Injuries
Among
Preschool
Children
Enrolled
in
Day-Care
Centers
Albert
Chang,
MD, MPH,
Marlene
M. Lugg,
DrPH,
and
Archibald
Nebedum,
MPH
From the Divisions of Population and Family Health and Health Services Administration, School of Public Health, University of California, Los Angeles
ABSTRACT. In this study, 423 injury incidents among preschool children enrolled in day-care centers reported to the Los Angeles Unified School District during the 2-year period 1983 to 1984 are reviewed. The relative risk of sustaining an injury between boys and girls was 1.5:1. Among sex and age groups, younger boys (2 to 3 years of age) showed the highest injury rate and older girls (4 to 5 years of age) showed the lowest. The overall incidence was 19.7 injuries per 1,000 child-years. The majority of the injuries were minor in severity, and medical attention
was recommended in only 12.8% of the injuries. The
highest incidence occurred during the late morning period (9 AM to 12 noon). A consumer product was involved in 53.7% of the incidents. Three of four injuries were con-sidered preventable by training and/or education or by the Haddon injury reduction strategies. Additional pro-spective studies are needed to develop and implement preventive measures. Pediatrics 1989;83:272-277; injury, preschool-aged children, day-care center.
In the pediatric literature, much attention has
been given recently to childhood injuries, the
lead-ing cause of mortality in the United States between
1 to 15 years of age.”2 Among epidemiologic studies,
there have been excellent reports describing injury
morbidity at the state and county level,3’4 in school
systems,57 and in a juvenile penal institution.8 Yet,
relatively little has been written concerning injury
morbidity in another setting in which large
num-bers of children receive care: day-care centers. In
the reports in which this topic is considered, the
source of the data are small samples of children’1
Received for publication March 2, 1987; accepted Jan 21, 1988. Presented, in part, at the annual meeting ofthe American Public Health Association, Washington, DC, Nov 18, 1985.
Reprint requests to (A.C.) School of Public Health, University of California, Los Angeles, CA 90024.
PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the American Academy of Pediatrics.
(usually from one center), represent a highly
selec-tive sample of children (accident insurance claims),’2 or are based on a limited period of surveillance.13
The Los Angeles Unified School District in
Cal-ifornia, the second largest school district in the
nation, has operated a system of day-care centers
for families with preschool and school-aged children since 1946. At the time of this study, it operated 90
day-care centers (enrollment range: 30 to 200
chil-dren) that served more than 10,000 children of
preschool age (2 to 5 years) annually. The centers
are open from 6 AM to 6 PM on weekdays,
year-round. The adult caretakers are trained in first aid measures; the staff to child ratio is one adult
care-taker for eight preschool-aged children.
The purposes of this retrospective study were to
describe the epidemiology of children with reported
injuries in day-care centers and to determine the
types of injuries amenable to future preventive
measures.
METHODS
In the event of an injury or accident, teachers
and staff of the Los Angeles Unified School District
are required to complete a Pupil Accident Report
Form (PARF) describing any accident coming to
their attention, according to the following
guide-lines: (1) “Report all accidents however slight that occur on school property, in school building, on way to and from school, and in any activity under school
jurisdiction,” and (2) “Report must be filled out by
person under whose immediate jurisdiction the
ac-cident occurs.” (Los Angeles Unified School
Dis-trict, Confidential Report of Pupil Accident,
Octo-ber, 1981). A copy of each PARF is filed in the
district safety office.
A total of 423 PARFs involving children of
pre-school age (2 to 5 years) were collated from records
of this study, only forms involving preschool chil-dren enrolled solely in day-care centers during 1983
and 1984 were analyzed. We did not include in the
analysis PARFs of preschool children (including
handicapped children) attending special education
centers or of school-aged children attending the
day-care centers for only part of the day (before
and after-school care).
The PARFs were coded for demographic (age and
sex) characteristics of the child, day-care center
identification, and injury type and contributing
fac-tor. Data analysis was performed using the
Statis-tical Package for the Social Sciences.
RESULTS
PARF and Enrollment in Day-Care Centers
A total of 423 preschool PARFs (246 for 1983
and 177 for 1984) were identified, abstracted, and
analyzed, which represents 1.95% of the total of
21,675 (11,839 for 1983 and 9,836 for 1984) PARFs
for all ages in the school district during the 2-year
study period. The enrollment of the day-care
cen-ters was 21,435 children (10,641 in 1983 and 10,794
in 1984), which represented 1.94% of the total
1,106,992 children enrolled in the school district for
the 2 years. Thus, the number of PARFs in
day-care centers was proportional to the representation
of day-care center children in the overall school
district population.
The children served came from a multiethnic
population: 54.5% Hispanic, 32.6% black, 7.4%
white, 5.4% Asian, and 0.1% other. A single parent
was the head of household in four of five families
(81.7%). The families were of low income: 46.6%
and 33.8% of the children, respectively, qualified
for free or reduced cost lunches within federal
in-come guidelines.
Sex and Age of Children
Who Sustained
Injuries
Of the 423 injury events, 176 (41.6%) occurred in
girls and 245 (57.9%) in boys. The sex of two of the
children was not stated.
Because there exist differences in physical
devel-opment, ability, and type of play activities of the
young child (ages 2 to 3 years) compared with the
older child (ages 4 to 5 years, the children were
divided into two age groups: 219 (51.8%) aged 2 to
3 years and 197 (46.6%) aged 4 to 5 years. (In seven
children, age was not stated.)
Incidence
by Age Group and Sex of Children
and
by Day-Care Center
Incidence by age group and sex are shown in
Table 1. The rates by sex are approximations
be-TABLE 1. Incidence by Age Groups and Sex of the
Child*
Age (yr) Incidence
Girls Boys Both Sexes
2-3 20.6 32.7 26.5
4-5 12.8 17.1 14.9
All preschool 15.8 23.1 19.7
children
* Incidence is given as number of injuries per 1,000 child-years. In two injuries, the sex of the child was not stated,
and in seven injuries, the age of the child was not stated.
cause the enrollment numbers by sex are calculated
on the basis of sex ratios (51.3% girls v 48.7% boys) in the ten largest centers. The ratio of boys to girls is 1.5:1.0 (23.1 injuries per 1,000 child-years to 15.8
injuries per 1,000 child-years). The overall
mci-dence for all preschool-aged children of both sexes
based on 423 injuries and 21,435 children enrolled
was 19.7 injuries per 1,000 child-years.
Injury incidence was calculated for each of the 90
day-care centers. The range was from zero injuries
(15 centers) to 86.3 injuries per 1,000 child-years
(one center). The numbers of injuries ranged from
zero to 22 for the 2-year period. The day-care
cen-ters were grouped into three categories: small
(en-rollment of as many as 100 children: 21 centers),
medium (enrollment 101 to 150 children: 62
cen-ters), and large (enrollment 151 to 206 children:
seven centers). The mean injury rates for these
three categories were 18.8, 19.8, and 18.8 injuries per 1,000 child-years, respectively.
Injury Events by Month of Year and by Time of
Day
The injury events varied from a low of four in
February to a high of 68 in October. In general,
there were fewer injury events in the colder months
(November through March). (Fig 1). The greatest
number of injuries occurred between 10 and 10:59
AM (125 or 29.6%). The next largest group (75
events) occurred between 9 and 9:59 AM, followed
by the period between 3 and 3:59 PM (56 incidents).
If hours of day are grouped, the majority (55.5%)
of injuries occurred between 9 AM and 12 noon, the
late morning period (Fig 2).
Type of Activity
and Supervision
at Time of
Accident
Half (50.1%) ofthe injury events occurred during
“outdoor activity” within school hours. Organized
physical education activities, which accounted for
70
#{149}0 51- .
#{149}0
\ N
38 \
:
22t0 17\\\\
0
MONTH
Fig 1. Injury events by month of year (combined 1983 and 1984 events).
EARLY I
(6-9 .. LAW A IU<NOUN
(3-6 PM)
Site No. (%) of Injuries Head
“On head” 76 (16.5)
Forehead 73 (15.8)
Mouth 58 (12.6)
Face 48 (10.4)
Eye 29 (6.3)
Nose 23 (5.0)
Chin 15 (3.3)
Teeth 12 (2.6)
Tongue 5 (1.1)
Scalp 4 (0.9)
Neck 4 (0.9)
Ear 2 (0.4)
Total 349 (75.7)
Upper extremity
Finger 25 (5.4)
Arm 21 (4.6)
Elbow 4 (0.9)
Hand 4 (0.9)
Wrist 2 (0.4)
Total 56 (12.1)
Lower extremity
Leg 4 (0.9)
Ankle 4 (0.9)
Foot 2 (0.4)
Knee 1 (0.2)
Toe 1 (0.2)
Thigh 1 (0.2)
Total 13 (2.8)
Genitals 9 (2.0)
Other sites 23 (5.0)
Not stated 11 (2.4)
TABLE 2. Injury by Anatomic Site (N = 461)
NOT STATED 1.9%
EARLY AFTERNOON (12 NOON-3 P)
Fig 2. Injury events by time period of day.
“other”, 5.0% of the injuries; and “not stated,”
21.5% of the injuries. Of children (350) who
sus-tamed an injury, 82.7% were in a “supervised
situ-ation” at the time of the injury event. Supervision
was available in 79.5% and 85.3%, respectively, of
injuries involving girls and boys. Supervision was
approximately the same for younger and older
chil-dren (83.6% and 82.2%, respectively). In 15
bicycle-related injuries, however, 73.3% occurred in the
presence of supervision.
Types
of Injury and Anatomical
Site Involved
Some injury events included more than one
in-jury; thus, 500 injuries were reported. Seventy-nine
children suffered two injuries and two children had
three injuries. The leading types of injuries were
contusions, 238 (47.6%); laceration, 115 (23.0%);
abrasion, 54 (10.8%); inflammation, 25 (5.0%); frac-ture, 18 (3.6%); and other injuries, 32 (6.4%). In 18
(3.6%) injury events, the type of injury was not
specified and, in four (0.8%), there was no physical
injury involved. In some injury events, there was
more than one anatomic site involved, for a total
of 461 sites (Table 2). Thirty-five children suffered
injury to two sites, and three children had three
sites involved. The head and the upper extremities accounted for 87.8% of the sites involved.
Contributing
Factors
A total of 555 contributing factors were involved in the 423 events, an average of 1.3 contributing
factors per event. A contributing factor includes
direct involvement of an object and/or aggressive
behavior by another child or a child’s own action.
Two factors were noted in 128 events and three
factors in four of the events. In 82.2%, the child
was alone when injured, that is, no other child was involved in the events. These included falls (40%), collision with an object (33.5%), and others as noted
in Table 3. In only 15.8% of events was another
child involved by hitting or pushing (11.9%), throw-ing an object at the injured child (2.3%), or biting
the other child (1.6%). Five events could not be
classified into either “child alone” or “with another child” and, in six events, the person or contributing factor was not stated.
Severity
of Injuries
The action taken and recommendations for
the severity of the injury event. In three events
(0.7%), paramedics were called (one child had a seizure and fell, one child inserted a foreign body
in his nose, and one child’s genitals were caught in
the pants zipper). In 54 events (12.8%), medical
evaluation was recommended by the school
author-ities, and these are the cases labeled “serious” in
the analyses that follow. In the remaining events,
first aid only was considered sufficient treatment
in 357 injuries (84.4%) and no first aid was
consid-ered necessary in three injuries (0.7%). (No
rec-ommendation was stated in six injuries.)
Consumer
Product
Involved
In 228 injuries (53.7%), the involvement of some
type of consumer product (equipment or object)
was stated. The leading types of consumer products
involved were playground equipment, 142 (62.3%);
toys, 26 (11.4%); bicycles, 15 (6.6%); chairs, 12
TABLE 3. Children Involved and Con tributing Factor
Person(s) Involved and Contributing Factor
(N = 555)
No. (%)
Injured child alone involved Fall
Collision with object Compression-pinch Human self-bite Contact with equipment Other
Other child involved
Pushed or hit by another child Object thrown by hand
Human bite-another child
Other Notstated
456 (82.2) 222 (40.0) 186 (33.5) 19 (3.4) 11 (1.9) 8 (1.4) 10 (1.8) 88 (15.8) 66 (11.9) 13 (2.3) 9 (1.6) 5 (0.9) 6 (1.1)
(5.3%); tables, ten (4.4%); and rope, five (2.2%).
Other types of consumer product-related injuries
that accounted for 1% or less of these injuries
included stairs, desks, beds, and a milk carton.
Playground equipment accounted for 13 (72.2%) of
fractures, 82 (35.3%) of contusions, 35 (31.8%) of
lacerations, and six (16.7%) of the abrasions. Fails
were the preponderant contributing factor in
inju-ries involving playground equipment (65.5%),
ta-bles (60.0%), chairs (66.7%), and bicycles (60.0%).
PREVENTION
Three of four (75.7%) of the injuries (320) were
considered potentially preventable. We considered an injury preventable if it could have been avoided
by training and education or by one or more of the
Haddon counterstrategies (Table 4) that were
re-cently applied for poisonings by Trinkoff and
Baker.’4 Of those injuries considered preventable,
the mode of prevention considered most likely to
be successful included training and education in
190 injuries (44.9%) and “prevent the creation of
hazard” in 109 injuries (25.8%).
DISCUSSION
This study represents the first description of
reported injuries in a large population of preschool
children enrolled in a single system of day-care
centers. With the increased interest in the health
and safety issues in child day care, it provides new
information for further discussion and
investiga-tion.’5 Several limitations exist, however. It is not
possible to establish uniformity of reporting or of
TABLE 4. Suggested Strategies to Prevent Injuries
Strategies (N = 423) No. (%) Preventive Measures
Training and/or education 190 (44.9) Instruct children not to run
or jump in crowded areas; settle arguments or dis-putes via adult mediation
Prevent the creation of the hazard 109 (25.8) Do not install climbing
ap-paratus
Modify the rate or spatial distri- 14 (3.3) Modify release of door with
bution of the hazard from its spring release
source
Reduce amount of hazard that is 2 (0.5) Remove high surfaces that
created children can climb
Interpose a material barrier be- 2 (0.5) Cover electrical outlets
tween the hazard and that which is to be protected
Modify the relevant qualities of 2 (0.5) Cover sharp corners of
the hazard wooden or metal
furni-ture
Prevent the inappropriate release 1 (0.2) Repair faulty hinges of door
of a hazard
Not preventable 90 (21.3)
consideration of “severity” of the injuries in a ret-rospective study. Certain types of injuries may have
been reported by some centers but not by other
centers. In an earlier published report, Solomons et
al” admitted the tendency of “overreporting” even
the most minor injury. Turnover in personnel,
in-dividual motivations and understanding of
report-ing requirements, and other administrative
varia-tions also increase the possibility of lack of
uni-formity in reporting. Internal checks for
consistency in reporting as described by Boyce et
al,6 should be performed, but the opportunity to do
so in this study has passed. The lesser number of
accident reports in 1984 (177) compared with 1983
(246) when the enrollment was approximately the
same also raises the possibility of variation in
re-porting. On the other hand, it should be noted that
this study is based on statistics from a 2-year period
when the reporting requirements and practice had
been well established for more than 10 years. Unlike the study of Tokuhata et al,’6 in this study follow-up data for medical care and the costs of medical care were not available. It should also be noted that
the rates calculated are based on the assumption
that all children were enrolled in full-time day care.
Because 10% to 15% of the children were enrolled
less than full time, the calculated rates may
under-estimate the incidence of injuries.
Given these limitations, this study can still
pro-vide a useful perspective to the consideration of
injuries in day-care centers. Compared with three
recent epidemiologic studies involving school-aged
children6’7”7 in which overall injury rates of 49
injuries, 28.2 injuries, and 54 injuries per 1,000
child-years were shown, respectively, the reported
lower rate of 19.7 injury incidents per 1,000
child-years in this study suggests that day-care centers
are relatively safe settings for preschool children.
That day-care centers may be relatively safe
set-tings for children was also the conclusion of an
extensive childhood injury surveillance study in the
city of Goteborg, Sweden.’8 Westfelt reported 317
injuries in 6,753 preschool-aged children attending
day-care centers during a 12-month period, an
an-nual incidence of 46.9 injury incidents for 1,000
child-years. The annual incidence calculated in the
present study is 58% lower than that in the Swedish
study. In addition, when compared with incidence
from community studies (205 per 1,000 child-years
in Ohio4 and 176.9 per 1,000 child-years in
Massa-chusetts3), the present study rate (19.7 per 1,000
child-years) represents a small percentage (10% to
11%) when all injuries are considered and an even
smaller percentage (1%) when the 54 “serious”
in-juries are considered. Because the community
stud-ies are based on emergency room visits, the 54
“serious” injury incidents should be used in
corn-parisons. Even if one allows for the shorter
expo-sure time in the day-care centers, the injury rate is
still substantially lower.
Several findings of this study deserve comment.
The relative risk of sustaining an injury between
boys and girls is consistent with the extensive
lit-erature that shows higher incidence in both injury
mortality and morbidity in boys with increasing
age.’9 The finding that the proportion of 56% of
injuries occurring in the late morning (9 AM to
noon) suggests that this may be the time when
children are physically most active. The month of
October showed the highest occurrence of injury
events; this higher incidence early in the school
year was also noted in two previous reports of
school injuries by Dale et al2#{176}and Taketa.2’ Two possible explanations may be: (1) early in the school year, children may be relatively unfamiliar with the
school physical environment or (2) there may exist
greater motivation in the school staff to initiate
reporting of injuries at the beginning of the school
year. The preponderance of head and upper
extrem-ity injuries probably represents the anthropo-morphic features of young children, with relatively higher centers of gravity and higher liability to falls.
More than half of the injury incidents involved a
consumer product. In these cases, playground
equipment was involved in 62.3% of the incidents.
This category of consumer product may potentially
represent a higher risk to preschool children in
centers in general, because the Los Angeles Unified
School District has made a deliberate effort to
exclude certain potential injury-causing playground
apparatus: swings and slides (Jack Waldron,
per-sonal communication, July 1985). Climbing bars,
however, are being allowed in the centers at present. An important implication of this study is the
development of possible preventive measures. In
some injury incidents, the preventive measure is
simple and obvious: plugs should be used to cover
electrical outlets in the two instances in which
children inserted a metal object and were shocked.
In the case of climbing bars, a case could be made,
as with slides and swings, to exclude them from the
premises. Some child care personnel, however,
might object to this action as being too extreme. If
the sentiment to retain them prevails, at least
care-ful inspection for protruding metal objects or lack
of energy-absorbing surfaces should be done and
necessary improvements should be made.22 In
ad-dition, there may be need for increased adult
care-taker supervision (both in quality and quantity)
when children are engaged in more active physical
activities.
future training and education efforts should be
made. For example, when children inflict injury on
each other, either intentionally or nonintentionally,
adult caretakers may anticipate such behavior and
arrange for separation, for comfort, and for
“cool-ing” off (The Christian Science Monitor, March 10, 1986, p 37). Perhaps, with some children, education in nonviolent settlement of disputes or negotiation may be worth trying.
Of course, it may not be possible to prevent all
injuries in a setting in which young children
partic-ipate in a group. Other researchers have
acknowl-edged that mild injuries may serve some useful
purpose in the physical and mental development of
young children.23
Because there is probably a strong association
between physical characteristics of a center and
level of adult supervision and the incidence of
in-juries in day-care centers, one must use caution in generalizing the findings in this study to other
out-of-home day-care programs. The centers in this
study are well established, adequately funded, and
in conformity with federal and state regulations.24’25
The administrative exclusion of slides and swings
from the playground areas also may account for the
low incidence of injuries. The risks of injury may
be greater in other day-care centers with less adult supervision or those with more playground
struc-tures.
This study also cannot answer the question of
whether children enrolled in day-care centers
ex-perience more or less injuries than their
counter-parts cared for at home, because injuries at home
were not monitored and there was no comparison
group of children. Future studies are needed to deal
with these and related questions. This study never-theless provides some information concerning the
nature and circumstances surrounding injuries
in-volving preschool children in an existing large
sys-tern of day-care centers. It is intended to draw
attention to this topic and to stimulate future
pro-spective studies.26 In addition, the proposed
coun-termeasures cited here for reducing injuries may
stimulate future development of injury prevention
programs for children in day-care centers.
ACKNOWLEDGMENTS
This study was supported, in part, by a grant from the Committee of Research, Academic Senate, University of California at Los Angeles.
We thank Jack Waldron and Al Southwood of the Los
Angeles Unified School District for their cooperation and
Ana Zeledon Friendly, Taunya Smith, and Paul Garcia
for research assistance.
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