Stair-Related Injuries to Young Children Treated in US Emergency Departments, 1999–2008

Discussion

To our knowledge, this study is the first to report national estimates and trends of stair-related injuries among young children. There were an estimated 931 886 children aged <5 years with stair-related injuries treated in US EDs during the 10-year period of this study. Although the number of injuries per year decreased 11.6% over that time period, stairs remain a common source of injury in this age group.

The findings of this study agree with those from previous studies on stair-related injuries. Like this study, previous studies demonstrated that head and neck injuries predominate, and injury severity tends to be low, with only a small percentage of patients requiring hospitalization.^6,9 In contrast to this investigation, previous studies did not report fractures to the femur and few to the humerus.^6,9 This study identified an estimated 3534 fractures to the humerus and 4527 to the femur. Research shows that femur fractures can occur from falls down stairs under certain conditions,^20,21 such as when a caretaker falls with the child; however, multiple injuries do not commonly result from stair-related falls.²¹ Therefore, the presence of multiple injuries warrants more investigation to rule-out intentional injury.^6,21 In our study, less than 1% of children sustained injuries to >25% of the body (6271 of 912 426).

An estimated 53 147 injuries resulted when children were being carried down the stairs by a caretaker who lost his or her balance. These falls often resulted in serious injuries, likely because of the force from the tumbling adult on the child. Caretakers should minimize stair use while carrying children by placing the child in a safe place instead of bringing the child with them if possible. Child caretakers can also reduce injuries by keeping the stairs well-maintained and free of objects that could result in tripping. Other items should not be carried in addition to the child, because this may make caretakers more likely to lose their balance; the spare hand should be on the handrail in case they do slip or trip. Caretakers should also avoid stair use when transporting a child using a stroller or other similar device. There were an estimated 10 233 injuries in which children fell down the stairs in a stroller or carriage. In many cases, the narratives indicated that the child was strapped in; however, this was not enough to prevent injury. Caretakers should not attempt to wheel the child on the stairs and should instead use an elevator, if available, or carry the child while keeping their other hand on the railing.²²

More consideration should be given to making stairs safer and more user-friendly, such as increasing the length of stair “goings,”²³ which are the horizontal depths of stair treads between vertical lines drawn from stair nosings (lead edges), in building codes. Missteps due to overstepping are a common cause of stair-related fall injuries.²⁴ Lack of uniformity in and/or short stair tread dimensions are important contributing factors to these events, especially in homes. Stair nosings should all line up as one sights down a flight of stairs. A misalignment of the top flight nosing is a common and dangerous defect found in many homes and elsewhere.²⁵ Additionally, handrails should allow a power grip, rather than a pinch grip, for enhanced stability.²⁶

Stair-related injuries involving baby walkers decreased significantly during the study period; however, there were still an estimated 1352 of these injuries in 2008. Given that baby walkers provide no essential benefit and have been shown by multiple studies to transiently delay normal motor and mental development, parents should be discouraged from letting their children use baby walkers to further reduce the number of baby walker–related injuries among children.⁸

Some injuries reported in this study resulted from children playing on or around stairs. There were an estimated 14 137 injuries caused by children jumping down the stairs, including an estimated 3363 fractures. To prevent such injuries, parents should closely monitor young children when they are using the stairs, discourage play on the stairs (including riding toys down stairs, which caused an estimated 10 115 injuries), and keep the stairs free of objects that could cause the child to slip or trip. Additionally, children should be discouraged from carrying objects down the stairs. Larger objects may cause the child to lose balance, and others can inflict wounds if the child falls.

Stair gates are an important way to prevent children from using the stairs unsupervised, but parents should not rely on them exclusively. A review of the case narratives in this study showed that the gates were often removed by another household member or the young child was able to knock or climb over the gate. One solution may be to improve stair-gate design to make gates more difficult for a child to get past. Injury-prevention theory indicates that the most effective strategies for prevention are those that do not require frequent human effort and vigilance.²⁷ Built-in, wall-mounted gates would ensure that the gates are always in place and may require less effort to use. Unfortunately, only 35% of household stairs can accommodate a wall-mounted gate at the top of the stairs, and only 62% of household stairs can accommodate a pressure-mounted gate at the bottom of the stairs.²⁸ Clearly, there is a need for both improved housing codes and stair gates that better fit staircases. Parents should be advised about proper use of stair gates at the top and bottom of stairs but reminded that their presence is not a substitute for proper adult supervision.

This study underestimates the actual number of stair-related injuries among young children, because the NEISS only includes injuries treated in EDs. Other injuries may be treated by the caretaker, in urgent care centers, other medical facilities, or receive no medical attention. Data from the NEISS may not be representative of all stair-related injuries. The NEISS injury code for “stairs and steps” included many minor injuries with bumps on steps rather than substantial falls down the stairs, which limited our ability to identify and analyze major falls alone. In addition, the NEISS is not a good data set for determining injury intent and therefore cannot be used to identify cases of abuse. Because of inconsistent documentation in case narratives, it was difficult to determine the mechanism of the fall in a large number of patients. The amount of exposure to stairs among young children is not known; however, the use of census data is an acceptable method for calculating population-based injury rates.