No. Please...just no.

No. Please…just no.

You are probably familiar with the occasional manufacturer recall warnings announced when a toy or other gadget, the majority of which can be categorized as “nursery products,” is found to be potentially dangerous. Unfortunately, most of these warnings go unheard or unheeded and as many as 80% of these recalled products remain in the home, where most early childhood product-related injuries occur. This, along with unique anatomic and developmental factors, is only one of the reasons why these injuries occur so frequently.

A historic victory for pediatric injury prevention advocates

While a variety of nursery products are known to play a role in early childhood injuries, the most infamous historically are baby walkers, and to a lesser extent the related jumpers and exercisers. These were once extremely popular products designed to support an older infant in a standing position and allow increased mobility, even the ability to push themselves across rooms (or over the edge of stairs), on wheeled platforms. The benefit of these products, it was claimed (and still often is), is improved motor and cognitive development, a belief that is not supported by evidence or endorsed by the American Academy of Pediatrics.

The AAP, which has repeatedly called for a total ban of this type of mobile product, once took part in a campaign aimed at educating parents and lawmakers, and increasing the awareness of potential harm. The reason pediatric healthcare professionals care so much is that these products allow infants to hurt themselves in a variety of terrible ways, the most serious of which being fatal head and spinal cord injuries occurring when children would tip over or fall down stairs during use. The campaign was very successful, resulting in an almost 90% decrease in injuries involving these products. Parents can still buy walkers, which we don’t recommend, but they are now much safer thanks to federal regulations mandating certain safety features.

The targeted intervention involving walkers and similar products worked and young children are safer because of it. But a study recently published in Pediatrics has revealed that nursery-product related injuries are still extremely common, and uncovered a concerning increase over the past several years.

Carriers, cribs, and strollers, oh my!

In the study, the first to evaluate a nationally-representative sample of children injured by nursery products, researchers retrospectively analyzed data obtained from 1991 to 2011 by the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System. This tool is used to keep track of consumer product-related, sports, and recreational activity-related injuries seen in American emergency departments. They specifically looked at children under the age of 3 years.

The researchers found that nearly 1.4 million children under the age of 3 years required emergency department evaluation for nursery product-related injuries between 1991 and 2011, which works out to about 66,000 every year. The majority, around 60% or so, occurred before the first birthday, with the single most impacted age range being 6 to 11 months. This group was involved in 35% of the total injuries, which may make sense considering that this is when babies are becoming mobile, more interactive with their environment, and harder to carry around. A little over half of injuries involved male children and almost 90% took place at home.

Concerning trends in the data

From 1991 to 2003, largely thanks to the efforts to reduce injuries from baby walkers, the number and rate of nursery product-related injuries each year plummeted by 33% and 34% respectively. Then they began to increase, and by 2011 had jumped back up by 24%. While no one type of nursery product can be blamed for the increase, replacing walkers as the primary causes of injuries were baby carriers, cribs/mattresses, and strollers/carriages.

The most interesting trend, in my opinion, regarded a diagnosis rather than a specific product. Increasing by over 100% since 2005, the diagnosis of concussion and closed head injury played a large role in the increasing number of reported injuries. This makes sense for two reasons.

Falls, either directly involving a child or when a parent takes a tumble while holding/carrying a child, was the most common documented inciting event. Infants and young toddlers have large heads in proportion to their bodies, a high center of gravity, and are unable to effectively use their arms to help shield their enormous noggins*. Also, concussion awareness has skyrocketed over the past several years. So I can’t be sure if more kids were actually concussed during this time period than in years prior.

Baby carriers, such as the detachable car seats commonly used by parents to transfer babies from the car to the house caused the most injuries overall, again only because walker injuries decreased so precipitously by 2003. Baby carriers are unwieldy and can be dropped or increase the chance of a parent falling while lugging one around. And many injuries occur when they are placed in precarious positions on elevated or slippery surfaces. They are also sometimes involved in cases of SIDS/SUID when used as a sleeping surface, something we strongly recommend against.

A close second was the category of cribs/mattresses, which were involved in nearly 19% of injuries. These products were also the most likely by far to be involved in fatal injuries, largely because of SIDS/SUID and suffocation caused by entrapment. I can’t stress enough how important it is to only allow young infants to sleep on a single, firm, and snug fitting mattress, and on a flat surface without pillows, blankets, or other soft materials. And please, no bumper pads.

Number three on the list of offenders, involving around 16% of injuries, was the category of strollers/carriages, mostly because of falls and tip overs. I will never forget the feeling of terror I experienced when the stroller carrying my first child got away from me once when walking down a sloped driveway. I watched in horror as it gained speed, moving further and further out of reach. Luckily it crashed into some bushes across the street and remained upright, but it could have resulted in a severe injury.

A few nursery product injury prevention recommendations

So what can we learn from this study? The authors provide a few suggestions for preventing nursery product-related injuries based on this new epidemiological data. Fall prevention strategies are key. Products should be installed correctly, making use of safety devices such as straps and harnesses, and young children should be appropriately supervised while using products which might result in a fall.

Caregivers should attempt to reduce the risk of tripping by keeping paths clear of clutter, something much more easily said than done. Avoiding carrying objects in addition to a child carrier if possible, particularly on stairs so that handrails can be used, may help reduce severe injuries from caregiver falls. Additional safety features, such as non-stick surfaces on the bottom of carriers and “dead man locks” on strollers, might also reduce risk of falls from elevated surfaces and runaway strollers respectively.

The authors point out that the data they worked with almost certainly underestimated the number of injuries that occurred during this time period. The NEISS only tracked injuries seen in emergency departments and many injuries would have been evaluated in primary care offices or urgent care facilities. It may have also missed fatal injuries that occurred at home or in the hospital after inpatient admission from an emergency department. On a happier note, safety regulations associated with the Consumer Product Safety Improvement Act of 2008 were still being rolled out during the tail end of the study period, so it is possible that injury risks have decreased since 2011.

*Older kids have better control of their flailing limbs as they go down and are thus increasingly prone to arm injuries after falls.


Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.