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Anotherbabywalker injuryvictim
Author: Carole C. A t k i n s o n , RN,C, MS, B o s t o n , M a s s a c h u s e t t s
302
No a d d i t i o n a l injuries w e r e i d e n t i f i e d d u r i n g the
a d m i s s i o n . After a n u n e v e n t f u l night, t h e b a b y w a s
a w a k e , alert, a n d d e m o n s t r a t i n g a g e - a p p r o p r i a t e
behavior. She h a d full r a n g e of m o t i o n w i t h no deform i t i e s of her e x t r e m i t i e s ; s h e w a s w a l k i n g , playing,
a n d m o v i n g freely in t h e crib w i t h o u t discomfort. She
w a s d i s c h a r g e d h o m e in t h e m o r n i n g , w i t h a h e m a t ocrit of 29%. T h e p a r e n t s w e r e a d v i s e d to s e e k followu p w i t h her p e d i a t r i c i a n a s needed.
A c c o r d i n g to s t u d i e s , 25% t o
50% of all b a b y - w a l k e r u s e r s
w i l l s u s t a i n a r e l a t e d injury.
T h r e e d a y s later t h e b a b y w a s referred b a c k to us
b y h e r p e d i a t r i c i a n for a n o r t h o p e d i c e v a l u a t i o n . The
baby's mother had reported that the baby was not
g r a s p i n g o b j e c t s or u s i n g her h a n d s to pull herself u p
s i n c e t h e fall. F o r e a r m r a d i o g r a p h s r e v e a l e d bilateral,
h e a l i n g , n o n d i s p l a c e d , distal r a d i u s fractures. T h e
f r a c t u r e s w e r e i m m o b i l i z e d w i t h c a s t s for s e v e r a l
w e e k s , a n d t h e r e w e r e no r e p o r t e d a d v e r s e s e q u e l a e .
Table i
Walker-related deaths: 1989-19931
Drownings
Suffocation (includes 1 walker seat failure)
Stair falls
Tip-over
Table 2
Walker-related m e c h a n i s m s of injury 8
Falls d o w n stairs
B e t w e e n levels
Basement stairs
Tip-overs
Burns
Other
Figure 1
40%
39%
3%
3%
15%
in t h e w a l k e r d u r i n g t h e fall, w i t h t h e h e a d e x p o s e d
a n d u n p r o t e c t e d . N i n e t y p e r c e n t of w a l k e r injuries
affect t h e h e a d or face. 5, 6 S i g n i f i c a n t h e a d t r a u m a ,
i n c l u d i n g skull fractures, i n t r a c r a n i a l h e m o r r h a g e s ,
a n d c o n c u s s i o n s , o c c u r s in o n e t h i r d of all walkerr e l a t e d injuries. T h e e x t r e m i t i e s w e r e i n j u r e d in 6% of
c a s e s , a n d t h e t r u n k in a p p r o x i m a t e l y 3% (Table 3). 6
Walker-related s t a i r w a y falls
result in t h e m o s t s e v e r e
injuries. T h e b a b y r e m a i n s
in t h e w a l k e r d u r i n g t h e fall,
with the head exposed and
unprotected. Ninety percent
of w a l k e r injuries affect t h e
h e a d or face.
JOURNAL OF EMERGENCYNURSlNG/Atkinson
Table 3
Baby w a l k e r - r e l a t e d injuries reported to CPSC
in 19941
Cases
Body part injured
Head
Face
Mouth
Eyeball
Ear
Neck
Shoulder
Hand
Lower arm
Upper arm
Wrist
Elbow
Foot
Lower leg
Upper leg
Lower trunk
Upper trunk
Internal
No.
13376
8079
2297
211
17
17
335
311
269
68
60
42
192
187
43
184
164
173
671
307
50
30
9
<1
<0.5
<0.5
1.24
1.15
1.0
<0.5
<0.5
<O.5
<1
<1
<0.5
<1
<1
<1
2.5
1.14
27006
100%
m e n d s t h a t p h y s i c i a n s c o u n s e l p a r e n t s on the risk of
injury from u s e of b a b y walkers7 The 1996 ENA G e n eral A s s e m b l y p a s s e d a resolution to incorporate b a b y
w a l k e r - r e l a t e d injury risks into ENA's Injury P r e v e n t i o n Position S t a t e m e n t .
Discussion
304
Figure 2
T h e r e d n e s s of t h e r i g h t forearm n o t e d b y t h e
t r i a g e n u r s e w a s n o t e v i d e n t on s u b s e q u e n t a s s e s s m e n t s a n d t h e r e f o r e w a s n o t followed u p w i t h r a d i o g raphy. T h e d i s c o v e r y of t h e b a b y ' s f o r e a r m f r a c t u r e s
c a u s e d us to r e v i e w our care. Should a f o r e a r m radiog r a p h h a v e b e e n o b t a i n e d ? If t h e p h y s i c a l a s s e s s ment had been more comprehensive, would the wrist
injuries h a v e b e e n d e t e c t e d ? W a s t h e b a b y ' s fussin e s s , i n t e r p r e t e d a s fear, a c t u a l l y p a i n ? Injuries m a y
b e m i s s e d in c h i l d r e n g i v e n their l i m i t e d ability to
c o m m u n i c a t e feelings a n d s e n s a t i o n s . It is p o s s i b l e
t h a t t h e f r a c t u r e s w o u l d h a v e b e e n m i s s e d , e v e n if
r a d i o g r a p h s h a d b e e n o b t a i n e d . Subtle c h a n g e s on
radiographs may be misinterpreted.
O n e m e t h o d of m i n i m i z i n g
m i s s e d injuries is to r o u t i n e l y
a s s e s s t h e b a b y ' s u s e of all
extremities as follows.
Observe the baby push the
u p p e r b o d y off t h e floor or
stretcher while prone.
O b s e r v e t h e b a b y ' s g r a s p of
a large, h e a v y o b j e c t , s u c h a s
a bottle; and a small light
o b j e c t , s u c h a s a rattle. N o t e
t h e b a b y ' s g r a s p of o b j e c t s
a n d t r a n s f e r f r o m h a n d to
h a n d . Pull a t o y f r o m e a c h of
the baby's clenched hands.
O n e m e t h o d of m i n i m i z i n g m i s s e d injuries is to
r o u t i n e l y a s s e s s t h e b a b y ' s u s e of all e x t r e m i t i e s a s
follows. O b s e r v e t h e b a b y p u s h t h e u p p e r b o d y off t h e
floor or s t r e t c h e r while prone. O b s e r v e t h e b a b y ' s
g r a s p of a large, h e a v y object, s u c h as a bottle; a n d a
small light object, s u c h a s a rattle. N o t e t h e b a b y ' s
g r a s p of o b j e c t s a n d transfer from h a n d to hand. Pull
a t o y from e a c h of t h e b a b y ' s c l e n c h e d h a n d s .
O b s e r v e t h e b a b y w i t h b o t h feet on a firm surface,
w h i l e g r a s p i n g t h e p a r e n t ' s fingers or t h e s i d e of a
crib or other safe, i m m o b i l e object. D o c u m e n t t h e
b a b y ' s p e r f o r m a n c e of e a c h activity. We r e v i e w e d this
e x p a n d e d a s s e s s m e n t w i t h our o w n staff after t h i s
case.
Injury p r e v e n t i o n e d u c a t i o n is v e r y i m p o r t a n t . A
crisis is n o t t h e m o s t effective t i m e to i n t r o d u c e inform a t i o n , so p r e p a r e a few h i g h - i m p a c t facts to deliver
in a n o n j u d g m e n t a l way. For e x a m p l e , d i s c u s s w i t h
t h e family t h e s u r p r i s i n g f a c t t h a t t h e r e are a n estim a t e d 30,000 ED visits a y e a r for b a b y w a l k e r - r e l a t e d
injuries. Tel1 t h e family t h a t t h e r e a r e s t a n d a r d s for
d e s i g n of b a b y w a l k e r s to p r e v e n t p i n c h e d fingers
a n d tip-overs, b u t no w a l k e r p r o t e c t s t h e b a b y from
falling over t h r e s h o l d s or d o w n stairs. R e m i n d t h e
family t h a t t h e r e is no p r o t e c t i o n for t h e b a b y w h e n
t h e w a l k e r e n a b l e s t h e b a b y to r e a c h u p a n d pull
d o w n h e a v y objects, t o u c h h o t objects, or i n g e s t toxic
s u b s t a n c e s , all of w h i c h w e r e p r e v i o u s l y i n a c c e s s i b l e .
Finally, tell families t h a t b a b i e s s h o u l d n e v e r b e left
u n a t t e n d e d in a w a l k e r a n d s t r o n g l y e n c o u r a g e families to d i s p o s e of t h e walker.
References
1. US Consumer Product Safety Commission. Baby Walkers;
Advance Notice of Proposed Rulemaking. Washington, DC;
1994; US Consumer Product Safety Commission 16 CFR part
1500.
2. American Academy of Pediatrics, Committee on Injury
and Poison Prevention. Injuries associated with walker falls.
Pediatrics 1995;5:778-80.
3. Chiavello CT, Christoph RA, Bond GB. Infant walkerrelated injuries: a prospective study of severity and incidence. Pediatrics 1994;6:974-6.
4. Parrington MD, Swanson JA, Meyer FM. Head injury and
the use of baby walkers: a continuing problem. Ann gmerg
Med 1991;6:652-4.
5. Trinkoff A, Parks PL. Prevention strategies for infant
walker-related injuries. Public Health Rep 1993;6:784-8.
6. US Product Safety Commission/Directorate of Epidemiology. Washington, DC: Estimates report source: National
Electronic Injury Surveillance System. 1994;2-7.
7. American Medical Association, Board of Trustees. Use of
infant walkers. Arch Pediatr Adolesc Med [Am J Dis Child]
1991 ;145:933-4.