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PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1188-1191
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ABSTRACT |
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Top
Abstract
Introduction
Recommendation
References
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Falls of all kinds represent an important cause of child injury and death. In the United States, approximately 140 deaths from falls occur annually in children younger than 15 years. Three million children require emergency department care for fall-related injuries. This policy statement examines the epidemiology of falls from heights and recommends preventive strategies for pediatricians and other child health care professionals. Such strategies involve parent counseling, community programs, building code changes, legislation, and environmental modification, such as the installation of window guards and balcony railings.
After motor vehicle-related injuries, falls of all kinds
are the second leading cause of death from unintentional injury in the
United States, accounting for more than 13 000 deaths during 1998 among persons of all ages, 126 of which were children 14 years and
younger.1 Falls are the leading cause of nonfatal injury,
with several hundred thousand hospitalizations annually and almost 9 million persons treated in emergency departments who do not require
hospitalization.2 Although falls are the most common cause
of childhood injury, these injuries are rarely fatal, in contrast with
a high rate of fall-related mortality among the
elderly.1,3,4 Fatalities occur primarily when children
fall from great heights (greater than 2 stories or 6.7 m [22
ft]), or when the head of a child hits a hard surface, such as
concrete. Falls from heights greater than 2 stories can include falls
from roofs, windows, and balconies.5-7 The purpose of
this statement is to review the epidemiology of falls from heights in
children and to suggest strategies for prevention.
Falls from heights are a major problem in urban areas, especially for
children living in multiple-story, often deteriorating, low-income
housing.5-7 In some urban areas, falls have represented
up to 20% of the deaths of children from unintentional injury, as
compared with an average of 1% to 4% nationally.1,8,9
The majority of fall-related fatalities among children are associated with falls from heights, most from 3 stories or higher. Falls from 1 or
2 stories are more frequently nonfatal, but second-story falls may
cause serious injuries (D. Tinsworth, US Consumer Product Safety
Commission [CPSC], written communication, June 13, 1994).5,7 The falls from greater heights tend to cluster
in the summer months, presumably because windows are more likely to be
open and children are more likely to be playing on fire escapes, roofs, and balconies.5,7,8,10 Although the average age of
patients injured in falls from heights is approximately 5 years, the
age distribution is bimodal; preschool children usually fall from
windows, and older boys fall from dangerous play areas, such as
rooftops and fire escapes.5,6,8,11 African American and
Latino children are overrepresented in published series of falls from
heights in which race or ethnicity is reported, probably reflecting
their increased likelihood of living in urban, multiple-story
low-income housing.11,12 Overall, fall-related injuries to
boys outnumber those to girls by approximately 1.5:1 to 2:1, as with
most other injuries.5,7,8,10-16
The nature of the injuries to children when they fall from heights has
been studied extensively.11,13-17 Data from the CPSC on
the approximately 4700 children who were examined in emergency
departments because of falls from windows during 1993 indicate that
90% fall from the first and second stories and that 45% had injuries
defined by the CPSC as "serious," such as fractures, internal
injuries, concussions, intracranial hematomas, and intracranial
hemorrhages. Of those injured, 28% were admitted to the
hospital compared with 4% for all consumer
product-related injuries reported to the CPSC during 1993. Approximately one third of children sustained only minor injuries, such
as contusions, abrasions, and lacerations.11 These are
usually young children who fall 1 or 2 stories. Fractures are the most
common of the serious injuries and the radius, ulna, and femur are the
most frequent sites.11,16,17 Rib, spine, pelvis, and
calcaneus fractures are much less common among children than among
adults. Children tend to use their arms to protect their heads, and
they have relatively flexible bones.11,15,17 Multiple
fractures are common, especially those resulting from falls from
greater heights. Craniocerebral trauma is frequent, particularly in
fatal falls.15,17 Abdominal and chest injuries are
relatively uncommon in falls from 1 or 2 stories, but they are more
frequent in falls from greater heights and in fatal
falls.5,10,15,17 In general, the greater the height from
which the child falls, the more severe the injury. However, the nature
of the surface onto which the child falls (concrete and trash are most
common; softer surfaces improve outcome13,14,18) and the
degree to which the fall is broken on the way down modify the pattern
and severity of injuries.5,6,11,14-16,18 Children younger
than 3 years are much less likely to have serious injuries than older
children who fall the same distance. It is thought that, because
younger children have more fat and cartilage and less muscle mass than
older children, they better dissipate the energy transferred by the
fall.11
Because witnessed falls of 2 stories or less usually do not result in
serious injury, child abuse should be considered in children with
serious injuries from falls that were reportedly from lower levels,
especially if the fall was unwitnessed.19-22 One large
series reported that about one fourth of the falls were "not
accidents"; some children jumped to avoid beatings or fires, some
were pushed by siblings or parents, and some attempted suicide (all the
suicide attempts were adolescents).14
Permanent physical sequelae The economic costs of these injuries from falls are considerable. In
Los Angeles County, where falls are possibly less frequent than in the
northeast, the annual hospital charges from 1986 to 1988 were more than
$600 000, or about $5000 per child admitted with fall-related injury;
almost half of these charges were paid by public
assistance.14 Data compiled by the National Center for
Health Statistics National Hospital Ambulatory Medical Care Survey for
1992-1994 revealed a national cost of $958 million for emergency care
for children who were seen for falls. Although fewer than 3% were
falls from buildings or extreme heights, they would still account for
almost $10 million annually, including 26% paid by
Medicaid.23
Case series have reported predisposing factors for fall injuries: a
history of previous major unintentional injury to the patient or
siblings; neurologic disorders, such as seizures, developmental delay
or hyperactivity; and documented parental neglect.5,8,10
The families of the victims are more likely than the general population
to experience social and demographic factors such as poverty,
single-parent households, inadequate child care, and acute stressors
such as recent moves, illnesses, and job changes.8 Some
central-city residents may have moved recently from rural areas and may
be unfamiliar with the hazards of living in multiple-story dwellings.5
A number of strategies, some of which have documented
effectiveness, have been suggested to prevent children falling from heights. Parent counseling has been effective in preventing infant falls and other injuries and should be part of any prevention program.20,22,24-26
Considerable success has been reported with modification of the
physical environment. Spacing of railings determines how well they
function to prevent falls from balconies, decks, porches, and
bleachers. Widely spaced rails are ineffective barriers because they
permit a child's body to slip through.27 Virtually all
children younger than 6 years can slip through a 6-in opening, and none
older than 1 year can pass through a 4-in opening.27 This
information resulted in the adoption of the 4-in spacing by all 3 of
the regional building code organizations in the United States. To
prevent falls from balconies, the building codes in many communities
now require railings through which a child cannot pass.28
All local building codes dealing with new construction should be made
to conform with the national codes that currently recommend 4-in
openings between vertical (not horizontal) bars. Because the codes
apply only to new construction, retrofitting of older dwellings also
should be encouraged. Most codes specify railing heights of 36 in.
Although an increase of railing height to 4 to 5 ft would add
protection, aesthetic concerns are likely to impede any efforts for
change.
Outside fire escapes are unnecessary in modern buildings that use
fire-resistant techniques such as internal fire stairs, but it is
unlikely that outdoor escapes can be eliminated from older housing, and
is it unlikely that urban housing will be air-conditioned, reducing the
need to open windows during hot weather. Providing safe ground-level
play areas with climbing equipment has been suggested as a strategy for
avoiding the falls from heights related to children playing on fire
escapes and roofs.6
Because the majority of serious injuries are related to falls from
windows,13,14,17 strategies designed to prevent these
falls should have a substantial effect. Modern window screens, although
easily removable to allow for escape during residential fires, are
designed to keep insects out of the house and do not provide a barrier
to falls.24 "Child safety" window screens made of
steel are available and are used in new construction in some areas.
These screens can withstand 67.5 kg (150 lb) of pressure, similar to
the standard for window guards, and need replacing less often, but
adding them to existing construction would be costly.
The installation of window guards is a proven preventive strategy. In
1976, the New York City Board of Health, noting that window falls
accounted for 12% of deaths from unintentional injury of children
younger than 15 years, passed a law requiring the owners of
multiple-story dwellings to provide window guards in apartments where
children 10 years and younger reside. This law was passed after the
implementation of a pilot program combining education with the
provision of free window guards. The pilot program resulted in a 35%
reduction in deaths attributable to falls from windows and a 50%
reduction in incidents; no child fell from a window equipped with a
window guard.7 The mandatory program resulted in a
reduction of up to 96% in admissions to local hospitals for the
treatment of window-fall-related injuries.14 Follow-up
through 1993 revealed a continuing downward trend.29
Education is important for teaching the appropriate installation of
window guards. Despite the proven effectiveness of window guards, other
major cities have been slow to adopt similar codes. The building code
in Chicago requires window guards if the height of the window sill is
less than 2 ft above the floor, but enforcement is reportedly
ineffective.10 A voluntary ordinance in Boston encourages
but does not mandate landlords to install window guards. The first 2 years' data after initiating this program showed an 83% decrease in
hospitalizations for the treatment of injuries attributable to falls
from windows, and there were no deaths, compared with 3 deaths during
the 2 years preceding the program.30 A survey of building
codes in several states found no regulations requiring window guards,
although New Jersey has since passed a law similar to that of New York
City.31 Some states prohibit or limit window guards in the
interest of providing fire egress.13
One survey of hardware stores found that the only devices available
were specifically designed and advertised to keep intruders out; they
were recommended for use on first floor windows.13 These
devices were expensive (approximately $50) and difficult to
install.13 Security devices are designed to keep people
out, and window guards are designed to keep people in Fire protection professionals have great concerns about the use of
fixed window bars (security bars) that prevent egress or access by fire fighters. It is important to install operable
window guards that can be released or removed without the use of a
separate key or excessive force. Operable guards must be too difficult for a child to release but easy enough for an adult or teenager to
release. Examples of operable guards include built-in bars that appear
automatically as the window is raised, guards on a hinge that swing in
when a "pin" is released, and a slide-out model that requires the
simultaneous depression of 2 pins for removal. Fire codes in some
communities prohibit the use of fixed bars on emergency and fire escape
windows. Organizations of fire protection professionals decry their
use, especially on first and second floors, but data are scarce that
would permit the risk-benefit consideration of the use of operable
guards, especially on higher floors.33 Recent data on the
New York City experience showed no increase in the number of deaths
attributable to residential fires (in fact, there was a decrease) after
the introduction of window guards as required by city
ordinance.29
1. Pediatricians should give the following anticipatory
guidance about prevention of falls from heights to parents of children who live in multiple-story dwellings:
INTRODUCTION
Top
Abstract
Introduction
Recommendation
References
primarily orthopedic problems related
to fractures and neurologic problems ranging from mild to severeoccur
in 4% to 22% of children who survive serious
falls.10,11,13,14,17 One study reported a significant
incidence of posttraumatic psychiatric and behavior
problems.14
PREVENTION
except for
necessary egress in the event of fire. It is easier to find inexpensive
window guards (starting at $6) in cities where window guards are
required, especially when public health programs have developed
networks of stores that offer them. Window stops are available that
prevent sliding windows from opening more than 4 inches. They are
available at hardware stores for around $2 and are easy to install.
Window guards can be obtained to fill the entire opening of a sliding or casement window. However, currently designed window guards are best
suited for double-hung (sash-hung) windows. If the guard does not fill
the entire opening of the window, additional devices, "L-stops,"
also are recommended to restrict the opening of the window above the
top bar of the guard to no more than 4.5 in. L-stops are not to be used
on windows designated for egress, that is, windows that are located
less than 75 ft above the ground.32
RECOMMENDATIONS
Top
Abstract
Introduction
Recommendation
References
2. Pediatricians should advocate for community-wide programs to encourage the use of window guards. Public health authorities, in conjunction with fire prevention officials, should guide such programs so that regulations may be based on concerns about both fire safety and fall prevention.
3. The American Academy of Pediatrics (AAP), state chapters, and local pediatricians should work with manufacturers of windows and window guards to encourage them to develop and make more widely available additional products that can prevent falls and allow egress in fires. Examples are windows that cannot be pushed out or up by a child and window guards with safety catches that can be operated only by adults.
4. Legislation requiring landlords to install releasable window guards or window stops above the ground floor in multiple-story dwellings where children live should be developed. Community outreach and education are important components of programs to prevent falls from heights. In many cities, the local government housing authority, a major landlord for low-income people, along with the AAP state chapters and local pediatricians, should take the lead in encouraging the installation of window guards.
5. Building codes should ensure that balconies, decks, porches, bleachers, roofs, and fire escapes have railings with vertical openings not greater than 4 in.
6. Local communities and recreation departments should develop strategies to reduce the number of children playing in dangerously high places. Such strategies might include the expansion of safe public playground activities, including child care and recreational programs, as well as attempts to make streets and public areas safer for children by implementing programs such as neighborhood watch and crime prevention.
7. Whenever possible, grass or shrubbery should be planted at the bases of tall buildings to soften the impact surface.
Committee on Injury and Poison Prevention, 2000-2001
Marilyn J. Bull, MD, Chairperson
Phyllis Agran, MD, MPH
H. Garry Gardner, MD
Danielle Laraque, MD
Susan H. Pollack, MD
Gary A. Smith, MD, DrPH
Howard R. Spivak, MD
Milton Tenenbein, MD
Liaisons
Ruth A. Brenner, MD, MPH
National Institute of Child Health and Human Development
Stephanie Bryn, MPH
Health Resources and Service Administration/Maternal and Child Health Bureau
Cheryl Neverman, MS
National Highway Traffic Safety Administration
Richard A. Schieber, MD, MPH
Centers for Disease Control and Prevention
Richard Stanwick, MD
Canadian Paediatric Society
Deborah Tinsworth
US Consumer Product Safety Commission
Section Liaisons
Robert R. Tanz, MD
Section on Injury and Poison Prevention
Victor Garcia, MD
Section on Surgery
Consultants
Susan B. Tully, MD
Murray L. Katcher, MD, PhD
Staff
Heather Newland
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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CPSC, US Consumer Product Safety Commission; AAP, American Academy of Pediatrics.
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REFERENCES |
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Top
Abstract
Introduction
Recommendation
References
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Statements of reaffirmation:
This article has been cited by other articles:
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  N Hussain, L Mewasingh, and J Gosalakkal Is the heat wave increasing the number of falls from open windows among children? Arch. Dis. Child., January 1, 2007; 92(1): 90 - 90. [Full Text] [PDF]
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 H. G. Gardner and and the Committee on Injury, Violence, and Poison Office-Based Counseling for Unintentional Injury Prevention Pediatrics, January 1, 2007; 119(1): 202 - 206. [Abstract] [Full Text] [PDF]
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 M Bulut, O Koksal, A Korkmaz, M Turan, and H Ozguc Childhood falls: characteristics, outcome, and comparison of the Injury Severity Score and New Injury Severity Score. Emerg. Med. J., July 1, 2006; 23(7): 540 - 545. [Abstract] [Full Text] [PDF]
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 J C Pressley and B Barlow Child and adolescent injury as a result of falls from buildings and structures Inj. Prev., October 1, 2005; 11(5): 267 - 273. [Abstract] [Full Text] [PDF]
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N L Vish, E C Powell, D Wiltsek, and K M Sheehan Pediatric window falls: not just a problem for children in high rises Inj. Prev., October 1, 2005; 11(5): 300 - 303. [Abstract] [Full Text] [PDF]
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 H. Dubowitz, R. R. Newton, A. J. Litrownik, T. Lewis, E. C. Briggs, R. Thompson, D. English, L.-C. Lee, and M. M. Feerick Examination of a Conceptual Model of Child Neglect Child Maltreat, May 1, 2005; 10(2): 173 - 189. [Abstract] [PDF]
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G R Istre, M A McCoy, M Stowe, K Davies, D Zane, R J Anderson, and R Wiebe Childhood injuries due to falls from apartment balconies and windows Inj. Prev., December 1, 2003; 9(4): 349 - 352. [Abstract] [Full Text] [PDF]
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 J. Krieger and D. L. Higgins Housing and Health: Time Again for Public Health Action Am J Public Health, May 1, 2002; 92(5): 758 - 768. [Abstract] [Full Text] [PDF]
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