The Turkish Journal of Pediatrics
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Characteristics of household falls in children under 2 years of age
Resmiye Oral1, Anna Floryanovichl1, Jill Goodmanl1, Münevver Türkmen2
1Child Protection Program, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
2Department of Pediatrics, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
|Oral R, Floryanovich A, Goodman J, Türkmen M. Characteristics
of household falls in children under 2 years of age. Turk J Pediatr 2007;
We hypothesized that young children uncommonly acquire significant injuries
due to household falls that necessitate medical attention.
Data on recalled fall experiences were collected from parents of children
younger than two years visiting the University Pediatrics Clinic. Statistical
analysis was performed using Student’s t test and chi square test.
Of 573 children, 36% experienced no falls, while 64% experienced
782 falls. Eleven percent of falls occurred from a distance of three to five
feet (~90-150 cm). In 6% of all falls, medical care was sought. In 40% of
this subcategory, examination was normal; in 33%, medical work-up revealed
normal results; in 23%, injuries necessitated subsequent intervention. No fall
led to neurological findings.
This study supports that it is uncommon for household falls to cause
injuries significant enough to require professional medical care. Even falls
from a distance of greater than three feet result in only mild injury with no neurological findings.
Household falls, population survey, injury, child
|Injuries in children are a leading cause of
morbidity and mortality in the United States.
Falls frequently result in emergency room
visits and are the fourth leading cause of
trauma deaths. Researchers have looked into
the consequences of falls in children from
an epidemiological perspective. There is an
abundant literature reporting on the spectrum
of falls in children presenting to medical
facilities with an injury[1-4]. Although home
is the primary place for injuries, especially
in children younger than two years of age1,
the existing literature is lacking with regard
to reports on the consequences of the full
spectrum of household falls.|
We were able to find only one study that
collected data about the type of fall, distance
fallen, resulting injury, and help sought for
children at six months of age. This study,
conducted via mailed questionnaire, concluded
that falls in infants are common but injuries
are rare. Serious injury in the form of skull fractures, concussion, and soft tissue injuries
reportedly occurred in only 0.2% of all infants,
despite the fact that 95% of injuries involved
the head. In another study, Agran et al. also
reported that falls were the major mechanism
of injury in toddlers.
Having baseline data on the rate and consequences
of household falls within the general
population of young children would be most
helpful in assessing cases of suspected child abuse
and neglect. Such data would provide a context for
viewing cases of non-trivial falls in the household
setting. The absence of such estimates poses legal
problems involving the medico-legal management
of suspected cases of child maltreatment.
In response to the scarcity of such studies in
the general population, we conducted a survey
of parents with children two years of age and
younger. We hypothesized it was uncommon
that young children acquire significant enough
injuries to necessitate medical attention due
to household falls.
|Material and Methods |
|This study was conducted at the University of
Iowa Family Care Center Pediatric Outpatient
Clinic between 7/15/2003 and 8/15/2004 to
investigate the full spectrum of memorable
falls, related consequences, and need for
medical attention after a fall. The study was
approved by the Institutional Review Board.
The study sample consisted of a convenience
sample of all families with children two years
of age or younger scheduled for a health
maintenance visit at the Clinic. An investigator
contacted parents at the time of registration,
explained the study, and obtained written
consent from those interested in participating.
The investigator then either presented a
questionnaire to the parents to complete and
return during the course of the appointment or
interviewed the subjects face to face using the
same questionnaire. The questionnaire obtained data on the child’s age, number of memorable
falls experienced, and the details of each fall,
such as age at the time of fall, distance fallen,
resultant injuries, and need for medical care.
If the child had more than one memorable fall
or if the family had more than one child in
this age range, a separate questionnaire was
completed for each individual child and fall.|
The hospital database was reviewed to verify
subsequent medical visits that followed the
reported falls. There was no discrepancy between
parental reports and the database data on
medical visits. “Memorable fall” was described
as one with either of the following features: a)
Child was symptomatic with bleeding, loss of
consciousness, vomiting, prolonged pain, refusal
to use extremity, or soft tissue injury, and b)
Child was asymptomatic but parent was worried
child might have subtle injury due to impact
to the head or distance fallen.
Fall rate was reported both cumulatively and
in quarter-year intervals (inclusive), as 0-3,
4-6, 7-9, 10-12, 13-15, 16-18, 19-21, and 22-
Two software programs were used for the
descriptive and comparative statistical analysis of
the data. Microsoft Excel software was used for
data entry and comparison of continuous variables
between groups was done via Student’s t test.
For categorical variables, contingency tables were
created and statistical analysis was performed
using Minitab software via chi square test.
|Of the 618 families approached, 573 (93%)
agreed to participate in the study. Every family
had one child in the study age range.|
A total of 204 (36%) children experienced no
significant falls. Three hundred and sixty- nine
(64%) subjects had experienced at least one
memorable fall. Of these, only three (1% of
those who fell) had fallen when they were
younger than four months old: one child fell
from a couch, another fell off a bed, and a third
fell off her mother’s abdomen while the mother
was sleeping on the floor. All three falls were
from a distance of less than three feet.
The remainder 366 subjects had experienced
the falls when they were aged four months
or older. There was no gender distribution
difference between the groups of infants based
on the presence of fall history.
When fall rate was examined by quarter-year
intervals, a very small number of infants had
experienced a fall between 0-3 months of age.
Memorable fall rate gradually increased from 4-
6 months of age, peaking at the 16-18 months
of age interval (Table I).
| ||Table I: Quarter-Year Interval Age Distribution of Subjects at the Time of a Memorable Fall|
The majority of parents stated that as soon
as their children began walking they “fell all
the time.” Three hundred sixty-nine subjects
experienced a total of 782 memorable falls.
The single most common cause of a fall was
tripping while walking or running, amounting
to 27% of reported falls. Falling from furniture
was the second most common mechanism of
a fall. The manner and location of all reported
falls are shown in Table II.
| ||Table II: The Manner and Location of the 782 Falls Experienced by 369 Subjects|
Eleven percent (84/782) of all falls involved a
fall distance of three to five feet (90-150 cm);
89% occurred from less than three feet (90 cm). The most common falls from greater
than three feet were: off a bed (31%), from
chairs (10%), off a counter (10%), and from
a crib (8%). The rest of the falls were from a
changing table or high table (8%), couch (7%),
and from a standing adult’s arms (6%).
Six percent (48/782) of fall episodes prompted
seeking medical care. In two children the
outcome of the medical visit was not
documented. One of these children had jumped
off a chair and was limping. The second child
fell off a recliner with subsequent refusal
to use her injured arm. In 19 of these fall
episodes (40%) in which medical care was
sought, physical examination was normal
and there was no intervention other than
recommending watchful monitoring at home.
These episodes accounted for 2.4% of all falls.
Sixteen fall episodes (33% of falls prompting medical care) led to a medical work-up that
revealed no abnormality. These accounted
for 2% of all falls. X–rays and computerized
tomography (CT) scans of the head were taken
in 39% (14/48) and 8% (4/48) of the falls,
respectively, that required medical attention
(2 falls required both an X-ray and a CT
scan). Only 11 falls (23% of falls prompting
medical care) generated significant injuries that
dictated medical work-up and intervention.
The injury spectrum included five facial/scalp
lacerations (45%), three fractures (27%), two dental injuries (18%), and one shoulder injury
(9%). The incidents that required medical
intervention due to injuries accounted for
1.4% of the total number of memorable falls
| ||Table III: Distribution of Medical Interventions Following 48 Falls|
Thus, a total of 27 fall episodes (27/782, 3%
of all falls) needed medical work-up and/or
intervention. The falls that prompted medical
work-up or intervention occurred at a younger
age than the falls that did not (8.9 ± 11.0 vs
19.9 ± 8.8 months, p<0.001).
Table IV summarizes the nature of the fall,
injury acquired and medical intervention needed
for the most significant 11 falls (1.4% of all
falls). Two of these 11 subjects (18%) fell from
greater than three feet. In 84 falls that occurred
from a distance of more than three feet (falls in vignette 1 and 3 on Table IV), only 2% (2/84)
resulted in any injury, none of which involved
neurological findings. Similarly, no neurological
findings were noted to result from any of the
falls from less than three feet.
| ||Table IV: Nature of the Fall, Injury Acquired and Medical Intervention Needed for the
Most Significant 11 Falls|
|This study reveals that falls in children under
two years of age are common but very rare
in infants under four months of age, the age
at which a child’s safety is virtually wholly
dependent on its caretakers. Most falls (69.4%)
in this study occurred in toddlers while walking
or running. The second most common type
of fall occurred from beds/couches/chairs
followed by falling downstairs, another
important category. Medical care was sought
in only 6% of all falls. When medical care was
sought, the need for medical intervention was
even rarer (1.4% of all falls). Medical workup
and intervention were more common in
children who fell at younger ages, with the
majority of the injuries involving the head,
face, and mouth.|
The findings of this study were consistent
with the literature, where comparisons were
possible. Most previous studies had been
hospital-based, introducing referral bias since
only a minority of accidents result in serious
injury or hospital referral. Thus, the falls
reported by most of the literature represent
the tip of the iceberg in terms of childhood
Many authors have reported on falls experienced
by infants. Warrington et al. reported that
22% of 11,466 infants six months of age and
younger had experienced 3,357 falls. However, they also concluded that only 5% of all falls
were in infants less than four months of age
and that most of the falls occurred between
5-7 months of age. In our study, 7.2% of all
falls occurred when the children were less than
seven months of age, which is comparable to
what Warrington et al. reported. Hennrikus
et al. also stressed the rarity of injuries due
to accidental falls in infants younger than
Agran et al. also reported that injury due to
falls rapidly increased with age beginning at
ages three to five months and peaking at 15
to 17 months. Another study conducted on
children who fell out of a bed, crib, chair, or
wagon while hospitalized for other medical
reasons reported that most of the falls were
experienced by children one and two years of
age. These findings are consistent with the
findings in our study, suggesting that it is
indeed uncommon for very young infants to
fall. This result is meaningful in light of the
fact that the majority of victims of inflicted
head trauma are one to six months of age
and present with either no history of a fall,
or a trivial fall. Thus, in children under two
years of age, serious or fatal intracranial injury
reportedly resulting from a household fall
needs to be investigated meticulously to rule
out inflicted trauma.
The most common mechanism of falling in our
study was tripping while walking or running
since the study population included toddlers.
Other most common fall mechanisms included
falling from beds/couches/chairs and stairway
incidents. This is in contrast with the findings
of Warrington et al. who reported that falls most commonly occurred from beds and settees
by rolling off surfaces or by being dropped by
caretakers. This is explained by the authors
themselves by the fact that their study focused
on a sample limited to infants less than six
months of age. Agran et al. reported different
mechanisms for each three-month period of
the first two years of life: being dropped
from a height (0-2 months), other falls from
battering (3-5 months), falls from furniture
(6-8 months), falls from stairs (9-11 months)
and falls from buildings (24-26 months) with
incidence peaking at different ages. In our
study, the most common mechanisms of fall
included falls from furniture (0-9 months),
falls from stairs (10-12 months), tripping while
running/walking (13-18 months), and falls
during play activities (19-24 months).
The injury spectrum caused by falls varies
depending on the study sample and inclusion
criteria. In our study, all memorable falls recalled
by parents retrospectively were included. Only
6% of all fall episodes prompted seeking
medical attention in this study, with warranted
medical intervention in only 1.4% of all fall
episodes. The most significant injuries in this
study included one skull fracture, two lower
extremity fractures, and two broken teeth. With
due acknowledgement of the fact that not all
fall experiences were recalled in detail, these
figures support the rarity of severe injuries
from household falls. This is consistent with
Warrington et al., who reported that most
falls resulted in no injury and serious injuries
were very rare. When fractures and other
serious injuries occurred due to a household
fall, they resulted predominantly from complex
accidents, and therefore it was expected that
a detailed circumstantial history would be
It has been suggested that falls from less than
10 feet result in predominantly trivial injuries,
although falls of 4-5 feet have resulted in
skull fractures[2,14-16]. Tarantino et al. reported
mainly minor injuries from short falls in
infants. Most children who fell down stairways
sustained minor injuries, involving mainly the
head and neck. Another study that focused
on infants 10 months of age or younger with a
history of a vertical fall from four feet or less
reported that such falls tend not to result in
significant injury, with most injuries involving
a minor hematoma or a contusion with no intracranial hematoma. This is in keeping
with our data, where the majority of falls led
to no serious injury. Plunkett, on the other
hand, reported that fatal injuries are possible
from short distance falls involving distances
of less than five to six feet. He was able to
recruit only 18 cases of fatal injuries from a
database of more than 75,000 falls. These cases
involved falls mostly in the playground setting
with rotational acceleration falls from swings,
very few of which were verified by neutral
observers, and there were only four cases under
two years of age. Thus, his results have been
questioned with regards to how representative
they are of household falls.
Eleven percent of all falls in our study occurred
from a distance of more than three feet. Of
these, only 2% resulted in mild/moderate
injury. These figures are in accordance with
the literature reports that falls from heights
of even more than three feet in the household
do not cause significant injuries[2,13,15,16,18]. The
fact that none of the children seeking medical
attention had any neurological symptoms is in
support of the literature that trivial household
falls do not cause significant, debilitating head
trauma. Nimityongskul et al. looked into
household falls and reported that children one
to two years of age fell mostly from one to
three feet with no subsequent extremity or
spine injuries. Most of the injuries were minor
head and face injuries. That study concluded
that severe injuries are extremely rare due to
Wang et al. concluded that children suffering
from falls from less than 15 feet were at
the same risk for intracranial and abdominal
injuries as those who fell from 15 feet or
more. In that study, not only are height
increments too large, age distribution was
also not taken into consideration in arriving
at this conclusion.
The strength of the present study is that our
sample of falls was not restricted to medical
referrals or use of medical services due to a fall.
Thus, this study covered a larger number of falls
experienced by children that would not have
come to medical attention in hospital settings.
However, the surveyed sample and spectrum
of falls are still limited. For instance, the data
obviously did not include falls considered too
trivial to be recalled in detail or reported. The
method of data collection also had limitations due to its reliance on parental recall; hence, the
time interval that elapsed between the accident
and completion of the questionnaire may
have influenced responses. It was constantly
reported by informants that children fell “all
the time”. Respondents were asked to provide
information on the most memorable incidents.
Thus, if anything, this study more likely
overestimates the need for medical assessment
and intervention after household falls.
Future research to determine the full spectrum
of childhood falls should take into consideration
settings outside the home but which represent
the household setting, such as day care facilities.
Utilizing video surveillance methodology may
enhance our epidemiological understanding of
the full spectrum of early childhood falls.
This study was partially funded by Carver
College of Medicine at the University of Iowa
via medical student research project grants in
2003-2004 and 2004-2005 academic years. It
was presented at the 19th San Diego Conference
of Child Maltreatment in January 2005.
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