ARE HOME ACCIDENTS IN CHILDREN PREVENTABLE?
Study
of 491 CasesBy JAMEs M. DENNIS, M.D.,* AND ALBERT D. KAISER, M.D.
Rochester, N.Y.
I
N THIS age of antibiotics and improvedpublic health practices, when a number
of infectious diseases have been reduced as
causes of illness and death in children and
adults alike, it is difficult to
overempha-size the importance of accidents in the
pedi-atric age range. Accidents have become the
leading cause of death in the age group of
1 through 14 years, killing more children
than the next six leading causes of death
combined. About two million child
acci-dents requiring medical aid occur in the
United States yearly.1
Home accidents in general are an
im-portant part of the total accident situation.
They are responsible for more than 30,000
deaths annually, and injure about 5 million
persons; the ratio of fatal to nonfatal
acci-dents being about 1 to 150.2
This survey was undertaken by the
Roch-ester Health Bureau in recognition of the
need for further study of nonfatal childhood
accidents in the home, an area with which
the Health Bureau, through the Public
Health Nurses and its health education
pro-gram, is intimately concerned. One purpose
was to determine and analyze the factors
involved in these accidents. A further
ob-jective was to attempt to decide what
pro-portion might have been prevented, and
what measures of prevention are most
ap-plicable and would yield the best results.
Studies by Prothro in Kalamazoo and
Rob-erts in Massachusetts have demonstrated
that local health bureaus can be effective
From the Rochester Health Bureau, in
coopera-tion with the Department of Pediatrics of the
Uni-versity of Rochester School of Medicine and
Dentistry, Rochester, N.Y.
(Received for publication Dec. 19, 1953.)
#{176}Rotating Inteme, Genesee Hospital, Rochester,
N.Y.
not only in the study of accidents in the
community, but also in their
METHOD
The period covered in this report is from
July 1, 1952 to May 1, 1953. The cooperation
of the 7 Rochester hospitals-Strong Memorial,
Municipal, Genesee, General, St. Mary’s,
Highland and Park Avenue-was obtained.
Small accident report cards were distributed
to the Emergency Rooms of the hospitals, to
be completed on all nonfatal accident cases
admitted, with the exception of traffic and
in-dustnial accidents. These cards gave brief
per-sonal information on the person injured, along
with the place, time, and nature of injury, and
a brief description of the accident.
Those cases involving persons under 19 yr.,
which occurred in the home or yard, and which
appeared likely to meet the definition of an
accident described by the National Safety
Council; that is, “any injury which causes an
interruption of normal activity for a period of
at least 24 hours,” were given to the Public
Health Nurses of the Bureau for further
in-vestigation. The nurses, and in some cases the
authors, went into the individual homes, and
using a longer form prepared for the purpose,
completed the information on each accident.
This form had 2 main parts; a written
descrip-tion of the accident, and a check list
subdi-vided under 8 headings, to insure uniformity
and completeness of recording. These
sub-divisions included location of the accident,
action of injured, type of accident, objects
in-volved, nature of injury, part of body injured,
and mechanical and personal factors involved.
Those cases which did not appear to constitute
an accident were then discarded.
Before tabulation, each case was evaluated
as to its preventability, using a group of
arbitrary criteria which will be discussed later.
The 2 groups, preventable and nonpreventable,
were then analyzed separately, to bring out
0-4
CHART 1. Age-Sex Relationship in Childhood Home Accidents in Series of 491 Nonfatal Cases
in Rochester, N.Y., in 1952-53. YEARS
15-18 \SSISIN
5-14
FEMALE
MALE
+ I I I
25 50 75 100 125
NUMBER OF ACCIDENTS
I-150 175
were made of age, sex, time of day and week,
significant factors present in the household,
and of the 8 subdivisions mentioned above.
The most obvious limitation of this approach
is that the group is not necessarily
representa-tive. Injured children who were treated at
home or by a private physician were not
in-eluded, because of the difficulty of getting
re-ports in these cases. The use of hospital
emergency rooms as a source tends to include
more persons of a low economic level, but at
the same time acts as a screen to eliminate
many minor incidents.
RESULTS
During the 10 month period covered by
this survey, a total of 491 nonfatal home
accidents involving children was collected
from the emergency room admissions of the
Rochester hospitals, and each one
com-pletely investigated. These form the
sub-stance of this report.
The age distribution and the relationship
to sex are shown in chart 1. Over half of the
accidents occurred in children under 5
years, and most of the remainder under 15
years. Boys outnumbered girls consistently,
taking the lead in all age groups.
Table 1 shows the time of occurrence of
accidents by day and by period of the day.
The ratio of weekday to weekend
acci-dents is not very different from that of the
number of days involved, indicating only
a slight increase on weekends, when
logi-cally they might be expected to go up. The
afternoon was the most dangerous time of
day, followed by the waking hours of the
evening. The sleeping hours were quite but
not entirely safe, and morning was only a
moderately hazardous period.
While inside the house children got into
trouble most often in the kitchen, but the
porch and yard were a source of even more
accidents, these two localities accounting
for more than half of the cases (chart 2).
The remainder of the accidents were spread
quite widely, with such supposedly
dan-gerous areas as bathroom and stairs
appear-ing relatively harmless.
TABLE 1
OCCURRENCE OF HOME ACCIDENTS BY DAY OR WEEK
AND PERIODS OF DAY, IN SERIES OF 491
NoN-FATAL CASES INVOLVING CHILDREN
No. of
cases
Per cent of total
Weekday Weekend
347 144
71% 29
6-12 noon 93 19
12 noon-6 p.m. 201 41 6-10 p.m.
10 p.m.-6 am. Unknown
157 23
17
32 4.7
Cl)
I-z w 9 .150
0 U
KITCHEN
O .100 QbWRS OTHER
SLEEPING QUARTER%TJRS
IlK
STEPS
CHART 2. Location of Childhood Home Accidents in Series of 491 Nonfatal Cases
in Rochester, N.Y., in 1952-53.
OTHER
570 JAMES M. DENNIS AND ALBERT D. KAISER
CHART 3. Types of Childhood Home Accidents in Series of 491 Nonfatal Cases
in Rochester, N.Y., in 1952-53.
PORCH AND YARD
Table 2 shows the activity of the child at
the time of injury. As might be expected
from a group consisting largely of young
children, more than half were hurt at play.
A much lesser number were injured while
walking or running. The “other” category
includes a diversity of things, such as
house-work, sleeping, climbing, bike riding, etc.
The relative frequency of the different
types of accidents is shown in chart 3. Falls,
as is usually the case, led all the rest, almost
half of the cases being of this type.
Han-dling objects and being struck by objects
POISONING
BURN
were the next most common types, with
stepping on objects, burns and poisoning
fol-lowing iii that order. Accidents involving
stepping are of note in that in more than two
thirds of these cases the object was a nail,
something which can usually be readily
re-moved. Poisons included turpentine, aspirin,
mothballs, phenol, brake fluid, arsenic,
ex-lax#{174}and a number of others. Most of the
burns were scalds from hot liquids spilled on
or by the child, often coffee or tea.
The objects involved were notable chiefly
by their variety (table 3). Household
fur-2
STEPPING ON OBJECT
STRUCK BY OBJECT
HANDLING OBJECT
FALL ON LEVEL
FALL FROM
TABLE 2
ACTIVITY AT TIME OF HOME ACCIDENTS, IN
SERIES OF 491 NONFATAL CASES INVOLVING CHILDREN
TABLE 3
OBJECTS INVOLVED IN hOME A(’CII)ENTS IN SERIES
OF 491 CASES IN CHILDREN
I
OTHER
No. of
cases
Per cent of
total
Playing 269 55%
Running 63 13
Walking 61 1
Other 98 0
nishings, actually a broad category, were
most often at fault, with broken glass
sec-ond but much less frequent. Drugs, nails,
tools, and hot liquids figured in a smaller
number of cases. Many other objects were
too varied to be grouped, and included such
things as fences, swings, golf clubs, stones,
ladders, etc.
The nature of the injuries sustained is
indicated in table 4. Cuts, lacerations and
abrasions were far and away the most
com-mon injury, occurring in half the accidents;
while fractures and dislocations were next
in incidence. Bruises and contusions, and
No. of cases
Per cent of total
Household furnishings and
equipment 108 22%
Broken glass 39 8
Drugs and chemicals 32 7
Nails 26 5
Tools and sharp objects 22 5
Hot liquids 18 4
Toys 13 3
Utensils 13 3
Slippery surface 13 3
Wheeled vehicles (bike,
strol-ler, etc.) 16 3
Other 116 23
None 75 14
burns were somewhat less common; with
poisoning, puncture wounds, and foreign
body making up most of the remainder.
The head was the part of the body most
often injured (37%), probably because of the
large number of falls and the awkwardness
DISORDER
I1M0R
USE
OF EQUIPMENT
I
IMPROPER EQUIPMENTI
HOUSE NEEDING REPAIR510 100 IO
2b0
2O
NUMBER
OF
ACCIDENTS
I
NONE
360
CHART 5. Personal Factors in Childhood Home Accidents in Series of 491 Nonfatal Cases in Rochester, N.Y., in 1952-53.
TABLE 4
NATURE OF INJURY IN HOME ACCIDENTS, IN SERIES
OF 491 CASES INVOLVING ChILDREN
No. of Per cent
occurrences of total
Cuts, lacerations and al)rasions 256 52%
Fracture and dislocation 72 15
Bruises and contusions 55 11
Burns 47 10
Poison 24 5
Puncture wounds 22 4
Foreign bo(ly 22 4
Other 13 3
of small children. Heads and arms were
each injured in about 17% of cases. Other
important areas were feet and toes, with
11%, and legs, with 8%. Injuries to the eye
occurred in only 15 cases.
Mechanical factors did not appear to be
involved in more than half of the accidents,
a surprising finding (chart 4). Disorder was
the most common factor, and usually meant
something out of place, as a nail on the
FATIGUE
EMOTIONAL
floor, broken glass in the yard, or poison
in an open drawer. Improper use of
equip-ment was a fairly common matter. Other
factors were of minor importance.
The personal factors at work are shown
in chart 5. An adult was thought to be at
fault in half of the cases, a critical factor in
prevention of childhood accidents. Hurry
and lack of knowledge were of secondary
importance, and other factors relatively
un-important. The emotional factor was the
most difficult to define, and was most
fre-quently applied to the “behavior problem”
-an unruly or disobedient child. No
per-sonal factor was apparent in a full third of
the cases.
Other factors which seemed to have a
bearing upon the accident were present in
about 13% of cases. Those were varied, and
included such things as: mother working
(15 cases), illness in family (9 cases), new
baby (7 cases), and a general upset of the
household occasioned by visitors or moving
to a new home (8 cases).
NONE
APPARENT
LACK
OF KNOWLEDGE
HURRY
CHILD
I
119 143
Ii 109
15 13 6
38 6 5 41%
51
4
4
TABLE 5
APPLICABILITY OF CRITERIA OF ACCIDENT PREVENTION, IN
SERIES OF 491 CASES INVOLVING ChILDREN
1. l)ue supervision by adult or older child 2. Use of reasonable precautions against accidents
a. Removal of dangerous objects b. Repair of home
d. Use of protective devices e. Other
3. Legal action on governmental level(as stricter dog laws)
4. Other (adequate housing, playgrounds or nurseries, medical therapy for illness
or disability, fire inspection, improved design of home or manufactured
product.) ii
No. of Per cent
cases of total
PREVENTABILITY
Each accident was evaluated as to its
preventability, on the basis of the criteria
listed in table 5. Two hundred and
eighty-four cases, or 58%, were considered to be
definitely preventable. This is far short of
the theoretic ideal of 100%, but is still
sub-stantial enough to be encouraging. It is
apparent that two methods-due
super-vision and reasonable precautions-were by
far the most pertinent, being applicable in
41% and 51% of the cases, respectively.
Under “Precautions,” the removal of a
dangerous object from the reach of a child
would have been most effective, and repair
of the home and the installation of
pro-tective devices considerably less so.
The comparative tabulation of
prevent-able and nonpreventable accidents revealed
a number of differences in the two groups.
The children who had nonpreventable
ac-cidents tended to be older, since more than
half of these were over 5 years; while more
than half of the other group were under 5
years. As to type of accident, burns,
poison-ing and stepping on objects were much
more common in the preventable group, as
were the corresponding types of injury;
while falls were appreciably more frequent
in nonpreventable accidents, and fractures
and dislocations a more common injury.
Similarly, glass, nails, hot liquids and
poi-sons were objects much more in evidence
in preventable accidents. This group was
also much more prone to involve mechanical
and personal factors, with disorder and
adult fault outstanding.
DIscussIoN
It might appear that in theory most
acci-dents are preventable, that the phrase, “It
was just an accident,” is self-contradictory. But the practical considerations of everyday
living in the home are such that children
cannot always be adequately supervised,
that not all potentially dangerous situations
anticipated; nor can all actions of an
ac-tively curious child be predicted. However,
much can readily be done to reduce home
accidents, and some of the findings of this
survey deserve consideration from this point
of view.
The age of a child has much to do with
the likelihood of his having an accident.
The younger the child, the more vulnerable
he is. Dietrich, in his discussion of a clinical
theory of accident prevention, emphasized
the need for total protection under one year,
with increasing use of education by the
parent as the child grows older.1 It also
seems that boys would bear watching more
than girls, since in both this and a recent
study by DeCrosse, boys were more prone
The importance of degree of activity and fatigue are reflected in the greater incidence
of accidents in the afternoon and evening, a
finding also confirmed by DeCrosse.5
Regu-lar rest periods for children may help them
to be safer.
The kitchen, where mother is usually
busy and dangerous objects abound; and
the yard, where close supervision is
diffi-cult, may be pinpointed as two particularlj
dangerous areas. Precautions with objects
and better supervision would make these
areas less hazardous.
There seems little to be gained from
re-vising the activities of children, since so
much of it is play. But the predominance of
falls, especially from a height, as a type of
accident, indicates the need for better
pro-tection in such places as bed, stairs and
steps, chairs and other furniture.
Although a wide variety of objects was
involved in this series, it is evident that
chil-dren can be protected from exposure to
several things which were responsible for
a considerable number of
accidents-namely, broken glass, nails, hot liquids and
poisons. Small children tend to gulp down
any substance which comes to hand, no
matter how distasteful it might seem to an
adult palate, and absolute protection seems
to be the only answer to the problem of
poisoning in this age group. This should
usually mean a lock and key-the lengths
to which a child will go to reach a
poison-ous substance are sometimes incredible.
The large number of cases in which an
adult was found to be at fault is a severe
indictment of the quality of parental care
-perhaps too severe, since this finding was
often a matter of judgment. It does
indi-cate, however, as DietricW has pointed out,
that the prevention of accidents in children
is largely an adult responsibility, not only of
parents but of physicians, health
depart-ments and other health agencies. It also
indicates the importance of education of
adults in furthering child safety. The
pin-pointing of dangerous locations, activities,
objects, types of accidents, and other
me-chanical and personal factors, as brought
out in this survey, enables the physician and
the nurse to give specific instruction in
ac-cident prevention to parents.
SUMMARY
A series of 491 nonfatal home accidents
involving children, occurring in a 10 month
period in the City of Rochester, New York,
is presented. These accidents were obtained
from hospital emergency rooms and
investi-gated by the authors and Public Health
Nurses. Of these 491 cases, 284, or 58%, were
judged to be preventable. Reasonable
super-vision by an adult, and the use of ordinary
precautions against accidents, were
out-standing as means of prevention. The
sta-tistically typical accident involved a boy
under the age of 5 years, who was playing
in the porch and yard in the afternoon, who
fell from a height and cut his head. No
mechanical factors were involved, and an
adult was at fault. Methods of prevention
of accidents are discussed.
ACKNOWLEDGMENTS
The authors are indebted to the following
persons and organizations for their advice
and cooperation:
The Public Health Nurses and Nursing
Supervisors of the Rochester Health
Bureau; the directors and emergency room
personnel of the Rochester Hospitals; and
to Mrs. Mary Karpiak Foster, Public Health
Educator; and Mr. Henry Lieberwurst,
Reg-istrar of Vital Statistics for the Health
Bureau.
REFERENCES
1. Dietrich, H. F., Clinical application of
theory of accident prevention in
child-hood, Am. J. Pub. Health 42 : 849, 1952.
2. Armstrong, D. B., Accident prevention, Pub.
Health Rep. 64:355, 1949.
3. Prothro, W. B., Home accident prevention
-research program, Am.
J.
Pub. Health41 :954, 1951.
4. Roberts, H. L., Community surveys its home
accidents, Am. J. Pub. Health 41:1118,
1951.
5. DeCrosse, J. J., Study of 212 home
acci-dents, New England J. Med. 248:837,
202 Brooks Avenue
SPANISH ABSTRACT
Son Prevenibles los Accidentes de los
Ni#{241}osen el Hogar ?
En esta #{233}pocade antibi#{243}ticos y de aplicaci#{243}n
de m#{233}todos de salubridad piblica que han
reducido los padecimientos infecciosos y las
causas de enfermedad en ni#{241}osy adultos,
re-salta ya la importancia de los accidentes en los
ninos, al grado de haber alcanzado el primer
lugar como causa de muerte en ni#{241}osde 1 a 14
aflos, COn cifras que sobrepasan Ia suma de las
siguientes seis causas de mortalidad infantil.
Los accidentes fatales a domicilio han llegado
en los Estado Unidos a ser 30,000 anualmente
y afectado a 5,000,000 de gentes, con una
relaci#{243}n de lo fatal a lo no fatal de 1 a 150. En
este artIculo los autores estudian y analizan los
factores de accidentes en Rochester, N.Y., y
tratan de investigar el porcentaje que pudo
prevenirse asI como los m#{233}todosaplicables para
evitarlos con los mejores resultados. El perlodo
abarc#{243}del lo. de julio de 1952 al lo. de mayo
de 1953 y reuni#{243}un total de 491 accidentes
a domicillio no fatales. Los datos se obtuvieron
de los servicios de emergencia de hospitales y
se investigaron por el autor y enfermeras
sani-tarias.
La mitad de los aeeidentes se presentaron
en ni#{241}osmenores de cinco a#{241}os,del sexo
mas-eulino pereferentemente, predominando
escasa-mente en los fines de semana y dentro del dIa
en Ia tarde y al principio de Ia noche. Dentro
del hogar los accidentes ocurrieron con mayor
frecuencia en la cocina, y ya afuera, en el
portal y el patio. Generalmente sucedieron
mientras jugaban los ni#{241}os,en la mayorIa de
las veces al caer bruscamente, manejar objetos,
golpearse con ellos, siendo las quemaduras y
las intoxicaciones de menor incidencia. Los
objetos caseros comprendidos fueron
funda-mentalmente muebles de la casa, vidrios rotos,
clavos y lIquidos calientes. El tipo de Ia lesion
que predomin#{243} fueron cortaduras, heridas,
raspones, en Ia mitad de los casos; las fracturas
y las dislocaciones en segundo lugar. La cabeza
ocupO el primer lugar en las partes del cuerpo
lesionadas y en seguida fueron los brazos. El
factor mec#{225}nico que predispuso m#{225}sde la mitad de los accidentes fue el desorden, a saber,
mala colocaciOn de objetos, como clavos sobre
el suelo y vidrios rotos en el patio. Los factores
personales dependieron fundamentalmente de
personas adultas, es decir, el error que llevO al accidente en el ni#{241}ofue en general culpa de
Un sujeto maduro; la ignorancia y Ia
precipi-taci#{243}nen las personas fueron factores secun-darios, como lo fueron tambi#{233}nel que Ia madre
trabajara, que hubiera enfermedad en la
famiia, etc.
De los 491 casos analizados, 284, es decir
58%, fueron considerados francamente evitables
por una vigilancia correcta y precauciones
razonables de parte de la gente. Los accidentes no evitables fueron en ni#{241}osmayores, en m#{225}s de la mitad con m#{225}sde 5 aflos de edad; en cam-bio los evitables se presentaron en m#{225}sde Ia mitad de los casos en ni#{241}osmenores de 5 a#{241}os.
Del grupo evitable ocuparon el primer lugar
las quemaduras, las intoxicaciones y los
tropie-zos por objetos mal colocados; mientras que
las caIdas y sus concecuencias (fracturas y dis-locaciones) fueron apreciablemente m#{225}s fre-cuentes en accidentes no evitables.
De estas observaciones se deduce que la
frase “Fu#{233}un accidente,” no es aplicable en
todos los casos. Mucho puede hacerse para
re-ducir los accidentes caseros: debe considerarse
la edad de los ni#{241}ospues entre m#{225}sjdven m#{225}s
vulnerables se encuentran; el grado de
activi-dad y de fatiga para regularlos; vigilarse mejor las cocinas y los patios, proteger a los niflos de las caldas y de objetos vulnerables como vidrios rotos, clavos, alfileres, etc., y por iltimo, hacer
ver a los adultos que ellos son los responsables