The infant walker. A previously unrecognized health hazard

Baby walker injury awareness among grade-12 girls in a high-prevalence Arab country in the Middle East

Baby walkers (BWs) are a consumer product frequently associated with infant injuries. With little research in the Middle East and few population studies anywhere, female students in grade 12 in the United Arab Emirates were surveyed, assessing the prevalence of use, perceived safety, and interventions. The study population included grade-12 students in a large UAE city. Multistage random sampling selected 4/8 female Arab government schools and 3 classes each from science and arts tracks for interview by self-administered questionnaire. Response was 100%, with a total of 696 students, 55% (n = 385) of whom were Emirati citizens; 90% (n = 619) of the families used/had used BWs. Among the reasons for use, 92% reported "keeping baby safe," with 11% perceiving BWs as very safe and 74% as moderately safe. Only 16% perceived that BWs could cause injuries. Despite causing many injuries, including fatalities, BWs were perceived to be safe and used by nearly all families. Effective education of professionals, patients, the public, and decision makers is needed. Governments should consider countermeasures such as prohibiting importation, sales, and advertising, together with public education and provision of stationary activity centers.

Success in the prevention of infant walker-related injuries: an analysis of national data, 1990-2001

OBJECTIVE

Here we describe the epidemiologic characteristics and secular trends of infant walker-related injuries among children who are younger than 15 months in the United States.

METHODS

A retrospective analysis was conducted of data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission, 1990-2001. Sample weights that were provided by the National Electronic Injury Surveillance System were used in all analyses to adjust for the inverse probability of case selection and make national projections regarding infant walker-related injuries.

RESULTS

An estimated 197200 infant walker-related injuries occurred among children who were younger than 15 months and treated in US emergency departments from 1990 through 2001. Five percent of these children required admission to the hospital. The number of infant walker-related injuries remained relatively constant from 1990 through 1994, averaging 23,000 cases per year. After the introduction in 1994 of stationary activity centers as an alternative to mobile infant walkers and the implementation of the revised American Society for Testing and Materials F977 voluntary infant walker standard in 1997, there was a marked decrease in the number of infant walker-related injuries. Overall, there was a 76% decrease in the number of injuries from 1990 to 2001 from 20,900 injuries in 1990 to 5100 in 2001. Soft tissue injuries and lacerations represented 63% of the injuries. Trauma to the head region occurred in 91% of cases. Skull fractures were the most common (62%) type of fracture. Falls down stairs was the mechanism of injury in 74% of cases.

CONCLUSIONS

The adoption of passive injury-prevention strategies, such as use of stationary activity centers as alternatives to mobile infant walkers and redesign of infant walkers to prevent falls down stairs, were associated with a marked decrease in the number of infant walker-related injuries.

An evaluation of the effectiveness of a baby walker safety standard to prevent stair-fall injuries

PROBLEM

During the early 1990s the number of baby walker injuries treated in U.S. hospital emergency departments averaged almost 25,000 annually; about 80% resulted from falls down stairs. After initiating a regulatory proceeding in 1994, the U.S. Consumer Product Safety Commission staff worked with industry to develop requirements to address the stair-fall hazard. This study evaluates the effectiveness of the stair-fall requirements, which became effective in 1997 as part of a revised voluntary standard.

METHOD

Annual baby walker emergency department injury rates were constructed for the 1981-2002 study period. A multivariate negative binomial regression model was used to estimate the effectiveness of the stair-fall requirements in reducing the injury rate.

RESULTS

The stair-fall requirements reduced the emergency department injury rate by an estimated 63% (95% CI, 52% to 71%).

IMPACT ON INDUSTRY

Given the substantial reduction in walker injuries, and the high level of industry conformance with the stair-fall requirements, the Commission terminated its regulatory proceeding in May, 2002. The success of the baby walker project highlights the ability of government and industry to work together cooperatively to develop effective safety improvements for consumer products.

Baby walkers--health visitors' current practice, attitudes and knowledge

BACKGROUND

Baby walkers are a commonly used item of nursery equipment. Between 12% and 50% of parents whose infant uses a walker report that their child has suffered a walker-related injury. Health visitors' knowledge, attitudes and practice with regard to walkers and related health education has not been explored so far.

AIM

The aim of the study was to describe health visitors' knowledge of walkers and walker-related injuries, their attitudes towards walkers and current practice with regard to walker health education, and to examine the relationship between knowledge and attitudes and knowledge and practice.

METHOD

A survey was carried out with 64 health visitors prior to participation in a randomized controlled trial assessing the effectiveness of an educational package in reducing baby walker use.

RESULTS

The response rate was 95%. Half of the health visitors always discussed walkers postnatally, most frequently at the 6-9 month check. Most did not usually discuss the frequency of walker-related injuries. Most had negative attitudes towards walkers, but believed that parents hold positive attitudes to them and that it is hard to persuade parents not to use them. Health visitors had a limited knowledge of walker use and walker-related injuries. Those giving advice on walkers most often had higher knowledge scores than those giving advice less often (P = 0.03). Those with higher knowledge scores held more negative attitudes towards walkers (rs = 0.29, P = 0.023) and believed parents to have more positive attitudes towards walkers (rs = -0.49, P < 0.001). Few health visitors had resources to discuss walkers.

CONCLUSIONS

Health visitor advice regarding walkers needs to be given earlier in the postnatal period than is currently common practice, and they need more knowledge about walker use and related injuries. Education about baby walkers needs to be incorporated into undergraduate and in-service education, which may need to include the development of skills in exploring reasons why parents use walkers and in negotiating alternatives to their use. The provision of audio-visual aids for discussing walkers might also be helpful.

Do baby walkers delay onset of walking in young children?

Baby walkers have been a source of considerable controversy. Some people suggest developmental benefit from their use while others focus on the potential harm that stems from accidents and even suggest developmental delay. This mini-review aimed to determine if use of a baby walker delays affects the onset of walking. The Cochrane library, Embase, CINAHL and Medline were searched for randomized controlled trials (RCTs) and cohort studies, which compared the onset of walking in infants who used baby walkers with a group who did not. Two RCTs and two cohort studies were identified and available for consideration. All of the studies examined the effect of infant walkers on the onset of walking. The results of the two RCTs did not demonstrate a significant effect on the onset of walking. The cohort studies suggest that the use of infant walkers delayed the onset of walking in young children and a pooled analysis of the four studies suggested a delay of between 11 and 26 days. Although the quality of the studies was relatively poor these studies lend no support to the argument that walkers aid the development of walking. The significance of a delay of this magnitude is however unclear. Further work is required to determine whether walkers are an independent causal factor in accidents.

Still falling: a community-wide infant walker injury prevention initiative

Despite the well-known risk of injury associated with use of infant walkers, they remain popular, leading to large numbers of walker-related injuries. A coalition of health care providers and educators, with the assistance of retailers and medical and human service agencies, undertook an intensive multifaceted, community-wide intervention to educate the general and health care public regarding the dangers of infant walker use and thereby reduce the number of walker-related injuries in our community. Following this intervention, 28% fewer children presented annually at the two area pediatric emergency departments for walker-related falls down stairs than during the 30 months before the intervention. The magnitude of this reduction attributable to the intervention, however, is uncertain, as national trends during the study period revealed a similar decrease in walker-related injuries. Educational interventions alone may significantly reduce but not eliminate walker-related injuries; national policy measures are likely also necessary.

Maternal use of baby walkers with young children: recent trends and possible alternatives

OBJECTIVES

To examine recent trends in baby walker and exersaucer use, and to assess maternal motivations for choosing to use or not use these devices with children.

SETTING

Small, Midwestern city in the United States.

METHODS

Retrospective telephone survey with a sample of 329 mothers who provided information about their use of walkers and exersaucers with 463 children born in Columbia, Missouri between January 1994 and April 1999.

RESULTS

Baby walker use in the sample declined fairly steadily from 1994 to 1999, whereas exersaucer use increased during the same period. Altogether 88% of mothers were aware of the injury risks associated with walkers, and this knowledge was the most commonly reported reason for abstaining from walker use. Remarkably, 38% of participants with knowledge of walker risks nevertheless used these devices. Participants reported many reasons for using walkers and exersaucers, including child entertainment, perceived developmental benefit, easy availability, and improved safety of exersaucers.

CONCLUSIONS

Public knowledge of the hazards of walkers seems to be high, and this awareness is a likely factor in many caregivers' decisions not to use them. Future interventions should focus particular attention on those caregivers who continue to use walkers despite knowledge of the associated risks. In addition to persuasive interventions, alternatives to walkers should be encouraged. Exersaucers represent one viable alternative, and should be promoted as such by the media, pediatricians, and other child care professionals.

Injuries associated with infant walkers

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.

Intussusception following a baby walker injury

Serious abdominal injury as a result of a fall in a baby walker has not been previously reported. We present the case of a 13-month-old boy who developed intussusception following a fall down five stairs in a baby walker. Attempted hydrostatic reduction was unsuccessful. At operation, a bowel wall hematoma, serving as a lead point, was identified. This case adds another type of injury to the list of those previously associated with baby walker use.

Babywalker-related injuries continue despite warning labels and public education

OBJECTIVE

To describe the epidemiology of babywalker-related injuries to children treated in a pediatric emergency department despite current prevention efforts, and to investigate the beliefs of parents regarding babywalker use.

DESIGN

A descriptive study of a consecutive series of patients.

SETTING

The emergency department of a large, academic children's hospital.

PARTICIPANTS

Children treated for babywalker-related injuries during the 3-year period of March 1993 through February 1996.

RESULTS

There were 271 children treated for babywalker-related injuries. The mean age was 9.2 months, and 62% of patients were boys. Ninety-six percent of children were injured when they fell down stairs in their babywalker. The number of stairs that a child fell down was significantly associated with skull fracture and admission to the hospital, and a fall down more than 10 stairs had a relative risk (RR) of skull fracture = 3.28 (95% confidence interval, 1.35 < RR < 7.98). There were 159 children with contusions/abrasions (58.6%), 35 concussions/head injuries (12. 9%), 33 lacerations (12.2%), 26 skull fractures (9.6%), 9 epistaxis (3.3%), 4 nonskull fractures (1.5%), 4 avulsed teeth (1.5%), and 1 burn (0.4%). Three of the skull fractures were depressed, and three also had accompanying intracranial hemorrhage. Ten patients (3.7%) were admitted to the hospital, and all had skull fractures resulting from falls down stairs. Supervision was present in 78% of cases, including supervision by an adult in 69% of cases. Forty-five percent of families kept the walker, and 32% used the walker again for the study patient or another child after the injury episode. Fifty-nine percent of parents acknowledged that they were aware of the potential dangers of babywalkers before the injury event. Fifty-six percent of parents favored a national ban on the sale of walkers, and 20% were opposed.

CONCLUSION

Despite the currently used prevention strategies, including adult supervision, warning labels, care giver education programs, and stairway gates, serious injuries associated with babywalkers continue to occur to young children. The US Consumer Product Safety Commission should promulgate a rule, similar to the voluntary standard adopted in Canada, regarding design requirements for babywalkers that will prevent their passage through household doorways at the head of stairs. The manufacture and sale of mobile babywalkers that do not meet this new standard should be banned in the US. A recall or trade-in campaign should be conducted nationally to decrease the number of existing babywalkers.

Infant walker use, injuries, and motor development

OBJECTIVES

To study the impact of infant walker use on motor development and injuries.

POPULATION

One hundred and eighty five parents or primary care givers who attended a Singapore government polyclinic from September 1993 to February 1994, with their infants between 7 to 10 months, for a developmental assessment session.

SETTING

A government polyclinic in Singapore.

METHODS

The parent or primary care giver answered questions pertaining to infant walker use and injuries attributed to its use. Each infant was then given the Singapore modified version of the Denver Developmental Screening Test (DDST-S), along with a full clinical examination; both testers were blinded to walker use.

RESULTS

One hundred and sixty seven (90%) of 185 infants used walkers regularly, and 21 (12.5%) of the users had one or more injuries. Most injuries were minor, such as bruises and swellings on the head, forehead, face, and cheeks. None of the children who did not use walkers showed any abnormal DDST-S results whereas 18 (10.8%) of the 167 walker users had either abnormal or questionable DDST-S results.

CONCLUSIONS

12.5% of walker users had one or more injuries and walker use may also delay the child's motor development. These findings will help the physician or nurse in primary care settings to advise parents about the potential hazards of walker use.

Hazards of baby walkers in a European context

OBJECTIVES

To identify conditions related to baby walker injuries in a Greek population.

DESIGN

Analysis of all baby walker related injuries recorded during a 12 month period by the childhood injury surveillance system established in one of the two teaching hospitals for children serving the population of Athens.

SETTING

Emergency clinics of A Kyriakou Children's Hospital in Athens, Greece.

SUBJECTS

49 babies with baby walker related injuries brought to the emergency clinics during the period May 1994 to April 1995.

RESULTS

The incidence of these injuries was 16 per thousand person years of users, or 3.5 per thousand babies per year. More boys than girls were brought to the hospital for these injuries and the incidence density was highest during the ninth and 10th month of age. Falls from heights, particularly stairs, were the most frequent cause of baby walker related injuries, especially among younger babies. The majority of these injuries were of minor severity, but three babies had bone fractures and one had a second degree facial burn. Six babies required hospitalization and for seven others, a follow up visit was needed. The higher proportion of hospitalization among girls than boys raises the possibility that boys with minor injuries are more frequently brought to the hospital.

CONCLUSIONS

Baby walkers impart a significant risk of injury from a consumer product that provides no clearly identifiable benefit. As most baby walker injuries happen on stairs, modifications in product design are required to reduce these injuries. Moreover, parents should be forcefully advised of the risks and predisposing conditions, if baby walkers are to be used at all.

Attitudes to and use of baby walkers in Dublin

OBJECTIVES

To identify the rate of baby walker use, parental attitudes, and associated injuries.

DESIGN

Parents of babies attending clinics for developmental assessment were surveyed by self administered questionnaire about their use, attitudes, and history of injuries associated with walkers.

SETTING

Dublin, Ireland.

SUBJECTS

Parents of 158 babies.

RESULTS

Fifty five per cent of the sample used a walker. The main reasons for doing so included babies' enjoyment of them and the fact that the walker was used for an older sibling. Although none of the users listed safety concerns as a reason to stop using the walker, non-users (45%) did so; 12.5% of the users had at least one walker related injury.

CONCLUSIONS

Parents of babies who use a walker perceive them as beneficial. However these babies are placed at unnecessary risk. It behoves all health professionals and child carers to alert parents to these dangers and the sale of walkers should be reviewed.

Head injury and the use of baby walkers: a continuing problem

STUDY OBJECTIVE

To determine the frequency of baby walker use as a contributing factor in head injuries in children less than 2 years old.

DESIGN

Retrospective clinical review.

SETTING

Urban Level I trauma center and multispecialty clinic.

TYPE OF PARTICIPANTS

All children less than 2 years old who were evaluated for a head injury during a three-year period.

MEASUREMENTS AND MAIN RESULTS

129 patients' cases were reviewed. Walker-related injuries occurred in 19 of 129 patients (14.7%). This represents the third most common mechanism of injury in this age group. Mean patient age at the time of injury was 8.7 months. Of the 19 accidents involving walkers, 18 (94.7%) involved falling down stairs. Nine children (47.4% of all walker-related injuries) suffered fractures of the cranial vault. No patients required surgical intervention, although one required treatment for post-traumatic meningitis.

CONCLUSION

Baby walkers continue to be a frequent cause of head injury in this age group, and further efforts must be made to deal with these preventable injuries.

Baby walker related injuries--a continuing problem

Baby walkers have been associated with burns, head trauma and other types of injury. A retrospective study of all infants under the age of two years attending an accident and emergency unit demonstrated 22 injuries associated with baby walkers from a total of 1049 attendances. The most serious injuries were three skull fractures, with the most common mechanism being of a fall downstairs in the walker. Injury while in a baby walker occurred with a similar frequency to injury due to road traffic accidents. We conclude that despite previous warnings Baby Walkers still represent a considerable hazard to infants.

The physician's role in injury prevention: beyond the U.S. Preventive Services Task Force report

Injuries and their prevention have received little attention by the medical community, despite the fact that injuries are the leading cause of premature death. However, much can be done to reduce the number and severity of injuries, and the practicing physician has an important role to play in this process. This report outlines the U.S. Preventive Services Task Force report recommendations for prevention strategies to reduce injuries and then seeks to define a broader role for the physician in prevention injuries that extends beyond the confines of office-based practice. While screening and counseling have proven effectiveness in certain situations, interventions that are passive or automatic in action, such as air bags, have proven to be more effective long-term solutions to reduce both the number and the severity of injuries. The author outlines and provides examples of seven areas where physicians can have a major impact either directly or through implementing effective injury-control strategies. These are: treatment, education, screening, hazard identification, research, advocacy, and policy making. Using all of these approaches, physicians can play a truly effective role in reducing the burden of injuries for their patients.

Outcome of craniocerebral trauma in infants and children

The authors examined 927 patients affected by craniocerebral trauma and analyzed the neurological complications that occurred most frequently. The study confirmed that the percentage of craniocerebral trauma, gravity, and complications were different in relation to the sex and age of the patients. Based on this analysis, a correlation was made between the traumatic pathologies and socioeconomic-environmental conditions.

Baby walkers . . . time to take a stand?

Experience in our hospital and figures from the Home Accident Surveillance System indicate that the number of accidents involving baby walkers is increasing. Safety specifications issued by the British Standards Institution are rarely, if ever, met in full by manufacturers. Home accident prevention measures have been shown to be of limited benefit. We advocate more stringent implementation of safety features in the design of baby walkers.

The effects of babywalkers on early locomotor development

The mothers of 66 infants were interviewed to obtain information on their children's motor development. The children were divided into three groups according to the length of time they spent in a babywalker. There was no difference between the groups in age at onset of sitting or walking, but children in the high-user group showed a significant delay in onset of prone locomotion compared with the low-user and non-user groups. This suggests that for some infants the excessive use of babywalkers alters the pathway of normal locomotor development.

Injuries at play

The problem of toy-related injuries is a complicated one. The authors detail specific hazards related to toys, playgrounds, skateboards, and baby walkers. Guidelines are provided for toy suitability for children of all ages.

Falls in children and youth

Falls account for considerable morbidity in childhood. The importance of the surface that the child strikes is highlighted as well as the parents' perceptions of the seriousness of the fall. Recommendations for prevention are made.

A home injury prevention program for children

Most injuries to children under age five occur in the home. This article recounts the experience of an injury prevention project in developing and implementing an approach combining educational, regulatory, and technologic methods to reduce home injuries.

Baby walker-related injuries

A retrospective review of charts of patients with baby walker-related injuries presenting to a large urban emergency room over a 23-month period was undertaken. Ninety-seven percent of the children sustained injuries to their head or face. Sixty-eight percent of the injuries were the result of falling down steps. Twenty-two percent of the injuries required surgical or dental evaluation in addition to pediatric evaluation.