Published online August 1, 2006
PEDIATRICS Vol. 118 No. 2 August 2006, pp. e273-e278 (doi:10.1542/peds.2006-0056)
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ARTICLE

Epidemiology of Lawn Mower–Related Injuries to Children in the United States, 1990–2004

David Vollman, BSa and Gary A. Smith, MD, DrPHb,c

a Medical Student
b Department of Pediatrics, Ohio State University College of Medicine and Public Health, Columbus, Ohio
c Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, Columbus, Ohio


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. Our objective for this study was to describe the epidemiology of lawn mower–related injuries among children in the United States.

METHODS. A retrospective analysis was conducted of data from children who were 20 years and younger in the National Electronic Injury Surveillance System of the United States Consumer Product Safety Commission for 1990–2004.

RESULTS. There were an estimated 140700 lawn mower–related injuries to children who were 20 years and younger and treated in hospital emergency departments in the United States during the 15-year period of 1990–2004. This yielded an average of 9400 injuries annually, or 11.1 injuries per 100000 US children per year. The mean age was 10.7 (SD: 6.0) years, and 78% were boys. The leading type of lawn mower–related injury sustained by patients was a laceration (41.2%), followed by soft tissue injury (21.4%), burn (15.5%), and fracture (10.3%). The most common body region injured was the hand/finger (34.6%), followed by lower extremity (18.9%) and foot/toe (17.7%). The eyeball/face and upper extremity accounted for 10.6% and 7.4% of injuries, respectively. Burns accounted for 34.5% of injuries to the hand/finger compared with 5.5% to other body regions. Ninety-seven percent of amputation injuries occurred to the foot/toe (49.5%) and hand/finger (47.5%) compared with 3% of amputations to other body regions. Burns accounted for 41.8% of injuries among children who were ≤5 years of age compared with 6.5% of injuries to children who were older than 5 years. Foreign body injuries accounted for 4.8% of injuries among children who were ≥12 years of age compared with 1.6% of injuries to children who were younger than 12 years. Amputations (31.9%), lacerations (28.8%), and fractures (26.0%) accounted for almost 87% of injuries among children who were admitted or transferred to another hospital. In contrast, lacerations (42.3%), soft tissue injuries (23.3%), and burns (16.9%) predominated among children who were treated and released to home from the emergency department. Children with amputations were more likely to be admitted than children with other types of injury.

CONCLUSIONS. Injuries related to lawn mowers are an important cause of pediatric morbidity. The relative consistency of the number of lawn mower–related injuries to children during the 15-year study period is evidence that current prevention strategies are inadequate. Passive protection that is provided by safer product design is the strategy with the highest likelihood of success in preventing these ongoing injuries. The lawn mower voluntary safety standard American National Standards Institute/Outdoor Power Equipment Institute B71.1-2003 should be revised to include more rigorous performance provisions regarding prevention of penetration of feet and toes under the mower and into the path of the blades, shielding of hot mower parts from access by young children, and equipping all ride-on lawn mowers with a no-mow-in-reverse default feature with location of its override switch behind the seating position of the ride-on mower operator. By locating the no-mow-in-reverse override switch behind the ride-on mower operator, the operator would be required to look behind the mower before mowing in reverse.

Key Words: lawn mower • pediatrics • injury • trauma • safety • prevention

Abbreviations: ANSI—American National Standards Institute • OPEI—Outdoor Power Equipment Institute • ED—emergency department • CPSC—Consumer Product Safety Commission • NEISS—National Electronic Injury Surveillance System • RR—relative risk • CI—confidence interval • NMIR—no-mow-in-reverse

Despite current prevention efforts and a voluntary standard American National Standards Institute/Outdoor Power Equipment Institute (ANSI/OPEI B71.1-2003)1 for lawnmower safety, thousands of children continue to receive emergency care for lawn mower–related injuries each year in the United States.1–9 The majority of these injuries are sustained by older children and adolescents, although one fourth are to children who are younger than 5 years. Boys account for three fourths of these injuries. Ride-on mowers and other power mowers account for 21% and 23%, respectively, of pediatric mower-related injuries.2

Of all pediatric mower-related injuries, >7% require hospitalization, which is roughly 2 times the hospital admission rate for consumer product–related injuries overall. Injuries that are associated with lawn mowers include amputations, lacerations, burns, and fractures.1–10 Case reports have described subdural and retrosternal hematomas secondary to projectiles that are propelled by lawn mowers.11 Amputations and avulsions account for 7% of pediatric mower-related injuries.9 Power mowers were the leading cause of amputation injuries among children who were admitted to 1 regional level 1 trauma center.12

Because of the continuing large number and severity of lawn mower–related injuries, this study was conducted to describe the epidemiology of children who required emergency department (ED) treatment for a lawn mower–related injury from 1990 through 2004 using data collected by the US Consumer Product Safety Commission (CPSC).


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The CPSC monitors consumer product–related injuries that are treated in US hospital EDs through the National Electronic Injury Surveillance System (NEISS). The NEISS was established in 1972 with revisions made in the sampling frame in 1978 and 1990. The NEISS receives data from a network of hospitals that represent a stratified probability sample of the ~6100 hospitals in the United States that have at least 6 beds and provide 24-hour emergency services.13 Because data are collected daily from a statistically representative sample of hospital EDs, weights can be applied to NEISS data to estimate the number and describe the epidemiology of injuries that are associated with 15000 consumer products for the entire nation.14,15 The NEISS has been shown to be highly sensitive and accurate in identifying consumer product–related injury cases.16–19

The type of injury was grouped into categories during study analyses. Soft tissue injuries included the NEISS categories of contusions, abrasions, crushing injuries, hematomas, and strains or sprains. Lacerations included the NEISS categories of lacerations, punctures, and avulsions. The other injuries category included the NEISS categories of anoxia, dermatitis or conjunctivitis, internal organ injuries, dental injuries, hemorrhages, dislocations, and concussions. Burns included the NEISS categories of burns, burns not specified, chemical burns, and thermal burns. The NEISS categories of foreign body, amputation, and fracture were each included as separate study categories without regrouping.

When injuries to various parts of the body were categorized, ear injuries were incorporated into head/neck injuries. The pubic region was combined with upper and lower trunk injuries under the heading of trunk injuries. The lower extremity injuries included injuries to the ankle, knee, lower leg, and upper leg. Shoulder, elbow, wrist, lower arm, and upper arm injuries were pooled to form upper extremity injuries. Hand/finger and foot/toe injuries were grouped separately from other injuries of the upper and lower extremities.

Data were obtained from the CPSC regarding lawn mower–related injuries (product codes 1401, 1405, 1422, 1439, and 1448) reported through the NEISS during the 15-year period 1990–2004. Lawn mower–related injury rates per 100000 US children who were 20 years and younger were calculated using US population data from the US Bureau of the Census for 2000, the last year of actual census numbers during the 15-year study period.20 These population-based rates were expressed as the number of injuries per 100000 population per year.

Some data entries were eliminated from the overall analysis on the basis of several criteria. First, incidences of lawn mower maintenance–associated injury were excluded because they did not involve direct mower operation. For example, several of these injuries resulted from using tools while repairing the lawn mower. Second, burn injuries from gasoline were excluded when the burn did not result directly from the lawn mower. For instance, the majority of these cases were caused by individuals' filling their lawn mowers with gasoline while having an open flame on hand (eg, smoking a cigarette). Finally, data entries were eliminated when the injuries occurred while the mower was nonoperational. Examples include individuals' tripping or falling onto a lawn mower.

Data were analyzed by using SPSS21 and EpiInfo22 software. Statistical evaluation included {chi}2 analysis with Yates' correction and computation of relative risk (RR) with a corresponding 95% confidence interval (CI). P < .05 was considered statistically significant.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
There were an estimated 140700 lawn mower–related injuries to children who were 20 years and younger and treated in hospital EDs in the United States during the 15-year period from 1990 through 2004. This yielded an average of 9400 injuries annually, or 11.1 injuries per 100000 US children per year. Children ranged in age from 1 month to 20 years, with the age distribution demonstrating a bimodal pattern with peaks at 1 to 2 years and 15 years of age. The mean age was 10.7 years (SD: 6.0). Seventy-eight percent of study patients were boys (Fig 1). Twenty-two percent of children were younger than 5 years, 30% were 5 to 12 years of age, and 48% were 13 to 20 years of age. During the 15-year period, the annual number of lawn mower–related injuries to children remained relatively consistent. The fewest number of injuries occurred in 1996 (n = 7500, or 8.9 injuries per 100000 US children), and the most injuries occurred in 1992 (n = 11300, or 13.4 injuries per 100000 US children; Fig 2). Seasonal variation was seen with the number of injuries peaking during the warm-weather months (Fig 3).


Figure 1
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  		FIGURE 1 Estimated number of children with lawn mower–related injuries according to age and gender: United States, 1990–2004.

 

Figure 2
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  		FIGURE 2 Estimated number of children with lawn mower–related injuries according to year of occurrence: United States, 1990–2004.

 

Figure 3
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  		FIGURE 3 Estimated number of children with lawn mower–related injuries according to month of occurrence: United States, 1990–2004.

 
The leading type of lawn mower–related injury (Fig 4) that was sustained by patients was a laceration (41.2%), followed by soft tissue injury (21.4%), burn (15.5%), and fracture (10.3%). The most common body region injured was the hand/finger (34.6%), followed by lower extremity (18.9%) and foot/toe (17.7%). The eyeball/face and upper extremity accounted for 10.6% and 7.4% of injuries, respectively (Fig 5).


Figure 4
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  		FIGURE 4 Type of Lawn mower–related injury among children who were treated in hospital EDs, United States: 1990–2004.

 

Figure 5
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  		FIGURE 5 Body region injured among children who were treated in hospital EDs for a lawn mower–related injury: United States, 1990–2004.

 
Burns accounted for 34.5% of injuries to the hand/finger compared with 5.5% to other body regions combined ({chi}2, P < .001; RR: 6.30; 95% CI: 6.12–6.49). Ninety-seven percent of amputation injuries occurred to either the foot/toe (49.5%) or the hand/finger (47.5%) compared with 3% of amputations to other body regions ({chi}2, P < .001; RR: 29.84; 95% CI: 26.04–34.20). Burns accounted for 41.8% of injuries among children who were ≤5 years of age compared with 6.5% of injuries to children who were older than 5 years ({chi}2, P < .001; RR: 6.40; 95% CI: 6.23–6.57). The most common mechanism of burn injury was contact with a hot surface on the mower. Foreign body injuries accounted for 4.8% of injuries among children who were ≥12 years of age compared with 1.6% of injuries to children who were younger than 12 years ({chi}2, P < .001; RR: 2.82; 95% CI: 2.64–3.02). There was no significant association between child's age (≤5 years, >5 years) and body region injured or between child's age and amputation injury.

An estimated 11200 children required admission to the hospital or transfer to another hospital for treatment of a lawn mower–related injury, averaging ~750 children annually. This represented 7.9% of all injuries that were related to lawn mowers among children. Amputations (31.9%), lacerations (28.8%), and fractures (26.0%) accounted for almost 87% of injuries among children who were admitted or transferred to another hospital. Children with amputations were more likely to be admitted than children with other types of injury ({chi}2, P < .001; RR: 9.09; 95% CI: 8.71–9.48). In contrast, lacerations (42.3%), soft tissue injuries (23.3%), and burns (16.9%) predominated among children who were treated and released to home from the ED. Among children who were admitted or transferred to another hospital, 48.2% had an injury to the foot/toe and 18.5% had an injury to the hand/finger. In contrast, among children who were treated and released from the hospital, 14.8% had an injury to the foot/toe and 36.3% had an injury to the hand/finger.

The location where the injury occurred was known in 70.6% of cases. Among these cases, 97.0% of injuries occurred at home. There was no relationship between age and location of injury. Lacerations accounted for 42.1% and soft tissue injuries accounted for 20.8% of lawn mower–related injuries that occurred at home.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
There was no significant change in the number of lawn mower–related injuries during the 15-year study period. Automatic, or "passive," protection that is provided by safe product design is the best strategy for prevention of lawn mower–related injuries.23 However, that injuries have continued demonstrates that current safety features on these products are not adequate to prevent lawn mower–related injuries.

Injuries that are associated with lawn mowers can be devastating.24 Amputations are especially debilitating, frequently requiring multiple surgical interventions and often leaving the child with a permanent disability.8,25–27 In our study, no statistically significant relationship existed between amputation injury and the child's age, and 98% of amputations occurred to either the foot/toe (50%) or the hand/finger (48%). Amputations accounted for only 5% of total injuries; however, amputations had a statistically significant relationship with disposition from the ED. Amputations required inpatient admission for treatment more frequently than other injury types.

These injuries can significantly affect a child's quality of life by limiting mobility or the ability to perform tasks of daily living. Mower manufacturers should consider design modifications to better prevent the toes and feet from penetrating under the mower and into the path of the rotating blades. These modifications also may have the advantage of preventing other large objects and debris from coming into contact with the blades. Such design modifications could be incorporated as revisions to the Guarded by Location section of the current voluntary lawn mower safety standard, ANSI/OPEI B71.1-2003.1 Mower blades also might be designed with less mass and altered cutting characteristics to minimize tissue damage if inadvertent human contact occurs.

A statistically significant relationship was demonstrated between age and foreign body–related injuries. Children who were older than 12 years were shown to incur foreign body injuries more frequently. These children are more likely to be the operators of power lawn mowers. The American Academy of Pediatrics recommends picking up objects from the lawn before mowing begins. Also, the grass catcher or a shield for the discharge area should be used at all times when mowing to reduce the risk for foreign body projectiles. Injuries to the eyeball/face (39%) and lower extremity (41%) accounted for 80% of foreign body–related injuries. This underscores the importance of wearing appropriate eye protection and long pants while mowing to reduce the risk for injuries from foreign bodies.

This study corroborates a statistically significant relationship between child's age and mower-related burn injuries that was found in our earlier study.28 Burns accounted for more than two fifths of injuries to children who were 5 years or younger. This is >6 times more frequent than among children who were older than 5 years. The most common mechanism of burn injury was contact with a hot surface on the mower. Redesign of mowers to shield better the hot mower parts from access by young children is the best solution to this problem. The ANSI/OPEI B71.1-2003 standard states in its heat-protection section that "a guard or shield shall be provided to prevent inadvertent contact with any exposed components that are hot and may cause burns during normal starting and operation of the machine."1 This provision of the standard should be implemented more effectively.

Although the relationships between type of lawn mower and mechanisms of injury were not able to be determined adequately because of lack of sufficient detail in the NEISS narrative, our previous study revealed that runovers/backovers from ride-on lawn mowers cause devastating injuries to children.28 Changes to the voluntary lawn mower safety standard ANSI/OPEI B71.1 and improvement in ride-on mower design led to significant decreases in injury rates that were related to blade contact and mower control layout during the period 1983 through 1993. However, similar declines were not observed in injury rates that were related to mower instability and incidents that involved running over or backing over a person.9,29 Of the estimated 850 children who are injured each year nationally as a result of runover or backover, approximately two thirds are injured while a ride-on mower is backing up.30 To help prevent backover injuries, all ride-on lawn mowers should have a no-mow-in-reverse (NMIR) default feature with a manual override option.9 Some manufacturers of ride-on mowers include the NMIR feature on their products, which disengages the blades when the mower is shifted into reverse gear. An override switch allows the operator to reengage the blades if desired. Currently, the manual override switch is located in front of the ride-on lawn mower operator, eg, on the front control panel of the mower. With this positioning, the operator is not compelled to look behind the mower before reengaging the blades while backing up. This largely defeats the benefits of the NMIR safety feature. Manufacturers should locate these override switches on either the posterior wheel well or behind the operator's seat, which would force the operator to look behind the mower and facilitate recognition of potential bystanders before disengaging the NMIR safety feature. Equipping all ride-on lawn mowers with an NMIR default feature and locating the NMIR override switch behind the operator should be incorporated as requirements in the voluntary standard ANSI/OPEI B71.1. If the voluntary standard fails to be modified in this manner, then a mandatory federal safety standard may be necessary.

This study has several limitations. A limitation of the NEISS is the potential selection bias inherent in who receives emergency care for an injury. NEISS data cannot be used to estimate the number of lawn mower–related injuries that are treated outside an ED or the number of injuries that do not receive medical attention at all. Lack of consistent detail in the NEISS narrative limited evaluation of the mechanism of injury and the circumstances of the event. The type of lawn mower was not specified in many cases, which also was a limitation. The absence of lawn mower exposure data prevented calculation of true injury rates.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Injuries that are related to lawn mowers are an important cause of pediatric morbidity. The relative consistency of the number of lawn mower–related injuries to children during the 15-year study period is evidence that current prevention strategies are inadequate. Passive protection that is provided by safer product design is the strategy with the highest likelihood of success in preventing these ongoing injuries. The voluntary standard ANSI/OPEI B71.1-2003 should be revised to include more rigorous performance provisions regarding prevention of penetration of feet and toes under the mower and into the path of the blades, shielding of hot mower parts from access by young children, and equipping all ride-on lawn mowers with an NMIR default feature with location of the NMIR override switch behind the seating position of the ride-on mower operator, which will require the operator to look behind the mower before mowing in reverse.


   FOOTNOTES
 
Accepted Feb 15, 2006.

Address correspondence to Gary A. Smith, MD, DrPH, Center for Injury Research and Policy; Columbus Children's Research Institute, Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: gsmith{at}chi.osu.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics




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