimming pools. The hospital admission rate for this group is highest for falls. This is followed by poisoning and burns (principally scalds) which both peak in this developmental stage. Although this age group is treated as a single age category in this study, children are still undergoing rapid development during this period which is reflected in the changing range and nature of factors involved in injury causation.

At two years of age the major factors associated with injury have changed considerably from those in the first year of life. The frequency of injury presentations to hospital Emergency Departments has almost doubled compared to the first year.

Furniture is still a predominate factor in injuries at this age. However, furniture is likely to be involved as a means of accessing hazards as well as being a fall hazard itself. Medications reach their peak involvement at this age and are represented by a high level of severity (16 percent of admissions at this age; Ozanne-Smith, 1992). Dog attacks, bicycles and tricycles and playground equipment (particularly slides) are also frequently associated with injuries. Finger jams in doors are also common at this age.

Toddlers apply their developing motor and cognitive skills to the task of exploring all aspects of their environment. While it must be accepted that infants and toddlers will experience minor injuries in the course of normal child development, it is unacceptable for children to suffer more serious injury. Thus a balance is required between a ‘safe’ environment and one which is stimulating and supportive of child development.

By the age of four years bicycles and playground equipment are more frequently involved in injury compared to younger children. Dog attacks remain constant and vehicles emerge as an important factor as children are transported more from their homes

As children of this age assert their independence, they are at risk of unwittingly exposing themselves or younger siblings to dangerous situations, such as the pre-school child who insists on crossing the road alone, or the four year old who loses control of the pram containing a younger sibling on a steep driveway.

Injuries to children aged 5-9 years

In this and other age groups (except less than 5 years), road trauma is the major cause of death from injury. Motor vehicles are also associated more severe injuries requiring hospital admission.

Sport and recreational factors, particularly bicycles and playground equipment predominate at this age. Falls remain the major cause of hospital admission due to injury. Among injuries requiring hospitalisation, falls from playground equipment provide an example of an injury type with a clear peak in this age-group, with monkey bars and other climbing equipment now predominant compared with the younger age group.

While males are generally over-represented in most categories of injury, the similarity in rates for males and females for playground equipment falls is noteworthy and probable relates to the relative levels of exposure.

Injuries to children aged 10-14 years

Motor vehicles remain a frequent factor in death and more severe injuries in this age group.

Although sports and recreational still dominate in both hospital admissions and Emergency Department presentations in this age-group, bicycles are more frequently involved and football and other ball sports have supplanted playground equipment. Other organised and informal sport/recreational activities such as in-line skating and skate boarding are most frequent at this age.

Male overrepresentation is marked in this age-group, particularly among bicycle related and sporting injuries.

SUMMARY OF MAJOR RECOMMENDATIONS

General Product Safety

Policy

A systematic data driven approach to consumer product safety and a systematic approach to improving product design should be promoted to minimise product-related injury to children in Australia.

A general product safety directive should be adopted and enforced in Australia and New Zealand. This should take into account the observed strengths and limitations of the European Community’s General Product Safety Directive (GPSD) of 1992.

Legislation, based on the U. S. model, should be introduced in Australia to require that manufacturers and importers to inform relevant consumer safety authorities of consumer complaints and other information pertinent to the safety of the products they manufacture or import.

Standardisation

As in the United States, mandation of standards should occur in Australia in cases where voluntary standards and marketplace forces have been shown to be ineffective in achieving compliance, and mandation is warranted by evidence.

Research and evaluation

The effects of the introduction of new standards and calls for the mandation of existing standards should be evaluated by monitoring injury data and conducting other investigations on products associated with injury such as cots, cigarette lighters, and baby walkers.

A model to identify priorities should be developed to assist with the setting of an evidence-based agenda for product-related injury prevention. An Australian injury cost and consequence model for product-related injury should be developed to assist in the evaluation of injury prevention programs.

Injury Data Collection

The establishment of a centralised clearinghouse is necessary to integrate and analyse data from all available sources (nationally and internationally) to identify potentially dangerous products and to disseminate information to regulators and other responsible bodies.

The National Coroners’ Information System (NCIS), currently under development, should identify products and their involvement in deaths. This may require the development of a specialist module on product related deaths to supplement the core dataset. It may also require the development of data collection protocols and training for those investigating death scenes.

Product Specific Recommendations

Swimming Pools

The effectiveness of pool fencing legislation as a countermeasure to toddler drowning should be more fully evaluated. In particular, current pool compliance with regulations and methods of increasing compliance by pool owners should be investigated.

Nursery Furniture

The Australian standard for baby walkers, currently being developed, should address the major issue of baby walker falls (particularly down steps/stairs) in line with the recently strengthened US ASTM standard. Compliance with the standard and the injury rate should be monitored to establish whether mandating the standard is warranted.

A voluntary Australian/New Zealand standard for baby walkers should be supported with an extensive and ongoing educational campaign directed at parents, caregivers, retailers and nursery furniture importers (no baby walkers are currently manufactured in Australia).

The current development of the Australian/New Zealand voluntary standard on high chairs should be completed and released as soon as possible.

A standard should be developed for change tables. The standard should be based on the best available international standards or draft standards.

Children’s furniture safety standards should be reviewed and modified, if necessary, at least once every five years to ensure that new requirements or revision of existing requirements occurs when new substantive information becomes available.

Ongoing surveillance of the second-hand products market should be undertaken to ensure the nursery furniture on display for sale complies with standards and to monitor any modification to product design and the general condition and level of maintenance of the furniture on sale.

Smoke alarms and other domestic fire prevention

Best practice state smoke alarm regulations should be implemented in all Australian States and Territories.

The availability and widespread installation of single purpose lithium smoke alarm batteries (which last ten years), mains powered smoke alarms and electric safety switches (power outlet, permanently installed switchboard units and portable units) should be promoted in existing homes.

Research into the development of suitable low cost, fire-retardant housing and furnishing/furniture materials should be promoted. Furthermore, information on the flammability of combinations of fabrics and fillings should be distributed to the furniture and furniture fabric industry.

Guidelines should be produced and implemented to improve data detail in surveillance systems, including the National Coronial Information System, so that the ignition source of the fire, premorbid conditions of victims, and alcohol involvement are routinely reported.

Poisoning

Medications identified in a recent MUARC study as warranting child resistant packaging (Scott & Ozanne-Smith, 1999b) should be mandated to be packaged in child resistant forms.

Comparisons of international poisoning rates and poisoning countermeasures are needed to identify best practice for childhood poisoning prevention.

Research is needed to identify children’s means of access to pharmaceutical products that currently require child resistant packaging (eg paracetamol, Dimetapp, Demazin).

A study should be undertaken to identify the reasons for, and solutions to, the marked variation in geographic rates of childhood poisoning between rural and urban populations.

Bunk beds

It is clear that voluntary standards and the market have been ineffective in achieving compliance in Australia since the release of the Standard in 1994. In light of this, the current revision of the Australian Standard (AS/NZS 4220:1994 Bunk Beds) should be made mandatory. A precedent for mandating the Standard exists; from July 1,1998 all cots supplied for household use on the new and second-hand markets must comply with the mandatory safety standard AS/NZS 2172: 1995.

An extensive and ongoing education program to warn parents and caregivers of the inherent dangers of bunk beds and to encourage appropriate use should support this move. A mandatory standard could also be supported by a recall or modification of non-compliant bunks, to reduce the number of hazardous bunks in the community.

Playground equipment

Develop strategies to increase compliance with the current Australian Standard for fall height, soft-fall undersurfacing requirements, design, siting and maintenance of equipment.

Further trial the combination of reducing fall heights to less than 1.5 metres and increasing compliance with under surfacing standards in preventing playground fall injuries.

Quantify children’s exposure to different equipment types (e.g. by observational studies) to assess the risks of certain equipment for different aged children.

Bicycles

Encourage the enforcement of bicycle helmet wearing legislation.

Research, focused on the non-wearing group, as well as on the overall exposure of cyclists and helmet wearing rates is required to establish the current situation. This is particularly important in Victoria, as the state is seen as a world leader in bicycle helmet research and is best placed internationally to continue a series of evaluation studies.

Trampolines

Australia should adopt the 1999 version of the US trampoline standard ASTM F381:99 (which includes some but not all of the NZ Standard amendments), and incorporate the remaining NZ amendments.

Trampoline injuries should then be monitored to determine the effectiveness of the voluntary Standard and response of the market place to the standard. If it is shown to be ineffective, a mandatory standard and further attention to safe design should be considered.

Skates and skate boards

Refine and promote standards for helmets, both multi-purpose and specifically for in-line skating and skate boarding (with extended coverage to protect the back of the head).

Undertake further ergonomic and biomechanical research into the design of protective equipment, especially to improve the effectiveness of wrist guards.

Identify and address barriers to wearing protective equipment, especially among adolescents.

KEY RECOMMENDATIONS

General

A systematic data driven approach to consumer product safety and a systematic approach to improving product design is required to minimise product-related injury to children in Australia.

Bunk beds

In Australia, it is clear that voluntary standards and the market have been ineffective in achieving compliance since the release of the Standard in 1994. In light of this, the current revision of the Australian Standard - AS/NZS 4220:1994 Bunk Beds - should be made mandatory.

Baby walkers

The Australian Standard, currently being developed, for baby walkers should address the major issue of falls particularly down steps/stairs in line with the recently strengthened US ASTM standard.

A voluntary Australian/New Zealand standard baby walkers should be supported with an extensive and ongoing educational campaign directed at parents, caregivers, retailers and nursery furniture importers (no baby walkers are currently manufactured in Australia).

Compliance with the standard and the injury rate should be monitored to establish whether mandating the standard is warranted.

Trampolines

Australia should adopt the 1999 version of the US trampoline standard ASTM F381:99 (which includes some but not all of the NZ Standard amendments), and incorporate the remaining NZ amendments.

Sponsoring organisation: Consumer Affairs Division of the Commonwealth Department of Treasury