Playground hazards in Atlanta child care centers

A systematic review of the risk factors and interventions for the prevention of playground injuries

OBJECTIVES

The primary objectives of this work were to (1) identify the risk and/or protective factors associated with playground injuries among children less than 18 years of age and (2) identify interventions/programs/policies aimed at preventing playground-related injuries among children less than 18 years of age. Secondary objectives include a summary of the data that reflect alignment with current playground standards.

METHODS

For the primary outcome, 4 databases and 12 online resources were systematically searched to include observational and experimental studies examining risk and/or protective factors or interventions associated with playground injury or outcomes related to playground injury (e.g., risky playground behaviour). Data extraction included study design, participants, outcome, exposure or intervention, data analysis, and effect estimates. The quality of evidence for all studies was assessed using the Downs and Black criteria.

RESULTS

This review included studies of moderate quality, revealing a number of risk factors and effective interventions for playground injury. Risk factors included absence of handrails and guardrails on playground equipment, non-impact-absorbing surfacing, and critical fall heights. Effective interventions included modifying playground surfacing and reducing equipment height to less than 1.5 m.

CONCLUSION

Equipment- and structure-based playgrounds should adhere to and maintain playground standards in order to reduce the risk of serious injury. Organizations responsible for installing and maintaining playgrounds should consider alternative play spaces that allow children to play outdoors, in a natural environment that supports healthy child development and promotes physical activity.

Unintentional injuries in child care centers in the United States: a systematic review

The study systematically reviewed all types of unintentional injury and injury prevention research studies occurring within child care centers in the United States. A total of 2 reviewers searched 11 electronic databases to identify 53 articles meeting inclusion criteria. No studies used trauma registries or randomized control trials. Data were not pooled for further analysis because studies lacked standardized definitions for injury, rates, severity, exposure, and demographics. The following child care center injury rates were reported: (0.25-5.31 injuries per 100,000 child-hours); (11.3-18 injuries per 100 children per year); (6-49 injuries per 1000 child-years); (2.5-8.29 injuries per child-year); (2.6-3.3 injuries per child); (3.3-6.3 injuries per 100 observations); (635-835 medically attended injuries per year per 100,000 children and 271-364 child care center playground injuries per year per 100,000 children); and (3.8 injuries per child per 2000 exposure hours). Child care center injury rates were comparable to injury rates published for schools, playground, and summer camp. Most injuries were minor, while most severe injuries (fractures and concussions) were falls from playground structures. Future studies need to use standardized injury definitions and injury severity scales, focus efforts on preventing severe playground injuries in child care centers, and report child care parameters for inclusion in national injury databases.

Severity of playground-related fractures: more than just playground factors?

INTRODUCTION

Despite the establishment of playground safety standards, playground-related injuries are still a significant cause of extremity fractures in Singapore. This prospective study evaluates the dimensions and characteristics of our playgrounds, and their effect on fracture severity in an Asian population. We aim to correlate various playground risk factors with severity of the fractures and give recommendations on future safety standards. Our data also allows us to compare the demographics of patients in our study group with that collected in our earlier study in 2004.

METHODS

From June 2005 to 2006, children who presented with extremity fractures to KK Women's and Children's Hospital after a playground injury were enrolled. Their clinical data were collected prospectively. Relevant playground details were collected on-site independently by another investigator. For analysis of severity, fractures were "major" if they required reduction or operative fixation and were "minor" if they did not.

RESULTS

Supervision at time of injury, especially from the child's parents or siblings, resulted in a lower likelihood of "major" fractures (P=0.002, likelihood ratio=1.97). Conversely, supervision from grandparents or maids was found to result in a higher likelihood of "major" fractures. Increased weight of patients was directly related to severity of fractures (P=0.000), and a body mass index (BMI) of less than 19.8 kg/m resulted in lower likelihood of "major" fractures (P=0.010, likelihood ratio=2.22). Height of equipments and other playground-related factors were not linked to severity of fractures.

CONCLUSIONS

Supervision at the playground, preferably from the child's parents or siblings, and keeping a child's BMI within limits as guided by the BMI charts, may potentially reduce the occurrence of severe fractures.

LEVEL OF EVIDENCE

Level I-prognostic study.

Annual risk of death resulting from short falls among young children: less than 1 in 1 million

OBJECTIVE

The objective of the work was to develop an estimate of the risk of death resulting from short falls of <1.5 m in vertical height, affecting infants and young children between birth and the fifth birthday.

METHODS

A review of published materials, including 5 book chapters, 2 medical society statements, 7 major literature reviews, 3 public injury databases, and 177 peer-reviewed, published articles indexed in the National Library of Medicine, was performed.

RESULTS

The California Epidemiology and Prevention for Injury Control Branch injury database yielded 6 possible fall-related fatalities of young children in a population of 2.5 million young children over a 5-year period. The other databases and the literature review produced no data that would indicate a higher short-fall mortality rate. Most publications that discuss the risk of death resulting from short falls say that such deaths are rare. No deaths resulting from falls have been reliably reported from day care centers.

CONCLUSIONS

The best current estimate of the mortality rate for short falls affecting infants and young children is <0.48 deaths per 1 million young children per year. Additional research is suggested.

Risk factors for unintentional injuries due to falls in children aged 0-6 years: a systematic review

OBJECTIVE

To identify risk factors for unintentional injuries due to falls in children aged 0-6 years.

DESIGN

A systematic review of the literature.

METHODS

Electronic databases from 1966 to March 2005 were comprehensively searched to identify empirical research that evaluated risk factors for unintentional injuries due to falls in children aged 0-6 years and included a comparison group.

RESULTS

14 studies met the inclusion criteria. Studies varied by the type of fall injury that was considered (ie, bunk bed, stairway, playground or infant walker) and with respect to the quality of evidence. In general, major risk factors for the incidence or severity of injuries due to falls in children included age of the child, sex, height of the fall, type of surface, mechanism (dropped, stairway or using a walker), setting (day care v home care) and socioeconomic status.

CONCLUSION

Despite a high burden, few controlled studies have examined the risk and protective factors for injuries due to falls in children aged 0-6 years. The only study to examine falls from a population health perspective suggests that age, sex and poverty are independent risk factors for injuries due to falls in children.

Playground safety and access in Boston neighborhoods

BACKGROUND

Youth physical activity is partly influenced by access to playgrounds and recreational opportunities. Playgrounds in disadvantaged areas may be less safe.

METHODS

Investigators assessed safety at 154 playgrounds in Boston between July 2000 and July 2001. Playgrounds were geocoded and safety scores assigned to census block groups (CBGs). For each of Boston's 591 CBGs, investigators calculated the total number youth and proportions of black residents, adults without a high school degree, and youth living in poverty. Investigators assigned each CBG a safety score, and calculated distance from the CBG centroid to the nearest playground and nearest "safe" playground (top safety quartile). Statistical analyses were completed using SAS PROC GENMOD by October 2002.

RESULTS

In bivariate analysis, playground safety was inversely associated with total CBG youth population (p =0.001) and proportions of black residents (p <0.001), youth in poverty (p =0.003) and residents with no high school degree (p <0.002). The proportion of black residents in the CBG was inversely associated with safety (p =0.013), independent of CBG educational attainment and numbers of youth. The average distance was 417 meters to the nearest playground and 1133 meters to the nearest "safe" playground. Distance to the nearest playground was inversely associated with the proportion of residents with no high school degree (p <0.0001) after controlling for numbers of youth and proportion of black residents. CBGs with more youth had greater distances to the safest playgrounds (p =0.04).

CONCLUSIONS

In Boston, playground safety and access to playgrounds varied according to indicators of small-area socioeconomic and racial/ethnic composition.

Trends and patterns of playground injuries in United States children and adolescents

OBJECTIVE

To determine the prevalence, trends, and severity of injuries attributable to playground falls relative to other common unintentional mechanisms that resulted in an emergency department (ED) visit in the United States.

DESIGN AND SETTING

Data from the emergency subset of the National Hospital Ambulatory Medical Care Survey collected from 1992 to 1997 for children <20 years.

METHODS

Injury rates and 95% confidence intervals (CIs) were estimated and injury severity scores were computed.

RESULTS

There were 920551 (95% CI: 540803 to 1300299) ED visits over the 6-year study period by children and adolescents that were attributable to falls from playground equipment. The annual incidence of visits for playground injuries did not significantly decrease over the course of the study (187000 to 98000, P =.053). Injury visits for playground falls were twice as prevalent as pedestrian mechanisms, but they were less prevalent than visits for motor vehicle-- and bicycle-related injuries. A larger proportion of playground falls resulted in "moderate-to-severe" injury than did bicycle or motor vehicle injuries. Children aged 5 to 9 years had the highest number of playground falls (P =.0014). Playground falls were most likely to occur at school compared to home, public, and other locations (P =.0016).

CONCLUSIONS

Playground injury emergency visits have not significantly declined and remain a common unintentional mechanism of injury. Injury visits for playground falls were proportionally more severe than injury visits attributable to other common unintentional mechanisms. Interventions targeting schools and 5- to 9-year-old children may have the greatest impact in reducing emergency visits for playground injuries.

Surface characteristics, equipment height, and the occurrence and severity of playground injuries

OBJECTIVES

To evaluate whether surface characteristics (absorption level (g-max), material) and the height of play equipment are related to the occurrence and severity of injuries from falls.

SETTING AND METHODS

During the summers of 1991 and 1995, conformity of play equipment to Canadian standards was assessed in a random sample (n = 102) of Montreal public playgrounds. Surface absorption (g-max) was tested using a Max Hic instrument and the height of equipment was measured. Concurrently, all injuries presenting at the emergency department of Montreal's two children's hospitals were recorded and parents were interviewed. Inspected equipment was implicated in 185 injuries. The g-max measurements (1995 only) were available for 110 of these playground accidents.

RESULTS

One third of falls (35 %) occurred on a surface exceeding 200 g and the risk of injury was three times greater than for g level lower than 150 (95% confidence interval (CI) 1.45 to 6.35). On surfaces having absorption levels between 150 g and 200 g, injuries were 1.8 times more likely (95% CI 0.91 to 3.57). Injuries were 2.56 times more likely to occur on equipment higher than 2 m compared with equipment lower than 1.5 m. Analysis of risk factors by severity of injury failed to show any positive relationships between the g-max or height and severity, whereas surface material was a good predictor of severity.

CONCLUSIONS

This study confirms the relationships between risk of injury, surface resilience, and height of equipment, as well as between type of material and severity of injury. Our data suggest that acceptable limits for surface resilience be set at less than 200 g, and perhaps even less than 150 g, and not exceed 2 m for equipment height. These findings reinforce the importance of installing recommended materials, such as sand, beneath play equipment.

Injuries in child care centers: gender-environment interactions

OBJECTIVES

To examine child characteristics (age, gender) and child care center environments (socioemotional quality, physical safety) that jointly predict injuries for preschool children.

METHODS

A two year prospective study of 360 preschool children, ages 2-6 years, was conducted in four urban child care centers. Composite scores for center quality and physical safety were derived from on-site observations, and injury rates were based on teacher reports. Poisson regression analyses examined age, gender, center quality, center safety, and the interactions of gender with quality and safety as predictors of injury incidence over one child year.

RESULTS

Age was significantly associated with injury rates, with younger children sustaining higher rates. An interaction between gender and center quality also significantly predicted injury incidence: girls in low quality centers experienced more injuries, while girls in high quality centers sustained fewer injuries than their male peers. Finally, an interaction between gender and center safety showed that girls in high safety centers sustained more injuries than boys, while girls in low safety centers sustained fewer injuries.

CONCLUSIONS

Injuries occur even in relatively safe environments, suggesting that in child care settings, the socioemotional context may contribute, along with physical safety, to the incidence of injury events. Further, gender specific differences in susceptibility to environmental influences may also affect children's vulnerability and risks of injuries. The prevention of injuries among preschool children may thus require attention to and modifications of both the physical and socioemotional environments of child care.

A case-control study of risk factors for playground injuries among children in Kingston and area

OBJECTIVE

To determine the risk for injury associated with environmental hazards in public playgrounds.

SETTING

One hundred and seventeen playgrounds operated by municipalities or school boards in and around Kingston, Ontario, Canada.

METHODS

A regional surveillance database was used to identify children presenting to emergency departments who were injured on public playgrounds; each case was individually matched (by sex, age, and month of occurrence) with two controls--one non-playground injury control, and one child seen for non-injury emergency medical care. Exposure data were obtained from an audit of playgrounds conducted using Canadian and US safety guidelines. Exposure variables included the nature of playground hazards, number of hazards, frequency of play, and total family income. No difference in odds ratios (ORs) were found using the two sets of controls, which were therefore combined for subsequent analysis.

RESULTS

Multivariate analysis showed strong associations between injuries and the use of inappropriate surface materials under and around equipment (OR 21.0, 95% confidence interval (CI) 3.4 to 128.1), appropriate materials with insufficient depth (OR 18.2, 95% CI 3.3 to 99.9), and inadequate handrails or guardrails (OR 6.7, 95% CI 2.6 to 17.5).

CONCLUSION

This study confirms the validity of guidelines for playground safety relating to the type and depth of surface materials and the provision of handrails and guardrails. Compliance with these guidelines is an important means of preventing injury in childhood.

Council playgrounds in New South Wales: compliance with safety guidelines

Despite initiatives to improve the safety of play environments, playground-related injuries continue to be a major public health problem. Efforts to address playground safety in New South Wales were consolidated during 1994 through the Kidsafe Playground Safety Project. In stage 1 of the project (described here), 240 council playgrounds were assessed to determine the extent to which playground equipment complied with safety guidelines. On-site inspection of the selected playgrounds provided data on 862 separate pieces of playground equipment. Of the 723 pieces requiring undersurfacing, less than half (45.4 per cent) had the recommended type of undersurfacing while only 42 of those pieces had undersurfacing to the recommended depth. However, when the fall height of equipment was considered in addition to the undersurfacing guidelines, only 13 (1.8 per cent) of the 723 pieces of equipment simultaneously satisfied all of the safety guidelines. Regrettably, none of the 240 council playgrounds assessed complied fully with the key safety guidelines. The results underscore the need for a collaborative effort on the part of local government, Kidsafe and health promotion and regional public health units to ensure that council playgrounds in New South Wales comply with recommended safety guidelines.

Safety of surfaces and equipment for children in playgrounds

BACKGROUND

The safety of playgrounds is important to protect children from injury, but studies are mostly done mainly under laboratory conditions without epidemiological data. We investigated the safety of different playground surfaces, and types and heights of equipment in public playgrounds in the City of Cardiff, UK.

METHODS

We did a correlational study of 330 children aged between 0 and 14 years. All children were hurt when playing in playgrounds in Cardiff and presented to the Accident and Emergency Department in Cardiff Royal Infirmary during summer (April to September) 1992 and 1993, and the whole of 1994. We studied the children's hospital records to establish the type of injury and interviewed their parents to find out the playground and type of equipment involved. The main outcome measures were the number of children injured whilst playing, and injury rates per observed number of children on different surfaces, types, and heights of equipment.

FINDINGS

Children sustained significantly more injuries in playgrounds with concrete surfaces than in those with bark or rubberised surfaces (p < 0.001). Playgrounds with rubber surfaces had the lowest rate of injury, with a risk half that of bark and a fifth of that of concrete. Bark surfaces were not significantly more protective against arm fractures than concrete. Most injuries were equipment related. Injury risk due to falls from monkey bars (suspended parallel bars or rings between which children swing) was twice that for climbing-frames and seven times that for swings or slides. The height of the equipment correlated significantly with the number of fractures (p = 0.005) from falls.

INTERPRETATION

Rubber or bark surfacing is associated with a low rate of injuries and we support their use in all public playgrounds. Bark alone is insufficient, however, to prevent all injuries, particularly arm fractures. Rubberised impact-absorbing surfaces are safer than bark. We believe that playing on monkeys bars increases the risk of injury in playgrounds and that they should generally not be installed. Safety standards should be based on physical and epidemiological data. Our data suggest that the proposed raising of the maximum fall height from 2.5 m to 3.0 m in Europe is worrying.

A descriptive analysis of children's playground injuries in the United States 1990-4

OBJECTIVES

To review playground injury statistics over a five year period in order to develop an awareness of how and where children in the United States are being injured.

METHODS

All data are based on the United States Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) for playground related injuries during 1990-4. The surveillance data includes injuries recorded in more than 90 hospital emergency departments located throughout the United States.

RESULTS

Each year there are roughly 211,000 preschool or elementary school-children in the United States who receive emergency department care for injuries associated with playground equipment. On average, 17 of these cases result in death. 70% of all injuries occur on public playgrounds, with nearly one third classified as severe. Swings, climbers, and slides are the pieces of playground equipment associated with 88% of all NEISS reported injuries. Falls to the surface are responsible for 70%.

CONCLUSIONS

NEISS playground injury statistics contribute to our understanding of playground injuries. By identifying where and how children are injured, suggestions can be made in an attempt to make playgrounds safer.

A statewide survey of hazards in child care centers

OBJECTIVES

The purpose of this study was to determine adherence to selected recommended safety standards in North Carolina child care centers.

METHODS

A self administered questionnaire eliciting information about safety practices in child care was mailed to a randomly selected sample of 409 North Carolina child care centers.

RESULTS

One hundred and ninety five usable questionnaires were returned from child care centers in 75 counties. Results indicated that all of the standards included in the state's child regulations were being adhered to by at least 80% of the centers. However, adherence to recommended standards not included in the state's regulations was quite variable, with one standard implemented by less than 5% of the centers. The lowest rates of adherence were found for standards specifying that resilient surface material be used under playground equipment (4%) and that certain foods that may present a choking hazard to small children not be served (27%).

CONCLUSIONS

Many hazards not addressed in North Carolina child care regulations are present in child care centers. Some safety standards are not adhered to due to lack of knowledge or limited resources. Inclusion of national standards in state child care regulations appears to reduce, but not eliminate, the likelihood of hazards being reported. Further research should include on-site inspections and attention to safety in family child care.

Height and surfacing as risk factors for injury in falls from playground equipment: a case-control study

OBJECTIVES

Despite the widespread promotion of safety standards no epidemiological studies have adequately evaluated their effectiveness in preventing injury in falls from playground equipment. This study evaluated the effectiveness of the height and surfacing requirements of the New Zealand standard for playgrounds and playground equipment.

SETTING

Early childhood education centres and schools in two major cities in the South Island of New Zealand.

METHODS

Data were collected on 300 children aged 14 years or less who had fallen from playground equipment. Of these, 110 (cases) had sustained injury and received medical attention, while 190 (controls) had not sustained injury requiring medical attention.

RESULTS

Logistic regression models fitted to the data indicated that the risk of injury being sustained in a fall was increased if the equipment failed to comply with the maximum fall height (odds ratio (OR) = 3.0; 95% confidence interval (CI) 0.7 to 13.1), surfacing (OR = 2.3; 95% CI 1.0 to 5.0), or safe fall height (OR = 2.1; 95% CI 1.1 to 4.0) requirements. Falls from heights in excess of 1.5 metres increased the risk of injury 4.1 times that of falls from 1.5 metres or less and it was estimated that a 45% reduction in children attending emergency departments could be achieved if the maximum fall height was lowered to 1.5 metres.

CONCLUSIONS

Although the height and surfacing requirements of the New Zealand standard are effective in preventing injury in falls from playground equipment, consideration should be given to lowering the maximum permissible fall height to 1.5 metres.

Injuries and their relation to potential hazards in child day care

OBJECTIVES

To prospectively determine the incidence rate of injuries that required medical attention among children in day care and to identify possible hazards related to these injuries.

SETTING

King County, Washington.

METHODS

Prospective cohort study of children in a sample of licensed day care facilities.

RESULTS

From 1 July 1992 to 30 June 1993, 53 medically attended injuries were reported by 133 day care sites; incidence rate 1.9 per 100,000 hours of day care attendance. The rate of injury in 91 small family day care homes was essentially the same as that in 42 larger day care centers; relative rate 1.0 (95% confidence interval 0.6 to 1.9). Injuries that required sutures accounted for 39% of the cases, while 17% required a cast, splint, or sling. No child was hospitalized. Sixty nine sites were inspected and all had potentially correctable physical hazards, with a median of 15 hazards per site (range 7 to 26). These potential hazards had little relationship to the risk of injury and a case-by-case review identified only two injuries that might have been prevented by a more energy absorbent playground surface.

CONCLUSIONS

The incidence of medically attended injuries found in this study is consistent with other studies from the United States. Most injuries were minor and had little relation to physical hazards at day care locations.

The compliance of licensed US child care centers with national health and safety performance standards

The American Public Health Association and the American Academy of Pediatrics recently published health and safety guidelines for child care centers. A survey was conducted to determine the extent to which practices in US child care centers are reflective of these guidelines. Compliance with 16 guidelines ranged from 19.5% to 98.6%, varied considerably by state, and was not consistently associated with selected center characteristics. Prevention efforts should focus on practices for which compliance is low and on those that have the greatest disease- and injury-reducing potential.

Creating a safe environment for children in daycare

Injuries represent the leading cause of death for children older than age one. Likewise, some 22 million children are injured each year, with more than 1 million requiring medical treatment. More than 40% of children currently receive full-time or part-time day care, but little research has examined the status of injuries to children in daycare. This paper provides information on the nature and extent of injuries to children, and contributing factors responsible for those injuries. One case study of research on injuries in Minneapolis, Minn., daycare centers is discussed. Recommendations for action are offered.

The risk of childhood injury on Boston's playground equipment and surfaces

The Childhood Injury Prevention Program of the Boston Department of Health and Hospitals conducted a survey of injury risk in Boston's playgrounds. A standardized checklist was used to assess a 25% sample of public playgrounds for hazards. Climbers accounted for 34% of the hazards observed and had the greatest proportion of significant hazards. The surfacing material in 100% of the playgrounds observed was unsafe. Urban children risk exposure to hazardous playground equipment frequently situated above unsafe surfacing material.

Surface-specific fall injury rates on Utah school playgrounds

The purpose of this study was to estimate surface-specific rates of fall injuries on school playgrounds. Playground injuries related to falls from climbing equipment and the surfaces involved were identified from injury reports for 1988 to 1990 from 157 Utah elementary schools. Enrollment data and playground inspections were used to estimate student-years spent over each surface. The fall injury rates per 10,000 student-years were asphalt, 44; grass, 12; mats, 16; gravel, 15; and sand, 7. These data did not show that impact-absorbing surfaces reduce fall injuries on playgrounds better than grass. Improved field studies are needed to guide policy decisions for playground surfacing.

Evaluation of an intervention to reduce playground hazards in Atlanta child-care centers

In 1988, we identified playground hazards at 58 child-care centers (CCCs) and intervened by showing the director the hazards and distributing safety information. In 1990, we evaluated the 58 intervention CCCs as well as 71 randomly selected control CCCs. Intervention centers had 9.4 hazards per playground; control centers had 8.0. We conclude that the intervention was ineffective.

Analysis of US child care safety regulations

BACKGROUND

With 1.9 million US children cared for in organized group child care, the safety of these children is a public health concern. In the absence of federal policy, each state has developed its own day care safety regulations.

METHODS

After creating a set of 36 criteria from three sets of national guidelines, we assessed the safety regulations of 45 states. With a mailed survey of state day care regulatory personnel, we examined the processes of formulating and implementing safety policy in 47 states.

RESULTS

For 24 of the 36 items, more than half the states' regulations were below the criteria or failed to mention the topic. Most notable is the inattention to playground safety, choking hazards, and firearms.

CONCLUSION

The uneven quality of regulations may be a reflection of a regulatory process that is fragmented, with many different groups sharing authority and with limited involvement of injury prevention specialists.