Journal of Pediatric Surgery (2013) 48, 1071–1076
Inappropriate use of infant seating devices increases risks of injury Marianne Beaudin a,b,⁎, Todd Maugans c , Dickens St-Vil b , Richard A. Falcone Jr.
Division of Pediatric General Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA Division of Pediatric General Surgery, CHU Ste-Justine, Montréal, QC, Canada c Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA b
Received 29 January 2013; accepted 3 February 2013
Key words: Seating devices; Fall; Head trauma; Infant
Abstract Purpose: The purpose of our study was to investigate the epidemiology and resulting injuries following falls sustained by infants seated in a variety of seating devices. Methods: A retrospective chart review of a cohort of infants less than 12 months old who presented to our institution from 1991 to 2010 after a fall from various seating devices was performed. Results: Two hundred five infants were identified, including 146 patients who were admitted to our institution (1991–2010) and 59 patients who were seen and discharged from the ED (2008–2010). Mean age of admitted infants was younger (3.5 vs. 5.3 months). Two patients (1%) required surgery for a depressed skull fracture. Overall, 18% had an intra-cranial hemorrhage. More patients requiring an admission secondary to their injuries fell from a table or counter (42% vs. 27%). Conclusion: Falls sustained by children seated in a variety of devices are frequent. Failure to restrain children in seating devices or improperly placing them on a table/counter is associated with more significant injuries. In order to minimize such injuries, it is important to educate caregivers of the risk in utilizing such seating devices. © 2013 Elsevier Inc. All rights reserved.
Injury remains the leading cause of death in children between the ages of 1 and 18 years in the United States . Among all children, falls are the leading mechanism of injury with a particular predominance among children between 0 and 4 years of age [2,3]. Importantly, among the youngest children, the majority of these injuries occur within the home . For children from 0 to 12 months of age, a significant number of falls are secondary to the use of car seats , infant carriers , bouncy seats , “Bumbo™” seats, grocery carts [8,9] or strollers . A survey of parents with ⁎ Corresponding author. Tel.: + 1 514 345 4931; fax: + 1 514 345 4694. E-mail address: [email protected]
(M. Beaudin). 0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.02.022
young infants revealed that seating devices were present in 100% of homes, and that 94% of these infants spent more than 30 min in their seating device every day, with an average time of 5.7 h . Many of these injuries occur as a result of the inappropriate use of these seating devices, such as use of car seats outside a motor vehicle. The use of seating devices for infants too young to sit is increasing and it is concerning that the number of related accidents is also on the rise [12,13]. Previous literature suggests that fall-related injuries in infants may be associated with the child being left unattended and/or with failure or improper use of restraints [6,14]. The purpose of this study was to further investigate
1072 the epidemiology and mechanism of injuries following falls sustained by infants who were seated in a variety of devices. Our ultimate goal was to provide some insight into potential prevention strategies for these specific patterns of injury.
1. Methods After receiving approval from the Cincinnati Children's Hospital Medical Center Investigational Review Board, we retrospectively reviewed a cohort of children less than 12 months of age who presented to our Level 1 Pediatric Trauma Center between January 1st, 1991 and December 31st, 2010. Patients were included in the cohort if they had an ICD-9 code E884.9: “fall from one level to another” in our trauma registry. We reviewed data pertaining to all patients who were admitted, were another hospital, were treated as a trauma resuscitation in the trauma bay or died in the ED. In addition, beginning in 2008, our trauma registry began including all injured patients evaluated in our emergency department. We therefore included this cohort of patients who were evaluated in the ED without admission or involvement of the trauma team from 2008 to 2010. All existing paper, microfiche and electronic medical records of the study subjects were reviewed. Only patients who had fallen from an infant automobile restraining device (infant seat, car seat, “pumpkin seat”) “bouncy” seat, “Bumbo™” seat, baby swing, grocery cart or stroller were included in subsequent analyses. Study variables included the following: age at time of injury, gender, device type, restraint use, parental supervision at time of injury, surface-to-surface description (e.g., countertop to floor), presenting symptoms (fussiness, drowsiness, vomiting, any neurological symptoms), neurological examination, physical injuries, imaging studies (radiographs and computed tomography), requirement for surgery, disposition (admission or discharge from the emergency room), condition at time of discharge, other related visits to the ED and readmissions. We excluded all patients who had provisional or confirmed diagnoses of inflicted injury or unclear mechanisms of injury. Standard descriptive statistics were performed to describe the demographic and injury-related characteristics of the study group. Continuous variables (i.e. age) were compared using the Student's t test. Categorical variables were analyzed using the chi-squared test. A p-value b 0.05 was considered statistically significant. All analyses were performed using the IBM Statistical Package for Social Sciences, Version 20.0 (IBM SPSS, Chicago, IL).
2. Results Between 1991 and 2010, 542,701 children were seen and evaluated for any type of injury at our institution and 30,862 were admitted. There were 27,673 children aged 0 to
M. Beaudin et al. 12 months evaluated with 2728 requiring admission. Among the admitted patients, 786 of the 0- to 12-month-old children (28% of all admitted 0–12-month-old children) had an ICD-9 code E884.9 (fall from one level to the other). There were a total of 86,294 injured children included in our outpatient registry from 2008 to 2010 and 4755 were aged 0–12 months. Of these, 1869 (39%) had an ICD-9 code E884.9. Among the admitted group (1991–2010), 146 infants met our inclusion criteria. An additional 59 patients were identified within the outpatient cohort (2008–2010). Thus, a total of 205 patients were included in our subsequent analysis. Demographic data for the admitted and outpatient groups are found in Tables 1 and 2, respectively. Infants who were admitted were younger (3.5 vs. 5.3 months old, p b 0.0005) and were more likely to have symptoms (39% vs. 20%, p = 0.0655) than those who were only observed in the ED. Four patients (3%) required admission to the pediatric intensive care unit (PICU) and were all discharged without complications within 2 to 4 days. Of these, two patients (50% of ICU admissions but only 1% of the total population) required neurosurgical interventions. Both patients required elevation of depressed skull fractures with good recoveries to normal neurological status at the time of discharge. The use of restraint devices while in seating devices is described for both groups in Table 3. Although restraint use was not documented in 26% of cases, 52% of all patients were unrestrained in their seating devices. The percentage of unrestrained children did not differ between those requiring admission and those observed in the ED (admitted 51% vs. observed in the ED 55%, p = 0.67). The most common circumstances leading to injury were falls from a counter or table followed closely by falls while being carried in the seat by a caregiver (Fig. 1). Looking at our data, more admitted infants fell from heights compared to the infants who were discharged from the ED (42% vs. 27%, p b 0.0005). This was the only statistically significant difference regarding circumstances of injury. Interestingly, of those who fell while in a car seat, 11.5% were in a grocery cart at the time. Injuries secondary to a fall from a bouncy seat occurred predominantly when the seats were placed on an elevated surface (82%). We specifically looked at the mechanism and circumstances of injury in the two patients who required elevation of a depressed skull fracture. One of the patients was seated in a bouncy seat that was placed on a standard kitchen counter. It is unknown whether this infant was restrained and no caregiver was present in the room to witness the exact mechanism of injury. The other patient fell from the car trunk while restrained in a car seat and a caregiver was nearby. Of all the admitted patients, only 4% had no head imaging (skull x-ray or head CT) performed while 66% of the patients discharged from the ED had no head imaging. Skull x-ray only was performed in 22% of the admitted patients and 5% of the outpatients.
Infant seating devices Table 1
Demographics and basic information of admitted patients after falls from seating devices (1991–2010).
n Average age ± SD (months) Average LOS ± SD (days) Documented presence of symptoms (%) Admitted to the floor (%) Admitted to the PICU (%) Surgery
3 2.3 ± 0.4 2.3 ± 1.5 2 (67)
22 3.1 ± 1.6 1.1 ± 0.5 7 (32)
2 6.0 ± 0 1±0 1 (50)
104 3.1 ± 1.8 1.1 ± 0.3 39 (38)
3 10.0 ± 1.7 1±0 1 (33)
12 5.3 ± 4.0 1.8 ± 1.8 7 (58)
146 3.5 ± 2.3 1 ± 0.7 57 (39)
2 (67) 1 (33) 0
21 (96) 1 (5) 1
2 (100) 0 0
102 (98) 2 (2) 1
3 (100) 0 0
12 (100) 0 0
142 (97) 4 (3) 2
LOS indicates length of stay; PICU, pediatric intensive care unit.
Among the admitted patients, 51 (35%) had an intracranial hemorrhage (ICH) discovered on head CT; none of which required neurosurgical intervention. Of these ICH, there were 8 intra-cranial hemorrhages non-otherwise specified (ICH NOS), 7 epidural hematomas, 9 subdural hematomas, 26 subarachnoid hemorrhages and 3 parenchymal contusions (Table 4). Skull fractures were seen in 71% of the admitted patients, and 31 patients (61%) presented with both ICH and skull fractures. In the outpatient group, three patients (5%) had a skull fracture and only one patient (1.7%) had an ICH. This ICH was identified in a 5-month-old with persistent somnolence who returned to the ED 2 days after injury. The CT study revealed minimal ICH. This infant was discharged from the ED after a few hours of observation. We were able to determine overall rates of symptoms and specific injuries when we examined the combined cohorts from 2008 to 2010, a period during which we had information for all patients. Sixty-seven percent of these infants had no injuries, 20% had a skull fracture and 18% had an intra-cranial hemorrhage with a subarachnoid bleed being most common (12/16; 75%). Regarding the patients with skull fractures but no ICH, 33% also had documented presence of symptoms either initially or during evaluation in the ED. Similarly, of all infants with skull fractures whether they had ICH or not, 35% had documented presence of symptoms (fussiness, drowsiness, vomiting, any neurological symptoms).
3. Discussion Falls from seating devices are a relatively frequent mechanism of injury at our institution. Of all children
under 1 year of age who were admitted after a fall, 19% occurred as a direct result of a seating device. Furthermore, these types of injury also affected a very young cohort of patients, with a mean age of only 3.5 months. This is consistent with the previous reports where most infant carrier-related falls occurred between 0 and 4 months of age [5,6,15]. Indeed, this might be attributable to the fact that parents have a false sense of security about leaving young infants in seating devices due to their assumed less developed motor skills that would presumably prevent them from falling off the seat. It was also demonstrated that infants too young to sit are more frequently placed in seating devices, whether at home or in child care centers [11,16]. Falls from seating devices that are placed on elevated surfaces such as counter tops, tables, or washing machines are prevalent [17,18]. The current study confirms the finding that the most common mechanism of injury was related to a fall from an elevated surface. The fact that more admitted infants fell from an elevated surface most likely reflects the higher force of injury of this mechanism. The only two patients who required a surgical intervention for elevation of a depressed skull fracture fell from elevated surfaces (counter top and car trunk). Additionally, these injuries often occurred despite the reported presence of an adult in the same room, supporting the fact that a few seconds of inattention is sufficient to result in a fall. Similarly, Harrell and Reid , in a report on car seat-related falls from grocery carts, demonstrated that an adult was present at the time of injury more than 90% of the time. Although inconsistently reported in this study, at least 51% of the admitted infants were unrestrained. The fact that most parents (1) under-estimate the ability of young infants
Demographics and basic information of infants in the outpatients (2008–2010).
n Average age ± SD (months) Documented presence of symptoms (%)
5 2.3 ± 2.4 0
5 3.5 ± 1.4 4 (80)
0 n/a n/a
35 4.9 ± 2.9 4 (11)
5 9.7 ± 2.8 2 (4)
9 6.8 ± 2.6 2 (22)
59 5.3 ± 3.2 12 (20)
M. Beaudin et al.
Table 3 Use of restraint devices in admitted patients and outpatients after falls from seating devices.
Use of restraint device in admitted patients (%) Use of restraint device in outpatients (%)
to move in their seating devices and (2) are unaware of the dangerous potential of leaving an infant in a seating device on an elevated surface , places this vulnerable group at significant risk of injury. Although the “Bumbo™” seat was recalled from the market by the U.S. Consumer Product Safety Commission (CPSC) in 2007 after 28 reports of infant falls from elevated surfaces linked with their use , we identified two patients who sustained falls from “Bumbo™” seats placed on counter tops in 2010. Despite the fact that these seating devices were recalled, a simple Web search revealed that they can still be easily purchased online. The rate of skull fractures and intra-cranial hemorrhages in our patient population was 20% and 18%, respectively, in both infants admitted and discharged from the ED between 2008 and 2010. Not surprisingly, the rate of these injuries is higher in the admitted population from 1990 to 2010 (71% skull fractures and 35% ICH). It is difficult to compare these numbers with the previous literature as the exact type of injury is infrequently reported in most studies. Greenberg et al.  reported a 34% incidence of skull fractures and 21% of ICH in a study using similar inclusion criteria in infant carrier-related falls. Although the incidence of ICH is similar in both studies, the incidence of skull fractures was lower in
Fig. 1 Circumstances of injury in admitted patients and outpatients after falls from seating devices.
Table 4 Description of injuries in admitted patients and outpatients after falls from seating devices. Patients Outpatients All admitted admitted (2008–2010) patients and (1990–2010) outpatients (2008–2010) n No injury (%) Skull fracture (%) Intra-cranial hemorrhage (%) ICH NOS EDH SDH SAH Parenchymal contusion Documented presence of symptoms (%)
146 15 (10) 104 (71) 51 (35)
59 56 (95) 3 (5) 1 (1)
90 60 (67) 18 (20) 16 (18)
8 (5) 7 (5) 9 (6) 26 (18) 3 (2)
1 (1) 0 0 0 0
2 (2) 1 (1) 3 (3) 12 (13) 0
ICH NOS indicates intra-cranial hemorrhage non-otherwise specified; EDH, epidural hematoma; SDH, subdural hematoma; SAH, subarachnoid hemorrhage.
our study. As the type and rate of imaging performed are unknown in the latter study, it is difficult to compare. Desapriya et al.  showed a much lower rate of injuries in children sustaining falls from child seats and bouncy seats (3.4% for skull fractures and 1.1% for ICH), but once again no data were collected regarding imaging. Although these injuries were not uncommon in our study, the need for PICU observation and surgery was quite low (2% and 1% respectively in admitted patients). None of the 36 patients with ICH required operative management and only 2 of the 107 skull fractures required surgical attention. Despite its prevalence, this pattern of injury has a relatively benign course in the acute setting. However, long-term outcome regarding learning disabilities and developmental problems remains a question that needs to be studied more. It remains unclear in the literature if all children who sustain falls from seating devices, especially if from elevated surfaces, should have head imaging with computed tomography. Some groups have strongly recommended mandatory head CT for all these patients due to the prevalence of intracranial hemorrhages . Although the design of our study was not aimed at investigating the appropriate imaging in infants after falls from seating devices, some findings are interesting to discuss. As much as 66% patients discharged from the ED had no imaging at all (including x-rays) and 71% had no head CT. The course of the only patient who returned to our ED and had a delayed head CT was not altered by the fact that he had imaging or not. From our analysis, the injury that required the most attention was a depressed skull fracture. There is probably a high percentage of over-imaging of the head performed in this particular patient population. In this clinical context, the use of CT in
Infant seating devices asymptomatic patients with a normal physical exam needs to be questioned and studied. The need for hospitalization in this patient population is another interesting question that cannot be directly addressed based on our results. However, since none of our patients with ICH required neurosurgical intervention, it might be reasonable to rely on the presence of symptoms instead of imaging results to decide if a patient needs to be admitted. Between 2008 and 2010, 66% of all the infants seen in our ED after a fall from a seating device were safely discharged home. Two percent of the patients discharged from the ED had documented presence of symptoms while 39% of the admitted patients did. The key findings from this study can be used to support aggressive prevention among parents of young infants, who are likely to utilize seating devices outside of the car. Seating devices should always be placed at ground level and not on elevated surfaces, even if the caregiver is present in the same room. Infants should not be left unattended even if placed on the floor as they have the capability of falling out of the seat or overturn the seat. They must be restrained at all times when placed in seats. Recalled products should not be used even if still accessible on the market. In addition to parental education by healthcare specialists, some groups have suggested adding warnings on the labels of the seating devices [15,18]. Pictorial diagrams have been specifically demonstrated as improving compliance to the warnings . Although interesting findings are suggested from our study, there are several limitations. First of all, our trauma database only allowed us to include patients discharged from the ED between 2008 and 2010. The total number of patients included in this analysis would have been considerably higher, thus increasing the power of this study, had we had complete outpatient data for the entire time period. Second, the retrospective nature of this study limits the amount of information that could be abstracted from the patient's charts. The exact mechanism and circumstances of injury, use of restraints, presence of symptoms and physical findings were not detailed for all patients. For the same reasons, decision to perform different types of imaging or to admit a patient could not be further clarified. Limiting the registry query to ICD9 code E884.9 only (fall from one level to another) could have missed injuries in which infants were in the seating device and did not sustain a fall, such as flipping and suffocation injuries. Future studies should concentrate on delineating the appropriate investigation and management in this specific group of patients. In 2009, Kupperman et al.  created a rule to identify the pediatric patients at very low risk of clinically important brain injuries. This rule could be prospectively verified in patients aged between 0 and 12 months that sustain falls from seating devices. Other studies could focus on comparing the different types of prevention tools, such as warning labels on the product and
1075 specific modifications of the product (e.g., device that prevents the seat from being left on a flat surface).
4. Conclusions Young infants placed in seating devices, especially on elevated surfaces and unrestrained, even in the presence of a parent, have a significant risk of falling and being injured. Fortunately the majority of these children will only sustain relatively minor injuries but many will require hospital admission, imaging and rarely neurosurgical intervention. Additional prevention education efforts and warning labels about the risks of these devices will be critical to reducing these injuries.
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