From the Division of Emergency Medicine, Department of
Pediatrics, Ohio State University College of Medicine, Children's
Hospital, Columbus, Ohio.
The use of babywalkers dates back to at least the
mid-1600s,1 and the hazards associated with their use
have been increasingly recognized during the last two decades. An
estimated 25 000 children are treated in hospital emergency
departments (EDs) annually in the US for babywalker-related
injuries.2 The annual cost of these injuries is
approximately $90 million.3 The rate of injury per 1000 babywalkers has continued to increase since 1984 according to data from
the National Electronic Injury Surveillance System.2 The
annual incidence of walker injuries resulting in an ED visit was 8.9 per 1000 children <1 year of age in one study.4 The number
of injuries attributable to babywalkers exceeds that associated with other baby products, including strollers, carriages, high chairs,
playpens and cribs.2,3 Eleven deaths associated with walkers were reported during the 5-year period from 1989 through 1993.2 Studies indicate that 55% to 92% of infants use
babywalkers, primarily between the ages of 5 to 15 months,3,5 and 12% to 40% of these infants experience
an injury related to their use.3,5,7,11,12 Boys are twice
more likely than girls to be placed in a babywalker.12 More
than 3 million walkers are sold annually, representing an estimated
$115 million per year in consumer spending.2
More than 75% of babywalker-related injuries are attributable to a
fall down a flight of stairs, and head injuries
predominate.1,7,13 Studies indicate that 60% to
>90% of stairway injuries among infants are related to the use of
babywalkers.12,17 Other injuries associated with
babywalkers include finger entrapment, tip-overs, and burns or
ingestions resulting from the infant's increased ability to reach
previously inaccessible areas.2,18
Although prevention strategies, such as warning labels and public
education, have been widely implemented, this study describes the
epidemiology of young children with babywalker-related injuries, who
continue to be treated in a pediatric ED despite these prevention efforts. This study also investigates the beliefs of parents regarding babywalker use.
METHODS 
This investigation was conducted by reviewing the medical
records of all children treated for a babywalker-related injury in the
ED of Children's Hospital in Columbus, Ohio, during the 3-year period
from March 1993 through February 1996. Children's Hospital is a
313-bed tertiary care facility affiliated with The Ohio State
University College of Medicine. More than 75 000 children are treated
in its ED annually. This study was approved by the Human Subjects
Research Committee.
Data were obtained from the ED medical records for all patients.
Inpatient medical records were reviewed for the 10 patients admitted to
the hospital. Attempts were made to contact parents of all study
patients by mail or telephone to obtain information not contained in
patient medical records. Follow-up occurred approximately 2 months
after the ED visit, and was completed for 57.2% of patients, including
20.7% by mail and 36.5% by telephone.
Data were analyzed using EpiInfo software.29
Statistical evaluation included 
2 analysis with Yates'
correction, the two-tailed Fisher's exact test, and the two-tailed
Mann-Whitney test. Comparisons were considered to be statistically
significant for P values < .05. Computation of
relative risk (RR) with a 95% confidence interval (CI) was also done.
RESULTS
From March 1993 through February 1996, 271 children were treated
in the Children's Hospital ED for a babywalker-related injury. Children ranged in age from 4 to 20 months, except for one outlier who
was 36 months old. The mean age was 9.2 (standard deviation, 3.1)
months with a median age of 8 months. Sixty-two percent of patients
were boys (Fig 1). An average of eight children (range 2 to
17) with a babywalker-related injury were treated each month, or
approximately one child every 4 days.
Fig. 1.
Number of patients by age and gender.
[View Larger Version of this Image (15K GIF file)]
The vast majority (95.9%) of children were injured when they fell down
stairs in their babywalker. Another 1.5% fell off of an elevated
surface, such as a curb or porch. The remaining 2.6% of patients were
injured attributable to various mechanisms, including falling out of
the babywalker, burning a hand on a kerosene heater while in a walker,
or shutting a finger in a door while in a walker.
The number of stairs that children fell down ranged from 1 to 30 (mean,
9.5; standard deviation, 4.6), and was more than 10 stairs in almost
one-half (47.6%) of cases. The number of stairs that a child fell down
was significantly associated with skull fracture (Mann-Whitney,
P = .004) and admission to the hospital (Mann-Whitney,
P = .02). When the number of stairs was grouped into
more than 10 stairs and less than or equal to 10 stairs, a fall down
more than 10 stairs was associated with a significantly increased risk
of skull fracture (2, P = .01; RR = 3.28; 95% CI 1.35 < RR < 7.98). When the type of surface
struck at the end of the fall (Table 1) was grouped as
concrete versus nonconcrete, 14.6% of patients who struck concrete sustained skull fractures compared with 8.1% in the nonconcrete group
(2, P = .21; RR = 1.80; 95% CI
.82 < RR < 3.97). Children who struck concrete at the end
of the fall were admitted to the hospital 7.3% of the time compared
with 3.2% in the nonconcrete group (Fisher's exact test,
P = .20; RR = 2.25; 95% CI .66 < RR < 7.73). The number of stairs that a child fell down was significantly
associated with skull fracture (Mann-Whitney, P = .02)
and admission to the hospital (Mann-Whitney, P = .02)
among children who landed only on concrete, demonstrating the effect of
the number of stairs on outcome while holding constant the influence of
surface.
|
Table 1.
Number and Percent of Patients by Type of Surface
Struck at Base of Stairs
[View Table]
|
Supervision, defined as observing the child in the same room at the
time of injury, was provided by an adult in 69.2% of cases. Supervision by a person under 18 years of age was present in another 8.7% of cases.
The types of babywalker-related injuries sustained by patients are
identified in Fig 2. Of the 26 patients with skull
fractures, 17 fractures were parietal (65.4%), 8 frontal (30.8%), and
1 occipital (3.8%). There were three patients with a depressed skull
fracture, and two of these children also had a second nondepressed
skull fracture. Three patients (1.1%) had intracranial hemorrhage on a
head CT scan, including two children with subdural bleeds. One patient
had possible generalized brain swelling, and another child had frontal
lobe edema. One patient with a subdural hemorrhage later developed a
subdural effusion, and another child developed a leptomeningeal cyst as
a delayed complication of a skull fracture. The four nonskull fractures
included three clavicular fractures and one child with fractures of the
radius and ulna.
Fig. 2.
Percent of patients by type of injury.
[View Larger Version of this Image (30K GIF file)]
Ten patients (3.7%) were admitted for inpatient treatment of their
injuries, including one patient admitted to the intensive care unit.
All 10 admitted patients had skull fractures resulting from falls down
stairs. None of the study patients required surgical intervention in
the operating room.
The fate of the babywalker after the injury episode was known in 143 cases (52.8%). Sixty-five of these families (45.4%) kept the
babywalker. Sixty-one parents (42.7%) reported destroying or
discarding the babywalker. Eight families (5.6%) gave the walker away
to another person, and 6 (4.2%) returned it to the person from whom it
was borrowed. Three parents (2.1%) removed the wheels from the walker.
Information was available in 157 cases (57.9%) regarding whether the
babywalker was used again by the child after the injury. Of these
children, 46 (29.3%) used the walker again after the injury episode.
In addition, five families (3.2%) used the babywalker for another
child after the study patient's injury. Among the 46 cases in which
the babywalker was used again by the patient after the initial injury,
16 parents (34.8%) indicated that the walker was used again only in
association with the use of stair gates; 13 parents (28.2%) indicated
that they did so while providing closer supervision than in the past; 9 parents (19.6%) indicated that the babywalker was used only in the
basement or in rooms without stairs; and 8 parents (17.4%) indicated
that there were no changes in how the babywalker was being used. One
patient was reinjured in the babywalker within 6 weeks of the initial
injury.
The reasons given for continued use of the babywalker after the initial
injury included: "the baby likes using it"; "it gives the baby a
chance to move and learn to walk"; and "the injury was attributable
to the stairs, and not the babywalker." One parent stated that the
babywalker was "a safe place, and keeps the child from getting
stepped on." Another parent indicated that "babywalkers are safer
than crawling or walking," and another stated that it was a gift from
a relative "who would be angry if the babywalker was thrown away or
given away."
Of the 135 parents (49.8%) who responded when asked during mail or
telephone follow-up if they believe that babywalkers help infants learn
to walk, 40 parents (29.6%) stated "yes," 68 (50.4%) stated
"no," and 27 (20.0%) were undecided. Of the 155 parents (57.2%)
who responded when asked if they were aware of the potential dangers of
babywalkers before the injury event occurred, 92 (59.4%) replied
"yes," and 63 (40.6%) stated "no." Of the 154 parents (56.8%)
who responded when asked if they would be in favor of a national ban on
the sale of babywalkers, 87 (56.5%) indicated that they support a ban,
30 (19.5%) were opposed to a ban, and 37 (24.0%) were undecided.
DISCUSSION
To our knowledge, this series of 271 babywalker-related injuries
is the largest described in the medical literature. The vast majority
(95.9%) of children were injured when they fell down stairs in their
babywalker. The amount of energy transferred to a child's body in a
fall is determined by the distance of the fall and the energy-absorbing
characteristics of the surface on which the child lands. The clinician
should consider these factors during patient evaluation. The number of
stairs that a child fell down was significantly associated with skull
fracture and hospital admission in this study, independent of the
influence of the surface on which a child landed. The relative risk of
skull fracture was more than threefold higher for children who fell
down more than 10 stairs. Children who landed on concrete were more
likely to sustain a skull fracture and be admitted to the hospital
compared with children who landed on other surfaces, but these
differences were not statistically significant.
Although 30% of parents in this study believed that babywalkers help
young children learn to walk, there is no evidence to support this
commonly held belief.30 In fact, studies suggest that
the opposite may be true.10,31,32 In a study of twin infants, the child who was placed in a babywalker had marked
electromyographic changes in locomotive motor pattern, because the
walker allowed gross mechanical errors to be committed without impeding
successful bipedal locomotion.10
Adult supervision is a strategy commonly suggested for the prevention
of babywalker-related injuries, but data do not support its
effectiveness. An infant in a babywalker can move at a speed of one
meter per second,33 and is developmentally unable to control this increased mobility. Because even the best care giver cannot watch a child 100% of the time, these injury episodes can, and
do, occur in the time it takes to reach for something from the
refrigerator. Moving at one meter per second, an infant can be across
the room before the care giver has time to react. Indeed, 78% of
children in this study were being supervised at the time of the injury,
and this supervision was by an adult in 69% of cases. This clearly
demonstrates that adult supervision will not adequately prevent these
injuries. These findings agree with those of others,2 and
with injury prevention theory, which states that prevention strategies
requiring frequent human action and vigilance are least likely to
succeed.34
Existing voluntary industry standards (American Society for Testing and
Materials 977-89), which address babywalker-related falls by use of
warning labels, do not adequately prevent these injuries. The lack of
effectiveness of these standards is demonstrated by the steady increase
in the rate of babywalker-related injuries since their
implementation.3 Public education efforts also fail to
deter parents from using walkers. Fifty-nine percent of study parents
acknowledged that they were aware of the potential dangers of
babywalkers before the injury event; and because this information was
obtained after the injury, it is likely to be an underestimate.
Twenty-nine percent of care givers in this study also continued to use
the device for the study child after the injury episode, and another
3% used it for another child. Therefore, increasing efforts to educate
parents, and even parents of children injured in a walker, about the
hazards of babywalkers will not be effective in preventing these
injuries.
Stairway gates also do not adequately prevent babywalker-related
injuries. Studies indicate that 60% to >90% of stairway injuries among infants are related to the use of babywalkers.12,17
More than 75% of babywalker injuries result from a fall down a flight of stairs,1,7,13 and approximately one-half of these
stairways have gates.12
Babywalker-like alternatives, that do not roll across the floor on
wheels, have been recently marketed in the US. These stationary devices
allow children to bounce, swivel and tip, and provide parents an
alternative to the use of a babywalker. Although no injury data are
available yet on these products, they eliminate the stairway-related
fall hazard, and therefore, should be a safer alternative.
The American Academy of Pediatrics has joined with other health care
organizations, child advocacy groups, and consumer groups calling for a
ban on the manufacture and sale of mobile babywalkers in the
US.3 The American Medical Association also supports a ban
and has called infant walkers a "lethal form of transportation" (Columbus Dispatch, December 10, 1992:6B). A petition
was filed with the US Consumer Product Safety Commission (CPSC) in
August 1992 requesting a ban. In April 1993, the CPSC rejected this
request and recommended that further studies be done on this issue.
Fifty-six percent of parents in this study favored a ban, and only 20%
were opposed.
In recognition of the dangers associated with babywalkers, a voluntary
standard went into effect in June 1989 in Canada that requires the
width of babywalkers be 900 mm (35.4 inches) or greater. This is wider
than standard household doorways.35 This strategy effectively addresses stairway falls, the cause of most
babywalker-associated injuries, without a ban on babywalkers. However,
it does not address the problem of future injuries associated with
existing babywalkers that do not meet this new standard. A national
recall or trade-in campaign, supported and promoted by a coalition of
manufacturers, governmental agencies, child advocacy groups, and
consumer groups, could decrease the number of existing babywalkers. Our
hospital coordinated a well-received city-wide babywalker bash in
October 1994, when babywalkers were collected from parents and then
crushed. Parents were given a bicycle helmet in exchange for the
walker.
This study was subject to the limitations of missing data and other
problems associated with retrospective chart review. Because there is a
potential selection bias regarding which children are treated in a
tertiary pediatric care facility like ours, patients in this study may
not be representative of children treated for babywalker-related
injuries in other health care settings, or children with walker-related
injuries who do not receive medical care. Data obtained from parents
after the ED visit could have been affected by recall bias or by a
respondent's wish to please the investigators.
CONCLUSION
Despite the currently used prevention strategies, including adult
supervision, warning labels, care giver education programs, and
stairway gates, serious injuries associated with babywalkers continue
to occur to young children. Similar to the voluntary product design
standard adopted in 1989 in Canada, a rule should be promulgated by the
US CPSC regarding design requirements for babywalkers that will prevent
their passage through household doorways at the head of stairs. The
manufacture and sale of mobile babywalkers that do not meet this new
standard should be banned in the US. A recall or trade-in campaign
should be conducted nationally to decrease the number of existing
babywalkers.
Reprint requests to (G.A.S.) Emergency Medicine, Children's
Hospital, 700 Children's Drive, Columbus, OH 43205.
ED, emergency department.
CI, confidence interval.
RR, relative risk.
CPSC, Consumer Product Safety Commission.
ABSTRACT
a continuing
problem.
Arch Emerg Med
1991;
8:52-55[Medline]
