PEDIATRICS Vol. 122 No. 5 November 2008, pp. e980-e987 (doi:10.1542/peds.2007-2995)
ARTICLE |
Risk Factors for Unintentional Injuries in Children: Are Grandparents Protective?
a Department of Population Family and Reproductive Health
d Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
b Research Institute at Nationwide Children's Hospital, Columbus, Ohio
c Department of Child Development, Tufts University, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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OBJECTIVE. We sought to identify sociodemographic and familial correlates of injury in children aged 2 to 3 years.
METHODS. The Healthy Steps data set describes 5565 infants who were enrolled at birth in 15 US cities in 1996–1997 and had follow-up until they were 30 to 33 months of age. Data were linked to medical claims reporting children's medically attended office visits by age 30 to 33 months. Each claim was accompanied by a reason for the visit. An analytical sample of 3449 was derived from the children who could be effectively followed up and linked to medical charts. Missing data were imputed by using multiple imputation with chained equations. The analytical sample showed no systematic evidence of sample selection bias. Multivariate logistic regression was used to determine the odds ratios of injury events.
RESULTS. Odds of medically attended injuries were decreased for children who received care from grandparents. Odds were increased for children who lived where fathers did not co-reside or in households where the parents never married. Statistical results were robust to the addition of a variety of covariates such as income, education, age, gender, and race.
CONCLUSIONS. Children are at higher risk for medically attended injury when their parents are unmarried. Having grandparents as caregivers seems to be protective. Household composition seems to play a key role in placing children at risk for medically attended injuries.
Key Words: child care • family issues • injury • safety
Abbreviations: OR—odds ratio
Injuries are the leading cause of death for children in the United States.1 Injuries that require medical attention affect roughly 1 of 4 US children every year.1,2 Current estimates are that in 2000, injuries to those 
14 years of age cost $50.6 billion ($11.9 in medical costs and $38.7 in productivity losses).3 Risk factors that are associated with unintentional nonfatal injuries in young children include individual characteristics of children (age, gender, temperament/behavior), the family environment (socioeconomic status, family structure, siblings, parental characteristics, child care arrangements), and community and neighborhood factors; therefore, childhood injuries are predicted by a complex and interacting set of sociodemographic and child-related factors that make it difficult to separate individual effects.4 Much of what has been learned has emerged from small injury registries that cover only a subsample of the population. These are sometimes complemented by studies of large national samples.5
Recent growth in the number of grandparental caregivers has some observers concerned that grandparents will apply a style of child care that is less adherent to modern safety practices.6 The number of grandparents who reside with children has been increasing since the 1970s.7 The US Census Bureau estimated that as of 2000, there were 5.8 million grandparents living with grandchildren, and 31% of these grandparents reported responsibility for grandchildren.8 If there is a systematic problem with the child safety practices of grandparent caregivers, then a relationship between injury rates and grandparental care could be a clue to this and would be a reason for greater concern. To our knowledge, there have been no previous studies of the relationship between grandparental caregivers and child injury rates.
The objective of this article was to examine individual and family risk factors for injuries in toddlers (2–3 years of age) using a large national survey. We pay particular attention to the potential relationship between grandparental caregivers and child injury rates.
Family characteristics and parental safety behaviors are particularly important in the case of toddlers, who depend on effective supervision by their adult caregivers for protection from injuries. We hypothesize that grandparental caregiving would be associated with injury risks in toddlers, and additional sociodemographic characteristics of caregivers would further help to explain toddlers' injury risks.
One of the particular strengths of our study is the presence of data on who was taking care of the child for mothers who worked. Whereas others have already noted that children of employed mothers have lower injury rates9 and that children in formal child care have lower injury rates,10 little is known about the effects of grandparents on child safety. A growing number of "grandparenting workshops" are premised on the belief that older caregivers need to be updated on the latest developments in modern child care, including car seats, lower hot water temperatures, and other child safety practices that emerged after their own children were toddlers. We hypothesized that if grandparents are indeed systematically applying outdated child safety practices, then there would be a positive association between grandparental caregiving and child injury and a negative association between grandparental caregiving and adoption of better safety practices.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Data Source and Study Design
Data are from the National Evaluation of the Healthy Steps for Young Children Program, and the sampling strategy is described in detail elsewhere.11 These data describe 5565 infants who were enrolled in 15 US cities in 1996–1997 and had follow-up until they were 30 to 33 months of age. Telephone interviews were conducted with parents of Healthy Steps families for phase 1 of the National Evaluation as the Healthy Steps children reached 30 months of age. The primary respondent for the interview was the mother or was the guardian or the primary caregiver when the mother was not available. The questionnaire included an update of sociodemographic characteristics of the family. This research was approved by the Johns Hopkins Committee on Human Research.
Study Sample
Of the 5565 children enrolled, 3737 (67%) were followed up at 30 to 33 months. A total of 2450 children had no missing data on any outcomes or covariates. For each variable, this sample did not differ significantly from the full sample on any variable. An initial analysis was performed without performing any imputation. Subsequently, an iterative multiple imputation procedure was performed by using switching regression and chained equations.12 This process resulted in a sample of 3449 children with some imputed values. The regression analysis was repeated on the imputed sample, yielding coefficients similar in size and significance to those estimated initially. Tables 1 and 2 report the findings from the imputed data set because the imputed values are less likely to be subject to sample selection bias.
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Dependent Variables
Serious child injury as a dependent variable was measured by records of medical use at hospitals, emergency departments, and urgent visits to the practice for each child. These data were gathered by staff from the pediatric practice and were based on both billing records and medical chart review. The original reason that the medical use data were collected was to test the hypothesis that the Healthy Steps Program would lower medical use and costs for sick visits. As part of the Healthy Steps study, office staff prepared electronic files that listed charges, International Classification of Diseases, Ninth Revision code, and Current Procedural Terminology procedure code, and an open-ended "reason for visit" was filled out by office staff. Entries in the "reason for visit" field were tabulated and coded as injuries or noninjuries by the investigators. The injury reasons ranged from "cut face" to "drank paint thinner" to "fall from shopping cart." Noninjury reasons ranged from "fever x3 days" to "turned blue." Differentiating injuries from noninjuries left little ambiguity and even permitted identification of the cause of each injury; however, only 6 burns requiring hospitalization and 18 poisonings requiring hospitalization were recorded. Efforts to model determinants of these specific events were attempted and later abandoned because of small sample size.
One limitation from the office-based approach is that there could have been some injury-related hospitalizations and emergency department visits that never came to the attention of the pediatric office and would be missed in the analysis, such as injuries that occurred while a child was traveling out of state. Conversely, a strength of this approach is that it avoids problems of parental recall or reporting bias, which has proved to be large with periods longer than 5 weeks.13
Independent Variables
On the basis of the literature, we included the following child, maternal, and family characteristics in our analysis: child gender; child birth weight; maternal demographics (age race/ethnicity, education status, first-time mother); maternal health (self-rated) physical limitations, sense of competence, Center for Epidemiologic Studies Depression Scale maternal depression score; household income; mother's behavior (smoking, drinking, illicit substances); mother's marital status; family structure (father co-resides, stepfather co-resides, members of household, siblings); whether the nonmaternal caregiver was a father, grandparent, other relative, or nonrelative; and whether the family had moved in the previous year. It should be noted that to remain in the Healthy Steps evaluation database, a child had to remain in the same pediatric practice, so the relocation in this database would have been confined to local relocation within the catchment area of a pediatric practice. Relocation was more common among families who had made a marital transition and among lower income households.
Mothers were asked to identify who the primary caregiver was, and they cited themselves 85% of the time, fathers 2% of the time, and grandmothers 13% of the time. In addition, mothers were asked whether they worked and, if they did, who watched the infant: mother herself, father, grandparents, other relatives, nonrelatives, or others. There was very little correlation between the identity of the "primary caregiver" and the alternative person who watched the child while the mother worked. The raw correlation between grandparents' being primary caregivers and grandparents' watching the child while the mother worked was 0.076; the corresponding correlation for fathers was 0.16.
Analyses
To determine which individual, maternal, and family characteristics affected the likelihood of childhood injury, we used logit models to regress the dichotomous indicator for injury on the independent variables discussed previously. The variables shown in Table 1 were entered into the model 1 block at a time, and the pattern of confounding was explored by observing how significance levels were altered as additional variables were entered. In Table 2, model A shows the results of bivariate models. For model B, multivariate regression models that do not adjust for household income are shown, and model C shows how the results differ when income is controlled. Model D is included to reveal what would emerge in the most parsimonious specification but was not guided by previous literature or theory. The complete models are listed in the Appendix.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Table 2 presents pertinent correlates of hospitalized injury that were found to be significant and pertinent variables that were found to be insignificant. Child's birth weight had no statistically significant effect on injury; boys had higher odds of injury at 1.121, but this was not statistically significant. Black and Hispanic children had similar injury rates to white children. Children of mothers who were >40 years old had lower injury rates.
There was no statistically significant relationship between income and injury, and including income measures in the model did not alter the effects of race and family structure. Compared with women who stayed married throughout the child's life, odds for injury were statistically significantly higher for children whose parents never married. Children of women who became divorced or separated had a higher odds ratio (OR) of injury at 1.143, but these results were not statistically significant and are not shown in Table 2. Also not shown in Table 2 are statistically insignificant results for mother's self-rated health, depressive symptoms, and sense of competence.
Compared with a situation in which the mother did not work, children whose mother worked and arranged for grandparent caregivers had a statistically significantly lower odds for injury, but child care by other relatives was not statistically significant. Because families are not always in a situation in which family members can provide child care while the mother works, a variable for child care by nonrelatives was included in the model, but it was not statistically significant. In households where the grandmother was listed as the primary caregiver, there was no difference in the odds for injury. Among the 64 households in which fathers were cited as the primary caregiver, the OR for child injury was higher with an OR of >2.0 in multivariate models; however, in situations in which the father watched the child while the mother worked, there was no statistically significant difference in the odds for injury.
Contrary to expectation, there was a protective association between residential relocation since birth and the odds for injury. This finding was robust to including or excluding controls for marital transitions, household income, and insurance.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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In this study we examined determinants of childhood injury and parental safety behaviors. We now examine our principal findings in light of previous research in this area.
Mother's Demographics
A previous study found that children of adolescents were more likely to have >1 serious injury.14 In contrast, we found that mothers who were older than 40 years had lower odds for children with an injury, but we did not find that younger or adolescent mothers had a significantly higher odds for injury among their children.
The literature suggests that parental education is negatively associated with childhood injury. Parents who did not complete high school had children who were more likely to be injured than children of parents with high school degrees.15,16 Our results confirm this by showing a significant relationship between the highest level of maternal education and lower rates of child injury. Although it is often hard to separate the effect of race and ethnicity from other socioeconomic determinants of injury, minority children are at higher risk for injury. In the United States, Native American children have the highest unintentional injury death rate followed by black children.17 Our analysis showed no difference in injury rates for black and Hispanic children in unadjusted models as well as models that controlled for income and other socioeconomic correlates of injury. In contrast to previous studies, 1 distinguishing feature of the sample that we studied was that all of the children in the Healthy Steps sample had regular pediatric care, and this may have partially mitigated the effects of race and ethnicity.
Family Composition
Previous studies showed that children who have serious injuries are more likely to have parents who are unmarried or single.5,14–16 Dawson18 found that children in divorced families or disrupted marriages had a 20% to 30% greater risk for injury. Our results support the previous findings. Children who lived with parents who were cohabiting and never married had roughly twice the odds for injury, and children without co-resident fathers had a higher odds for injury, although the results were significant only in the bivariate and stepwise models.
Source of Child Care
Interpreting the relationship between child care and injury is complicated by the presence of 2 alternative indicators with minimal overlap. The correlation between who was named as primary caregiver and who watched the child while the mother was working was weak. Having fathers named as primary caregiver was associated with significantly higher rates of injury, but having fathers watch the children while the mother worked did not have a significant association with child injury. Having the grandmother named as primary caregiver was not associated with the odds for injury, but having the grandmother watch the child while the mother worked was associated with fewer injuries (P < .1). A safe conclusion from these data is that there is no evidence to support the hypothesis that grandparental care is associated with more childhood injuries.
We speculate that the question of who the primary caregiver for a child was could have been decided differently by different respondents (mostly mothers). Some might have interpreted the question to mean "who makes the primary decisions about child care," others as "who actually delivers care." For example, in 90% of the 252 cases in which the mother worked and the father watched the child, the mother stated that she is the primary caregiver, and the same was stated for 81% of the 508 cases in which the grandmother watched the child during the mother's work hours. Of the 64 men described as primary caregiver, only 24 of them watched the child while the mother worked. Because the respondents who stated that fathers were primary caregivers seem to have been influenced by psychosocial circumstances other than the time that fathers spent watching children, we suspect that it is these other, unspecified circumstances that are more strongly associated with higher rates of child injury and not the actual process of fathers' watching children.
The OR in Table 2 compares a situation in which grandmothers watch a child while the mother works with a stay-at-home mother. To compare grandmothers with other relatives and child care, we ran an additional model similar to model C (data not shown), in which other relatives/child care was the excluded category. This model demonstrated an OR of 0.71 with (P = .109) for the protective effect of grandmothers relative to child care or other relatives.
According to the literature, better supervision of children is associated with fewer injuries,19 but it is still not clear what kind of child care situations provide the best form of supervision. What is known is that children in child care centers rarely sustain severe injuries.20 Children who spent more time in nonparental child care were slightly less likely to have an unintentional injury after adjustment for other known risk factors and characteristics of child care centers.10 Child care centers are highly regulated for safety in the United States, but the protective effect extends to less regulated family child care environments as well.10 In a study that compared children who received home care, center-based care, and other forms of out-of-home child care, the rate of minor injuries was highest in center-based care, but there was not a significant difference among the 3 types of care for severe injuries.21 We did not find any significant associations between child care centers or nonrelative child care.
There are several limitations in this study. It is unknown who was watching the child at the time of the injury, and it is possible that some injuries that did not come to the knowledge of the pediatric office occurred. The 7% incidence of injuries is lower than the 11% rate for children who were younger than 15 reported by the Centers for Disease Control and Prevention.22 Unfortunately, despite the sample size of 3449, there is still not sufficient sample size to break down the effects of grandparental care by race/ethnicity or by the number of children being watched by 1 caregiver. The data do not allow us to know how old the grandparents were, and this could affect the results. Other unmeasured aspects of the family may still confound this relationship.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Our study of a nationwide survey of children who were enrolled at birth and followed until age 30 to 33 months found that having grandparents as caregivers was protective, cutting the odds for injury roughly by half compared with having a stay-at-home mother. We cannot claim that this association is causal, although it remains robust after controlling for socioeconomic status, race, ethnicity, parental safety behavior, and measures of family composition.
To our knowledge, this is the first analysis to look at an association between grandparental caregivers and child injury. Our results provide evidence that children who are cared for by grandparents have a lower incidence of a medically attended injury. It may still be the case that the households that choose grandparents as caregivers selectively choose only grandparents who will enforce healthier child safety behaviors; however, we note that when households "choose" relatives other than grandparents to look after their children, the risk for child injury increases slightly. Although additional studies of how households choose relatives to watch their children and the actual caregiving styles of grandparents are warranted, for now there is no evidence that grandparental care places children at higher risk.
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APPENDIX |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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ACKNOWLEDGMENTS |
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This work was supported by Maternal and Child Health Bureau grant R40MC05475.
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FOOTNOTES |
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Accepted Jul 29, 2008.
Address correspondence to David Bishai, MD, PhD, MPH, Johns Hopkins Bloomberg School of Public Health, Department of Population Family and Reproductive Health, 615 N Wolfe St E4622, Baltimore, MD 21205. E-mail: dbishai{at}jhsph.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject There is only conjecture that grandparents have old-fashioned sensibility about child safety and child care practices that could put children at risk. Children who are watched by grandparents are a select group, and the reasons that they enter grandparent care may confound inference.
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| What This Study Adds We found that children who were aged 30 to 33 months, whose mothers work, and who are watched by grandparents have a statistically significantly lower rate of having an injury hospitalization in the previous 12 months.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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