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PEDIATRICS Vol. 108 No. 3 September 2001, pp. 790-792
In 1999, an estimated 8800 children younger than
15 months were treated in hospital emergency departments in the United
States for injuries associated with infant walkers. Thirty-four infant walker-related deaths were reported from 1973 through 1998. The vast
majority of injuries occur from falls down stairs, and head injuries
are common. Walkers do not help a child learn to walk; indeed, they can
delay normal motor and mental development. The use of warning labels,
public education, adult supervision during walker use, and stair gates
have all been demonstrated to be insufficient strategies to prevent
injuries associated with infant walkers. To comply with the revised
voluntary standard (ASTM F977-96), walkers manufactured after June 30, 1997, must be wider than a 36-in doorway or must have a braking
mechanism designed to stop the walker if 1 or more wheels drop off the
riding surface, such as at the top of a stairway. Because data indicate
a considerable risk of major and minor injury and even death from the
use of infant walkers, and because there is no clear benefit from their use, the American Academy of Pediatrics recommends a ban on the manufacture and sale of mobile infant walkers. If a parent insists on
using a mobile infant walker, it is vital that they choose a walker
that meets the performance standards of ASTM F977-96 to prevent falls
down stairs. Stationary activity centers should be promoted as a safer
alternative to mobile infant walkers.
ABSTRACT
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Abstract
Recommendation
References
An infant walker, or baby walker, consists of a wheeled
base supporting a rigid frame that holds a fabric seat with leg
openings and usually a plastic tray. The device is designed to support a preambulatory infant, with feet on the floor, and to allow mobility while the infant is learning to walk. Some walkers are equipped with
bouncing mechanisms, activity toys, or locking devices that keep them
from moving, and some fold flat for storage.
Estimated annual sales of walkers are more than 3 million.1 Older studies have found that 55% to
92% of infants between 5 and 15 months of age use
walkers.2-6 Parents give various reasons for using
walkers According to the National Electronic Injury Surveillance System
(NEISS) of the US Consumer Product Safety Commission (CPSC), an
estimated 8800 children younger than 15 months were treated in hospital
emergency departments in the United States in 1999 for injuries
associated with the use of infant walkers.8 This
represents a 56% decrease in these injuries since 1995, when 20 100
injuries were reported.8 Thirty-four deaths associated with the use of infant walkers were reported to the CPSC during the
years 1973 through 1998 (D. Tinsworth, personal communication, November
2000). Population surveys suggest that there may be as many as 10 times
more injuries that are sufficiently minor that they are treated in
physicians' offices or do not require medical attention.5
Parents report that walker-related injuries occur at some time in 12%
to 40% of infants who use walkers.6,9 A study of 65 Virginia children injured in walkers estimated the annual incidence of
walker injuries resulting in emergency department visits to be 8.9 per
1000 children younger than 1 year. Severe injuries occurred at a rate
of 1.7 per 1000.10 Approximately one fourth of infant
walker-associated injuries reported to the NEISS are described as
"more severe," and these are nearly all fractures and closed head
injuries. Skull fractures accounted for almost 10% of all
walker-related injuries in one large series of patients.11
Reported injuries are overwhelmingly caused by falls, either from the
walker or with the infant remaining in the walker. Stairs are
implicated in 75% to 96% of cases and in almost all of the severe
injuries.11 A small number of pinch injuries to fingers
and toes occur.1,12 Burns account for 2% to 5% of
walker-related injuries.7,8,10 Walkers also have been
commonly associated with poisonings of infants under 1 year of
age.13 These burns and poisonings are attributable to the
increased access to these hazards afforded by an infant's increased
mobility in a walker. Although submersion is not a commonly reported
mechanism of nonfatal injury, 4 of the 11 deaths reported between 1989 and 1993 were from drowning (in a pool or toilet), 4 were from
suffocation (compression of the neck against the feeding tray), and 3 were from falls.12
Little effort has been made to compare the rates and severity of
various injuries in children of the same age who do or do not use
walkers. A report from Toronto's Hospital for Sick Children, however,
states that during 1984, 123 infants who had fallen down stairs in
walkers were evaluated; only 1 infant in the same age group who had
fallen down stairs was not in a walker.7 Although walkers
do not consistently account for the majority of infant injuries
associated with falls down stairs, in another study,14
walkers accounted for 45% of falls down stairways causing head injury
in children younger than 24 months, and these walker-related stairway
falls caused more severe injury. The study authors14
believe that the walker predisposes infants to more serious injury by
increased kinetic energy resulting from the larger mass and higher
initial speed (speeds of more than 3 ft/sec have been
recorded15) and because the infant tends to remain
in the walker while falling, resulting in unprotected head
exposure.14
Parents who use infant walkers often express their perception that the
walker keeps their child safe (a form of baby-sitting), or that it
helps the infant learn to walk. Data supporting such benefits do not
exist. One study that evaluated children between 6 and 15 months of age
demonstrated that walker-experienced infants sat, crawled, and walked
later than no-walker controls, and they scored lower on Bayley scales
of mental and motor development.16 At first, the
unassisted gait of infants who use walkers may be slightly
abnormal.2 There is no evidence, however, that such
effects are lasting in typical children or that they have any impact on
the child's ultimate motor development or
intelligence.2,17 Anecdotal reports suggest that children
with cerebral palsy who use walkers experience exaggerated abnormal
motor reactions and delay in development of normal balance and
protective responses; however, the duration of these signs and the
consequences of these observations have not been addressed
systematically.18-20 Beyond parental impressions that
infants seem happier in walkers, it does not appear that any real
benefits of using a walker can be found to balance the considerable
risk of injury.
Strategies to prevent infant walker-related injuries include 1)
warning labels and public education, 2) adult supervision during walker
use, 3) barriers such as stair gates, 4) infant walker design changes
to prevent falls down stairs, and 5) a proposed ban on mobile infant
walkers.
Until the 1996 revision of the voluntary standard for infant walkers
(ASTM F977-96),21 injuries attributable to falls were
addressed only through warning labels, which was an ineffective
strategy in reducing these injuries.1 Several studies have
shown that even the occurrence of a walker-related injury does not
deter parents from the continued use of walkers for the injured child
or subsequent siblings. In one study, 32% of parents reported that
they used the walker again after the injury, and 59% acknowledged that
they were aware of the potential dangers of walkers before the injury
episode.11 Thus, more labeling and educational efforts are
not likely to lead to an additional decrease in
walker-related injuries.4,5,7,11
Adult supervision also cannot be relied on to prevent infant
walker-related injuries. Moving at more than 3 ft/sec, an infant can be
across the room before an adult has time to react. In one study, 78%
of children were being supervised at the time of the injury, including
supervision by an adult in 69% of cases.11 Other studies
have also shown that many of these events occur with 1 or both parents
in the room.7,12,22 Stair gates are not uniformly
effective even when present; more than one third of falls down stairs
in one study occurred with stair gates in place, but the gates were
either left open or improperly attached.7
Both mandatory and voluntary standards exist for infant walkers. The
mandatory standard that has been in effect since 1971 (16 CFR 1500.86 [a]4) primarily addresses injuries to digits caused by pinching or
shearing in the frame of the walker and by collapse of the walker.
Judging from CPSC statistics, these types of injuries are infrequent,
suggesting that these standards are effective.1 The
voluntary standard (ASTM F977) addresses the more difficult problems of
falls and tip-overs. The standard's performance requirements to
prevent walker tip-overs and structural failures appear to have been
effective, because these types of incidents are now uncommon.
In 1996, the voluntary standard was revised to include performance
standards for infant walkers to prevent falls down stairs. To comply,
walkers manufactured after June 30, 1997, must be wider than a 36-in
doorway or must have a braking mechanism designed to stop the walker if
1 or more wheels drop off the riding surface, such as at the top of a
stairway. A similar voluntary standard was adopted in Canada in June
1989 requiring the width of walkers to be at least 900 mm (35.4 in).23 In the United States, CPSC data confirm that
basement stairs are involved in approximately half of walker injuries
and that about 80% of the doorways to these stairs are 36 in wide or
less.12 Although walkers meeting the new standard began
appearing in retail stores at the end of 1997, overall industry
compliance remains to be evaluated. Because compliance is voluntary,
the incentive for manufacturers to meet the new safety standards is a
product certification by the Juvenile Products Manufacturers
Association (JPMA). The manufacturers most likely to comply with the
revised voluntary standard are members of the JPMA; however, nearly
40% of the new baby walkers sold in the United States are manufactured
by firms that do not belong to the JPMA. Because the rule-making
proceeding that the CPSC began in 1994 is still open, the CPSC could
pursue the development of a mandatory standard to prevent infant walker
stairway falls if the industry's compliance with the voluntary
standard were judged to be inadequate.
Baby walker-like devices that do not roll across the floor on wheels
are also available to consumers. These stationary activity centers
allow children to bounce, swivel, and tip, and they provide parents an
alternative to the use of mobile infant walkers. Injury data for these
devices are not yet available. Their stationary design eliminates the
risk of stair-related falls, however, and therefore they should be
safer than mobile walkers. The recent decrease in the number of baby
walker-associated injuries is likely to be attributable in part to the
availability of walker alternatives, such as stationary activity
centers, and a decrease in the use of baby walkers manufactured before
July 1997.
OVERVIEW
to keep the infant quiet and happy, to encourage mobility and
promote walking, to provide exercise, and to hold the infant during
feeding.4,5,7 One third of parents in one study used
walkers because they believed that walkers would keep their infants
safe.5
DATA
PREVENTION
RECOMMENDATIONS
Top
Abstract
Recommendation
References
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 Services 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
Victor Garcia, MD
Section on Surgery
Robert R. Tanz, MD
Section on Injury and Poison Prevention
Consultant
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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NEISS, National Electronic Injury Surveillance System; CPSC, Consumer Product Safety Commission; JPMA, Juvenile Products Manufacturers Association.
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REFERENCES |
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Abstract
Recommendation
References
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Statement of reaffirmation:
The following policy statement has been revised:
This article has been cited by other articles:
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  K. A. Mack, J. Gilchrist, and M. F. Ballesteros Injuries Among Infants Treated in Emergency Departments in the United States, 2001-2004 Pediatrics, May 1, 2008; 121(5): 930 - 937. [Abstract] [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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B. J. Shields and G. A. Smith Success in the Prevention of Infant Walker-Related Injuries: An Analysis of National Data, 1990-2001 Pediatrics, March 1, 2006; 117(3): e452 - e459. [Abstract] [Full Text] [PDF]
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 X. Dedoukou, T. Spyridopoulos, S. Kedikoglou, D. M. Alexe, N. Dessypris, and E. Petridou Incidence and Risk Factors of Fall Injuries Among Infants: A Study in Greece Arch Pediatr Adolesc Med, October 1, 2004; 158(10): 1002 - 1006. [Abstract] [Full Text] [PDF]
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 N.C. Tan, N.M.L.H. Lim, and K. Gu Effectiveness of Nurse Counselling in Discouraging the Use of the infant Walkers Asia Pac J Public Health, January 1, 2004; 16(2): 104 - 107. [Abstract] [PDF]
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 G. J. Lonergan, A. M. Baker, M. K. Morey, and S. C. Boos From the Archives of the AFIP: Child Abuse: Radiologic-Pathologic Correlation RadioGraphics, July 1, 2003; 23(4): 811 - 845. [Abstract] [Full Text] [PDF]
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P. F. Agran, C. Anderson, D. Winn, R. Trent, L. Walton-Haynes, and S. Thayer Rates of Pediatric Injuries by 3-Month Intervals for Children 0 to 3 Years of Age Pediatrics, June 1, 2003; 111(6): e683 - 692. [Abstract] [Full Text] [PDF]
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 B. Taylor Babywalkers BMJ, September 21, 2002; 325(7365): 612 - 612. [Full Text] [PDF]
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