Chaudhary et al.

Injury Epidemiology 2018, 5(Suppl 1):7

https://doi.org/10.1186/s40621-018-0147-x

RESEARCH Open Access

Pediatric falls ages 0–4: understanding

demographics, mechanisms, and injury
severities
Sofia Chaudhary1*, Janet Figueroa2, Salah Shaikh3, Elizabeth Williams Mays4, Rana Bayakly5, Mahwish Javed6,
Matthew Lee Smith7,8,9, Tim P. Moran10, Jonathan Rupp10 and Sharon Nieb10
From 22nd Annual Injury Free Coalition for Kids® Conference: Forging New Frontiers: Moving Forward with Childhood Injury
Prevention
Fort Lauderdale, Florida, USA. 01-03 December 2017

Abstract
Background: Pediatric unintentional falls are the leading cause of injury-related emergency visits for children
< 5 years old. The purpose of this study was to identify population characteristics, injury mechanisms, and injury
severities and patterns among children < 5 years to better inform age-appropriate falls prevention strategies.
Methods: This retrospective database study used trauma registry data from the lead pediatric trauma system in
Georgia. Data were analyzed for all patients < 5 years with an international classification of disease, 9th revision,
clinical modification (ICD-9 CM) external cause of injury code (E-code) for unintentional falls between 1/1/2013 and
12/31/2015. Age (months) was compared across categories of demographic variables, injury mechanisms, and
emergency department (ED) disposition using Kruskal-Wallis ANOVA and the Mann Whitney U test. The
relationships between demographic variables, mechanism of injury (MOI), and Injury Severity Score (ISS) were
evaluated using multinomial logistic regression.
Results: Inclusion criteria were met by 1086 patients (median age = 28 months; 59.7% male; 53.8% White; 49.1% < 1 m
fall height). Younger children, < 1-year-old, primarily fell from caregiver’s arms, bed, or furniture, while older children
sustained more falls from furniture and playgrounds. Children who fell from playground equipment were older
(median = 49 months, p < 0.01) than those who fell from the bed (median = 10 months), stairs (median = 18 months),
or furniture (median = 19 months). Children < 1 year had the highest proportion of head injuries including skull fracture
(63.1%) and intracranial hemorrhage (65.5%), 2-year-old children had the highest proportion of femur fractures (32.9%),
and 4-year-old children had the highest proportion of humerus fractures (41.0%). Medicaid patients were younger
(median = 24.5 months, p < 0.01) than private payer (median = 34 months). Black patients were younger (median =
20.5 months, p < 0.001) than White patients (median = 29 months). Results from multinomial logistic regression models
suggest that as age increases, odds of a severe ISS (16–25) decreased (OR = 0.95, CI = 0.93–0.97).
Conclusions: Pediatric unintentional falls are a significant burden of injury for children < 5 years. Future work will use
these risk and injury profiles to inform current safety recommendations and develop evidence-based interventions for
parents/caregivers and pediatric providers.
Keywords: Falls, Unintentional, Pediatrics

* Correspondence: [email protected]
1
Division of Emergency Medicine, Children’s Hospital of Philadelphia,
Philadelphia, PA, USA
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 78 of 87

Background identify trends and patterns from these data to make rec-
Unintentional falls were the leading cause of nonfatal ommendations for age-directed fall prevention education
injury among children 0–4 years old from 2000 to 2015 in and interventions.
the United States (Centers for Disease Control and
Prevention, 2017a). Over the past decades, both national Methods
and local childhood injury prevention efforts have pro- A retrospective analysis was performed on trauma registry
vided education and interventions in an effort to reduce data for children ages 0–4 years presenting to Children’s
these injuries. Amongst the successful local programs Healthcare of Atlanta (CHOA) with a fall-related injury
were the “Children Can’t Fly” and “Kids Can’t Fly” cam- between January 1, 2013 and December 31, 2015. CHOA,
paigns in New York City and Boston, respectively. Within the lead pediatric referral center for the state of Georgia, in-
the first 10 years of implementation, these public health cludes two tertiary free-standing pediatric trauma hospitals:
campaigns resulted in up to a 96% reduction of window level 1 (regional) and level 2 (suburban). Data extraction
falls for children < 5-years-old (Harris et al., 2011). Na- was based on chief complaint of fall injury and international
tionally, the American Academy of Pediatrics (AAP) has classification of disease, 9th revision, clinical modification
been at the forefront of providing pediatric caregiver and (ICD-9 CM) unintentional fall-related external cause of
community education as well as fall prevention strategies injury codes (E-codes) (Additional file 1). Patients were ex-
through Council on Injury, Violence, and Poison Preven- cluded if they showed evidence of child abuse (i.e., by diag-
tion (COIVPP) policy statements about injuries associated noses code or by documentation of diagnosis of child abuse
with infant walkers, shopping carts, trampolines, and falls or high suspicion of child abuse by child advocacy team in
from heights (American Academy of Pediatrics, 2001a; the medical record). Human studies approval was granted
American Academy of Pediatrics, 2006; American Acad- by the CHOA Institutional Review Board.
emy of Pediatrics, 2012; American Academy of Pediatrics, CHOA trauma registry inclusion criteria during the
2001b). Despite these injury prevention efforts, uninten- study period followed National Trauma Data Standard
tional pediatric falls have remained a significant cause of Dataset (NTDSD) standards, which indicated all pa-
injury, medical morbidity, and cost to the healthcare tients: 1) Sustained a traumatic injury and had at least
system in the youngest population. According to the one of the following injury ICD-9 CM diagnosis codes
Centers for Disease Control and Prevention, in 2010, un- (800.00–959.9); 2) Be either admitted for 23 h or trans-
intentional falls in children < 5 years led to 1,077,652 ferred to/from another facility (regardless of length of
emergency department (ED) visits with lifetime medical stay [LOS] or discharge from ED), died (regardless of
costs of over 2.5 billion dollars as well as 22,451 hospitali- LOS), admitted to the ICU (regardless of LOS), dead on
zations with lifetime medical costs of over 750 million dol- arrival, or have an unscheduled readmission associated
lars (Centers for Disease Control and Prevention, 2017b). with trauma within 72 h of discharge from the first visit.
These data exemplify the magnitude of the financial and Patients evaluated in the ED, not transferred from an-
medical burdens caused by pediatric fall-related injuries. other institution, and discharged home are not included
Prior studies on pediatric falls have evaluated specific in the trauma registry. Exclusion criteria for NTDSD in-
mechanisms of falls (windows, stairs, furniture) (Harris et cluded having the following ICD-9 CM diagnosis codes:
al., 2011; Pressley & Barlow, 2005; Zielinski et al., 2012; 905–909 (late effects of injury), 910–924 (blisters, contu-
Pomerantz et al., 2012; Kendrick et al., 2015; Kendrick et sions, abrasions, and insect bites), and 930–939 (foreign
al., 2016) or specific injuries sustained (head injury) (Love bodies). CHOA trauma registry data contained 70% of
et al., 2009; Ibrahim et al., 2012). Few population-based the state pediatric falls injury-related patients included
studies have examined overall risk factors and injury in the Georgia Central Trauma Registry Database
mechanisms for falls as a function of age (Khambalia et (GCTR) for the same age group during our study period.
al., 2006; Pitone & Attia, 2006; Unni et al., 2012; Wang et GCTR is a statewide trauma database that follows
al., 2013). Fall injury prevention efforts are enhanced when NTDSD inclusion criteria and collects trauma registry
population risk factors, typical injury mechanisms, and in- data from all level (I through IV) trauma centers across
jury patterns according to developmental age are used to the state.
provide targeted recommendations. Better understanding A standard dataset was extracted from the CHOA
of expected injury patterns from fall mechanisms can trauma registry including demographic variables (age,
guide clinicians to distinguish between child abuse and gender, race, ethnicity, payer, street address, and zip code)
unintentional injuries (Thompson et al., 2013). and non-demographic variables (medical record number
The primary objectives of our study were to examine [MRN], height of fall, MOI, injuries sustained, procedures
population characteristics, mechanisms of injury (MOI), in- performed, Injury Severity Score [ISS], and ED dispos-
jury patterns, and injury severities from falls among chil- ition). MOI, injuries sustained, and procedures performed
dren < 5-years-old. The secondary objectives were to were extracted from ICD-9 CM E-codes included in the
Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 79 of 87

trauma registry. Payer (Medicaid, private, or other primary square or Fisher’s exact tests. Continuous variables were
insurance) was selected as proxy for socioeconomic status compared using Mann-Whitney U tests for two-level
(SES). Fall injury mechanisms were differentiated using variables and Kruskal-Wallis ANOVA for three or more
the following distinctions: falls on the same level versus level variables. Post-hoc comparisons using adjusted stan-
multilevel falls or falls from stair/steps, falls from house- dardized residuals (z) and Bonferroni correction were con-
hold furniture versus falls from stairs/steps or playground, ducted if omnibus p-values were significant (i.e. p < 0.05)
and low versus high height falls. These distinctions were in order to determine the sources of significant differences
made to identify age-associated risk factors, injury trends, between variables with 3+ response categories (Agresti,
and provide targeted falls prevention recommendations. 2007; Garcia-Perez & Nunez-Anton, 2003; Beasley &
Thus, MOI was subcategorized into general MOI (fall on Schumacker, 1995). To identify potential age-specific high-
same level, fall from stairs/steps, multilevel fall, or other) risk populations, age was assessed as a continuous variable
and specific MOI (fall from bed, furniture, stairs, play- (in months). Results were reported as medians due to
ground, or other) through coding by keyword search from non-normal distributions. A multinomial logistic regres-
the initial MOI ICD-9-CM E-codes (Additional file 1) sion model was used to predict the odds of a moderate or
pulled from the trauma registry. Medical records were in- severe ISS score relative to a mild score (odds ratios (OR)
dividually reviewed to investigate circumstances around and 95% confidence intervals (CI) are presented). Multi-
falls and general MOI were further characterized by age nomial logistic regression was used because the propor-
according to narratives and by product coding (Additional tional odds assumption for ordinal regression was not met.
file 1). Height of fall was grouped into 4 categories (< 1 m Variables included in the multivariate model were age,
[< 3.3 ft], 1 m-6 m [3.3 ft–19.6 ft], > 6 m [> 19.6 ft], and gender, race, SES, and MOI.
unknown height) ranging from low-level fall to high-level
fall. The Injury Severity Score (ISS) is an established scor- Results
ing system used to calculate trauma severity by trauma During the three-year period, 1086 patients 0–4 years
services and is based on the sum of the squares of the old with a fall-related injury were included in the CHOA
highest Abbreviated Injury Score (AIS) for the three most trauma registry and met study criteria. The majority of
severely injured body regions (Baker et al., 1974). Severity patients (n = 606, 55.8%) presented to the level 2 (subur-
of injury was trichotomized based on standard ISS ban) pediatric trauma center and 44.2% (n = 480) pre-
categories: mild (1–8), moderate (9–15), moderate/severe sented to the level 1 (regional) pediatric trauma center.
(16–25), and severe/critical (25+). There were no fatalities.
All statistical analyses were performed on de-identified
data using SAS 9.4 (Cary, NC) and SPSS (v. 24; Armonk, Demographics
NY). Descriptive statistics including medians and counts/ Tables 1 and 2 present sample demographics by age. The
frequencies were reported for variables of interest (listed majority of falls patients were male (n = 648, 59.7%), White
above). Categorical variables were compared using the chi- (n = 584, 53.8%), non-Hispanic (n = 944, 86.9%), and on

Table 1 Demographics for falls population in years, ages 0–4 (2013–2015)

Demographics All patients (N = 1086) Age < 1 (N = 326) 1 year (N = 150) 2 year (N = 209) 3 year (N = 181) 4 year (N = 220)
Gender
Male n(%) 648 (59.7%) 189 (58.0%) 94 (62.7%) 132 (63.2%) 109 (60.2%) 124 (56.4%)
Female n(%) 438 (40.3%) 137 (42.0%) 56 (37.3%) 77 (36.8%) 72 (39.8%) 96 (43.6%)
Race
White n(%) 584 (53.8%) 156 (47.9%) 77 (51.3%) 116 (55.5%) 103 (56.9%) 132 (60.0%)
Black n(%) 334 (30.8%) 130 (39.9%) 47 (31.3%) 63 (30.1%) 47 (26.0%) 47 (21.4%)
Other n(%) 168 (15.5%) 40 (12.3%) 26 (17.3%) 30 (14.4%) 31 (17.1%) 41 (18.6%)
Ethnicity
Hispanic n(%) 142 (13.1%) 32 (9.8%) 26 (17.3%) 25 (12.0%) 26 (14.4%) 34 (15.5%)
Non-Hispanic n(%) 944 (86.9%) 295 (90.5%) 124 (82.7%) 184 (88.0%) 155 (85.6%) 186 (84.5%)
Primary Payer
Medicaid n(%) 718 (66.1%) 246 (75.5%) 107 (71.3%) 132 (63.2%) 110 (60.8%) 123 (55.9%)
Private n(%) 269 (24.8%) 69 (21.2%) 24 (16.0%) 53 (25.4%) 46 (25.4%) 77 (35.0%)
Other n(%) 99 (9.1%) 11 (3.4%) 19 (12.7%) 24 (11.5%) 25 (13.8%) 20 (9.1%)
Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 80 of 87

Table 2 Age (months) by demographics, disposition, MOI, and ISS Medicaid insurance (n = 718, 66.1%). The median age of
Predictor % of Total Median SIQR p*,a
patients was 28 months. Black patients were significantly
sample Age (M) younger than White patients (median = 20.5 months vs. me-
Sex .69 dian = 29 months). Medicaid patients were significantly
Male 59.7 27.0 17.0 younger than private payer patients (median = 24.5 months
Female 40.3 28.0 18.0 vs. median = 34 months). In post-hoc analyses (tables not
shown), Black patients were less likely to be on private insur-
Payer <.001
ance than Medicaid (14.6% vs. 38.3%, z = − 6.7 vs. + 6.3,
Medicaid 66.1 24.5 16.5
respectively). Conversely, White patients were more likely to
Private 24.8 34.0 19.5 be on private insurance than on Medicaid (77.5% vs. 46.1%,
Other 9.1 32.0 13.0 z = + 8.8 vs. -8.5, respectively). For comparisons by primary
Race <.001 payer and comparisons by race there were no significant
Black 30.9 20.5 16.0 differences in gender, mechanisms of injury, or ISS level.
White 55.0 29.0 18.0
Mechanisms of injury
Other 14.1 29.0 18.0
Height of fall
Ethnicity .06 The majority of the falls were from a low height of < 1 m
Hispanic 13.1 28.0 17.0 (3.3 ft) (n = 533, 49.1%) (Table 2). There were 10 children
Non-Hispanic 86.7 27.0 17.5 (0.9%) that fell from a height > 6 m (> 19.6 ft); this included
General MOI <.001 three children 1–2 years old (0.3%) who fell from balcony
or building structures, six children 2–4 years old (0.6%)
Fall on the Same Level 25.1 34.0 13.5
who fell from windows at least two stories high, and one
Fall on/from Stairs 5.5 18.0 12.5
4-year-old child (0.1%) who fell from a playground surface
Multilevel Fall 63.1 22.0 17.5 (trampoline).
Other 6.3 33.5 12.5
Specific MOI (specific) <.001 General and specific injury mechanisms
Bed 16.0 10.0 11.5 As seen in Table 2, most patients experienced a multi-
level fall (n = 685, 63.1%). Those who fell from multi-level
Furniture 8.0 19.0 16.5
(median = 22 months) or stairs (median = 18 months)
Playground Equipment 9.1 49.0 8.0
were significantly younger than those who fell from the
Stairs 5.6 18.0 12.5 same level (median = 34 months). For multi-level falls,
Other 61.2 29.0 17.0 most children < 1-year-old fell from a caregiver’s arms or
Height of fall .35 furniture; most children 1–2 years old fell from furniture;
Fall-Under 1 m (< 3.3 ft) 49.1 27.0 17.0 and most children 3–4 years old fell from furniture, out-
door surfaces, and playground surfaces. For same level
Fall – 1 m - 6 m (3.3 ft–19.6 ft) 20.3 27.0 18.0
falls, most children < 1-year-old fell from a caregiver’s
Fall – Over 6 m (> 19.6 ft) 0.9 36.0 7.5
arms; and most children 1–4 years old fell from running,
Fall – Height unknown 29.7 27.0 18.0 slipping, or tripping. When looking at specific mecha-
ISS Levels <.001 nisms of injury, those who fell from playground equip-
1–8 63.3 32.0 18.5 ment (median = 49 months) were significantly older than
9–15 31.7 23.0 14.0 those who fell from furniture (median = 19 months), stairs
(median = 18 months), or a bed (median = 10 months).
16–25 5.1 9.0 10.5
Table 3 provides findings from medical records and prod-
ED disposition .01
uct coding (Additional file 1) and shows a variety of fall
Floor Bed 72.0 27.0 18.0 mechanisms according to age.
Home without Services 17.5 29.5 16.0
Intensive Care Unit 4.9 25.0 22.0 Falls from caregiver’s arms
Operating Room 5.6 34.0 13.0 A majority of children who fell from caregiver’s arms
*Mann-Whitney U or Kruskal-Wallis Test
(n = 156) were < 1-year-old (n = 131, 84.0%) (Table 3).
Note: SIQR: semi-interquartile range Among the children who fell from caregiver’s arms,
a
Posthoc comparisons shown in Additional file 1: Table S3 17.9% (n = 28) were from another child (sibling, friend,
or relative) holding the patient, 11.5% (n = 18) were while
being carried on stairs, 10.9% (n = 17) were from being
carried in an unbuckled car seat (using car seat as a
Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 81 of 87

Table 3 Specific mechanisms according to age in years

Category Total (n) < 1 year n(%) 1 year n(%) 2 years n(%) 3 years n(%) 4 years n(%)
Balcony 6 0 0 3 (50.0%) 3 (50.0%) 0 (0.0%)
Bed 177 88 (49.7%) 29 (16.4%) 26 (14.7%) 23 (13.0%) 11 (6.2%)
Bouncy house 6 0 0 2 (33.3%) 3 (50.0%) 1 (16.7%)
Bouncy seat 3 3 (100.0%) 0 0 0 0
Caregiver’s arms 156 131 (84.0%) 11 (7.1%) 8 (5.1%) 4 (2.6%) 2 (1.3%)
Chair 54 9 (16.7%) 13 (24.1%) 9 (16.7%) 9 (16.7%) 14 (25.9%)
Changing table 7 6 (85.7%) 0 1 (14.3%) 0 0
Couch 58 12 (20.7%) 9 (15.5%) 15 (25.9%) 13 (22.4%) 9 (15.5%)
Counter 27 21 (77.8%) 2 (7.4%) 2 (7.4%) 1 (3.7%) 1 (3.7%)
Crib 5 1 (20.0%) 4 (80.0%) 0 0 0
Deck 3 0 0 0 3 (100.0%) 0
Other furniture 10 2 (20.0%) 1 (10.0%) 1 (10.0%) 3 (30.0%) 3 (30.0%)
High chair 7 1 (14.3%) 5 (71.4%) 1 (14.3%) 0 0
Playground 105 1 (1.0%) 6 (5.7%) 14 (13.3%) 26 (24.8%) 58 (55.2%)
Porch 11 0 (0.0%) 2 (18.2%) 3 (27.3%) 2 (18.2%) 4 (36.4%)
Shopping cart 13 2 (15.4%) 2 (15.4%) 7 (53.8%) 1 (7.7%) 1 (7.7%)
Sports 9 0 2 (22.2%) 1 (11.1%) 1 (11.1%) 5 (55.6%)
Stairs 54 10 (18.5%) 11 (20.4%) 15 (27.8%) 10 (18.5%) 8 (14.8%)
Stroller 11 9 (81.8%) 0 2 (18.2%) 0 0
Table 21 11(52.4%) 3 (14.3%) 3 (14.3%) 3 (14.3%) 1 (4.8%)
Toy 7 0 0 3 (42.9%) 1 (14.2%) 3 (42.9%)
Trampoline 33 1 (3.0%) 4 (12.1%) 3 (9.1%) 7 (21.2%) 18 (54.5%)
Tree 3 0 0 0 (0.0%) 0 3 (100.0%)
Vehicle 13 1 (7.7%) 1 (7.7%) 4 (30.8%) 5 (38.5%) 2 (15.4%)
Wheeled toy 15 0 3 (20.0%) 3 (20.0%) 5 (33.3%) 4 (26.7%)
Window 23 0 3 (13.0%) 8 (34.8%) 8 (34.8%) 4 (17.4%)

carrier), 3.8% (n = 6) were from an adult caregiver falling Falls from playground and strollers
asleep with the child (while on bed or other furniture), As seen in Table 3, the majority of children who fell from
and 1.3% (n = 2) were from being carried in an unbuckled the playground were 4-year-olds (n = 58, 55.2%). Falls from
bouncy seat. playground (n = 105) included falls from monkey bars (n =
24, 22.9%), swings (n = 22, 21.0%), or slides (n = 15, 14.3%).
Of the 11 children who fell from a stroller, the majority were
Falls from furniture < 1-year-old (n = 9, 81.8%). About half of stroller falls (n = 4,
As seen in Table 3, falls from furniture were docu- 44.4%) occurred because an unbuckled car seat was placed
mented for patients 0–4 years old, but falls based on fur- on top of the stroller or a stroller was being used on stairs.
niture type varied by age. Falls from beds (n = 177) were
the most frequent mechanism of injury. Among the 27 Injury severity scores
children who fell from a counter, the majority were As seen in Tables 2, 63.3% (n = 687) of patients had a mild
children < 1-year-old, and 59.3% (n = 16) resulted from ISS, 31.7% (n = 344) had moderate ISS, and 5.1% (n = 55) had
placing baby products (car seat [4 unbuckled], bouncy severe ISS. Table 4 presents findings from the multinomial
seat [3 unbuckled], booster seat, or baby seat) on top of logistic regression examining factors associated with ISS level
the counter. Falls from a table (n = 21) were predomin- (mild ISS served as the referent category). Older children were
antly among children < 1-year-old, three of which resulted significantly less likely to have moderate (OR = 0.98, 95% CI =
from baby products (infant seat, car seat [unbuckled], and 0.97–0.98) or severe (OR = 0.95, 95% CI = 0.93–0.97) ISS. In
bathtub) being placed on the table. the model comparing mild ISS to moderate ISS, females (OR
Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 82 of 87

Table 4 Multinomial logistic regression predicting ISS* level, Table 4 Multinomial logistic regression predicting ISS* level,
N = 1086 N = 1086 (Continued)
Predictor Odds Ratio 95% CI p Predictor Odds Ratio 95% CI p
ISS Level: 16–25 vs 1–8 (referent) Height of Fall
Age (Months) 0.95 0.93; 0.97 <.001 <1 m Reference Reference
Gender 1 m–6 m 1.3 0.89; 1.92 0.17
Male Reference Reference Over 6 m 1.1 0.20; 6.05 0.93
Female 0.94 0.52; 1.69 0.84 Unknown 1.07 0.78; 1.47 0.68
Race *ISS groups (1–8 = mild, 9–15 = moderate, 16–25 = severe)

White Reference Reference

Black 0.70 0.36; 1.38 0.31 = 0.63, 95% CI = 0.48–0.84), those who fell from multi-level
(OR = 0.50, 95% CI = 0.35–0.69), and those who fell from
Other 0.95 0.39; 2.33 0.91
stairs/steps (OR = 0.43, 95% CI = 0.22–0.84) were less likely to
Payer
have a moderate ISS (relative to their respective referent cat-
Medicaid Reference Reference egories). In the model comparing mild ISS to severe ISS, those
Private 0.72 0.34; 1.56 0.41 who fell from 1 m-6 m (3.3 ft–19.6 ft) (OR = 2.45, 95% CI =
Other Payer 0.80 0.23; 2.80 0.72 1.20–5.01) and those who fell from > 6 m (> 19.6 ft) (OR =
General MOI 12.9, 95% CI = 1.80–93.29) were more likely to have a severe
ISS (relative to those who fell from < 1 m [< 3.3 ft]).
Same Level Reference Reference
Multi-Level 0.97 0.37; 2.54 0.96
Stairs/Steps 0.70 0.15; 3.25 0.65 Procedures and injuries sustained
Other MOI 1.22 0.27; 5.52 0.80 Table 5 presents medical procedures performed on
Height of Fall pediatric fall patients. The highest percentage of neuroim-
<1 m Reference Reference aging (including MRI Brain, Head CT) (n = 336) and neuro-
surgical procedures (n = 20) were for children < 1-year-old
1 m–6 m 2.45 1.20; 5.01 0.01
(43.8% and 50.0%, respectively). In contrast, the highest per-
>6 m 12.9 1.80; 93.29 0.01
centage of orthopedic surgical procedures (including open
Unknown 0.83 0.38; 1.80 0.63 and closed reduction with/without pinning) (n = 442) were
ISS Level: 9–15 vs 1–8 (referent) seen among patients ages 2 years (23.8%), 3 years (24.0%),
Age Months 0.98 0.97; 0.98 <.001 and 4 years (34.4%). This correlated with the number of
Gender particular injury patterns according to age (Fig. 1). Head in-
juries such as skull fractures (n = 290) and intracranial
Male Reference Reference
hemorrhage (n = 177) represented the majority of injuries
Female 0.63 0.48; 0.84 0.002
for children < 1-year-old (63.1% and 65.5%, respectively).
Race Two-year-old children had the highest percentage of femur
White Reference Reference fractures (32.9%), and 4-year-old children had the highest
Black 1.18 0.86; 1.60 0.30 percentage of humerus fractures (41.0%).
Other 0.66 0.42; 1.04 0.08 Mechanisms for these injuries varied. Among children
with a skull fracture (n = 290), 31.7% (n = 92) had fallen
Payer
from a caregiver’s arms, 17.9% (n = 52) from a bed, 5.5%
Medicaid Reference Reference
(n = 16) from stairs, 5.2% (n = 15) from a counter, 3.8%
Private 1.17 0.84; 1.62 0.37 (n = 11) from a window, and 2.4% (n = 7) from a shopping
Other Payer 1.34 0.84; 2.15 0.22 cart. Among children with an intracranial hemorrhage (n
General MOI = 177), 32.2% had fallen from caregiver’s arms (n = 57),
Same Level Reference Reference 20.3% from a bed (n = 36), 6.8% from a counter (n = 12),
4.0% from stairs (n = 7), and 4.0% from a window (n = 7).
Multi-Level 0.50 0.35; 0.69 <.001
Among the children with femur fractures (n = 213), 17.8%
Stairs/Steps 0.43 0.22; 0.84 0.01
had fallen from a bed (n = 38), 13.6% from a caregiver’s
Other MOI 0.58 0.31; 1.09 0.09 arms (n = 29), 4.7% from stairs (n = 10), and 4.7% from
a couch (n = 10). Among the children with a humerus
fracture (n = 295), 21.7% had fallen from a playground
(n = 64), 14.6% from a bed (n = 43), 8.1% from a couch
Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 83 of 87

Table 5 Procedures according to age

Procedure Total < Age 1 n(%) Age 1 n(%) Age 2 n(%) Age 3 n(%) Age 4 n(%)
Body CT 197 68 (34.5%) 28 (14.2%) 36 (18.3%) 32 (16.2%) 33 (16.8%)
Skeletal Series 180 126 (70.0%) 25 (13.9%) 22 (12.2%) 7 (3.9%) 0
Neuroimaginga 336 147 (43.8%) 45 (13.4%) 53 (15.8%) 48 (14.3%) 43 (12.8%)
Neurosurgicalb 20 10 (50.0%) 3 (15.0%) 4 (20.0%) 3 (15.0%) 0
c
Orthopedic 442 24 (5.4%) 55 (12.4%) 105 (23.8%) 106 (24.0%) 152 (34.4%)
Intubations 8 0 2 (25.0%) 4 (50.0%) 2 (25.0%) 0
Total Procedures 1183 375 (31.7%) 158 (13.4%) 224 (18.9%) 198 (16.7%) 228 (19.3%)
a
Neuroimaging includes: Computerized axial tomography of head, magnetic resonance imaging of brain and brain stem, magnetic resonance imaging of
spinal canal
b
Neurosurgical procedures includes: craniotomy, ventriculostomy, elevation of skull fragments, incision of cerebral meninges
c
Orthopedic procedures include: closed reduction of fracture without internal fixation, closed reduction of fracture with internal fixation, open reduction with
internal fixation

(n = 24), 7.1% from a chair (n = 21), and 7.1% from a to the operating room (n = 61), and 6.0% to the intensive
trampoline (n = 21). care unit (ICU) (n = 54). Those admitted to the operating
room (median = 34 months) were significantly older than
Disposition those admitted to the ICU (median = 25 months) or floor
Among patients admitted after their fall (n = 896, 82.5%), bed (median = 27 months) (Table 2). Of all children in-
87.2% (n = 781) were admitted to a general floor bed, 6.8% cluded in the study, 69.1% (n = 750) were transferred from

Fig. 1 Fall injuries according to years of age

Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 84 of 87

an outside facility to CHOA. Of the transfers admitted carriers were over five times more likely to be related to
(n = 562), 5.9% were admitted to the ICU (n = 33) and caregiver falls than other product groups and found a ma-
6.4% to the operating room (n = 36). Injuries from the 750 jority of their caregiver falls to be related to carrying child
transferred patients included: skull fracture (n = 206, in a baby carrier. In our study, multiple cases of head in-
27.5%), ICH (n = 119, 15.9%), concussion (n = 50, 6.7%), juries and extremity fractures resulted from children fall-
humerus fracture (n = 194, 25.9%), and femur fracture ing out of caregiver’s arms. Based on these findings,
(n = 142, 18.9%). ISS for the 750 transferred patients were educational interventions should remind parents/care-
as follows: mild ISS (n = 475, 63.3%), moderate ISS givers to keep items off the floor and stairs to avoid trip-
(n = 238, 31.7%), and severe ISS (n = 37, 4.9%). Discharged ping hazards, actively supervise younger children carrying
patients (n = 190) included those with the following injuries: infants/toddlers, and avoid using baby carriers (car seats,
skull fracture (n = 44, 23.2%), ICH (n = 9, 4.7%), concussion bouncy seats) to carry children outside of their intended
(n = 25, 13.2%), humerus fracture (n = 28, 14.7%), and purpose (in motor vehicles, stationary floor surfaces).
femur fracture (n = 3, 1.6%). Like prior studies (Pomerantz et al., 2012; Kendrick et al.,
2015; Khambalia et al., 2006; Pitone & Attia, 2006; Unni et
Discussion al., 2012; Wang et al., 2013), our study found that many
Pediatric falls are frequently seen among young children children fell from furniture beyond age 6 months. Educa-
and can cause injuries requiring hospitalization. Our study tional interventions should remind parents/caregivers not
illustrates how low-level falls can cause a variety of severe to place infants on beds unsupervised since they can often
injuries and involve a variety of fall surfaces depending roll or fall from a bed. Further, parents/caregivers should
upon the child’s age. A prior systematic review found that supervise toddlers and older children because they can
young age, male sex, and low socioeconomic status were climb onto and jump from beds/furniture and may push
consistent risk factors for fall injuries among children ages younger siblings from the bed. A majority, of the children
0–6 (Khambalia et al., 2006). Similarly, our study found that fell from a counter in our study were < 1-year-old and
that the majority of the children with falls were male and fell from a type of baby carrier (car seat, booster seat,
had Medicaid insurance. Although most of these falls were bouncy seat) placed on top of the counter. Likewise, we also
from a low height and with mild ISS, many sustained in- saw cases of children falling from baby carriers when they
juries requiring medical procedures. Younger children were placed on top of furniture. Kamboj et al. (Kamboj et
were found to have the most severe ISS and the most crit- al., 2017) reported infant patients were more likely than
ical fall-related injuries were seen in children < 1-year-old. older children to sustain a traumatic brain injury from fall-
Children < 1-year-old also required the most imaging ing off, from, or with a product. Parents/caregivers should
(neuroimaging, skeletal series, and body CT) and neuro- be advised to place all infant seats and carriers on the floor
surgical procedures given their injury patterns. and not high surfaces. Current AAP anticipatory guideline
As children age, their mobility increases from generally recommendations review falls from furniture with parents/
being able to roll over at 4–5 months, sit up at 6 months, caregivers only through 6 months of age, falls from win-
pull to a standing position at 9 months, walk starting at dows and stairs starting at 9 months (to continue through
12 months, and run/climb stairs at 18 months (Centers age 2), and outside play at 3-year-old and 4-year-old visits
for Disease Control and Prevention, 2017c). In our study, (Hagan et al., 2017). As reiterated by our data the current
older children were more likely to fall from the same level guidelines miss critical ages for continued supervision at
or fall from stairs mechanisms. This finding is intuitive be- home around furniture and should be expanded to address
cause older children have more independent mobility and furniture falls beyond 6 months of age.
may fall from running, tripping, or stumbling. Conversely, Although falls from playground and trampolines were
based on their dependent mobility, younger children were mostly seen among older children in our study, there
more likely to experience a multi-level fall because they were cases identified among children < 1-year-old. To
were dropped from caregiver’s arms or inappropriately reduce playground injuries, parents/caregivers should in-
placed on household surfaces. crease supervision of young children on playground sur-
Similar to Unni et al.’s study (Unni et al., 2012), our faces. Further, communities, daycare, and schools should
study shows that a majority of ICD-9 CM. routinely inspect and assess their playground surfaces
E-codes in children < 1-year-old involve a MOI of and playground equipment to ensure they are updated,
multi-level fall including falling from caregiver’s arms, a safe, and meet national consumer safety standards
bed, or furniture. In our study, children in this age group (American Society for Testing and Materials Inter-
that fell from caregiver’s arms included those that were national, 2017). Trampolines should not be used for rec-
carried in baby carriers (such as car seats), by young chil- reational use given inadequate standards for equipment
dren, or from caregiver’s falling asleep with patient in their safety and supervision from structured training pro-
arms. Gaw et al. (Gaw et al., 2017) reported that baby grams (American Academy of Pediatrics, 2012).
Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 85 of 87

Although infants have decreased mobility compared to child advocacy, hospital summary and discharge notes), it is
older children, they are at higher risk of fall-related head possible the research team was unable to identify and ex-
injuries (even from low heights) because of their larger clude all intentional injury cases based on available data. Sec-
cephalic mass in proportion to the rest of their body (Wang ond, our data only included patients in the trauma registry,
et al., 2013). As a child ages, they have increased upper which represents the most severe cases and explains our
body strength, smaller head circumferences, and are able to high admission rate in our dataset. Thus, our results may
brace their falls with their upper extremities (Kamboj et al., not be generalizable to other institutions that primarily see
2017). In our study, these anatomical characteristics are non-acute falls. Third, the large percentages of ‘other’ or ‘un-
reflected by the higher proportion of head injuries among known’ MOI and ‘unknown’ height should be considered
younger children study and the higher proportion of upper when interpreting the results of this study. Fourth, since this
extremity injuries among older children. retrospective study used ICD-9 coding, patient misclassifica-
We found a statistically significant younger Medicaid tion could have occurred and led to under- or over-
population over private payer presenting with falls. Black pa- reporting. Similarly, investigators used product coding based
tients were also significantly younger in our dataset and had on medical record review for specific mechanisms, which
been found to be more likely on Medicaid. Often these fam- could have been misclassified leading to under- or over-
ilies with public insurance seek the ED for minor illnesses counting reporting. Additionally, MOI is reliant on caregiver
outside of their acute injury visits (Flores & Tomany- reports, which could have been inaccurate in some instances.
Korman, 2008). These caregivers also may not be able to Fifth, ISS is based on the three most severely injured body
leave their jobs during the day due to sole income and other regions and does not account for multiple severe injuries
hardships and thus utilize the ED after hours for minor ill- within the same body region (Smith et al., 2015). This limita-
nesses. It is in these instances where brief targeted age appro- tion of the ISS can result in a misleadingly low or high score
priate falls education can be given. Providing age-appropriate based on which injuries are included in the scoring system.
and brief injury prevention education in an ED setting at
non-urgent visits may add to current public health efforts in Conclusions
reducing pediatric falls. Another potential option for injury Despite being highly preventable, unintentional pediatric
prevention education in this demographic would be to pro- falls are the leading cause for childhood injury ages 0–
vide falls education at local governmental resource offices 4 years. Our research identified trends for children < 1-
such as Women, Infants, and Children (WIC). year-old having a majority of low-level falls and sustaining
The majority of our patients were admitted to the general majority of severe head injuries. Children < 1-year-old most
inpatient floor, which reinforces previous research evaluating frequently experienced multi-level falls MOI predominantly
trauma registry data for falls among children < 5 years old from bed or caregiver’s arms while older children primarily
(Pomerantz et al., 2012). Reasons for admission included experienced multi-level falls MOI from furniture and out-
medical care of injuries, observation of children < 1-year-old door surfaces. In comparison to older children, those < 1-
with head injuries, concerns for possibility of child abuse, and year-old had more household falls from baby carriers being
parental request for admission. Children that were admitted placed on raised surfaces. Our study showed larger propor-
to the operating room were older relative to those admitted tions of younger Medicaid patients sustaining falls.
to the ICU. This correlates with the higher percentage of Further prevention efforts should target low height falls
orthopedic extremity fractures needing surgical repair among at home with education from pediatric clinics, emergency
older children compared to the higher percentage of non- departments, and community centers/daycares. Health care
operatively managed head injuries among younger children providers and community workers should consider age-
in the ICU. The majority of our patient population were appropriate recommendations and population-based tar-
transferred from an outside facility and accounted for most geted education towards caregivers using injury and demo-
of the injuries seen, admissions, and discharges. One prior graphic patterns identified in this study. Parents/caregivers
study found that EDs with a larger proportion of Medicaid should be advised on recommended best practices for
patients had a higher odds of transferring patients with Me- supervision and care of young children both indoors and
dicaid over private payer (Huang et al., 2017). Of the outdoors to prevent falls effectively. They should be given
remaining 30% of children in the GCTR database that were education on available products and behaviors to reduce
not transferred to CHOA for care, the majority received care falls including: 1) use of window guards and stair gates; 2)
at either an adult level 1 or level 2 trauma center. avoidance of placement of children on high surfaces both
with and without baby carriers; 3) only placing baby carriers
Limitations on ground surfaces; 5) use of safety belts with baby carriers,
There were limitations in our study. First, despite efforts by high chairs, and changing tables; 6) safe play recommenda-
the trauma registrar coordinators and investigators to iden- tions for playgrounds and bounce houses; and 7) avoidance
tify abuse (review medical records including social work, ED, of use of trampolines for child recreational play.
Chaudhary et al. Injury Epidemiology 2018, 5(Suppl 1):7 Page 86 of 87

Additional file Author details

1
Division of Emergency Medicine, Children’s Hospital of Philadelphia,
Philadelphia, PA, USA. 2Department of Pediatrics, Emory University School of
Additional file 1: Tables S1-Tables S3. This additional file contains the
Medicine, Atlanta, GA, USA. 3Rollins School of Public Health, Emory
Appendix for the manuscript. Table S1 lists all of the ICD-9-CM E-codes used for
University, Atlanta, GA, USA. 4Department of Trauma and Surgical Services,
the study population. Table S2 lists product coding performed by investigators.
Grady Health System, Atlanta, GA, USA. 5Georgia Department of Public
Table S3 shows the post hoc comparisons for Table 2. (PDF 101 kb)
Health, Chronic Disease, Healthy Behaviors and Injury Epidemiology Section,
Atlanta, GA, USA. 6Safe Kids GA, Children’s Healthcare of Atlanta, Atlanta, GA,
Abbreviations USA. 7Center for Population Health and Aging, Texas A&M University, College
AAP: American Academy of Pediatrics; AIS: Abbreviated Injury Score; Station, TX, USA. 8Department of Environmental and Occupational Health,
CHOA: Children’s Healthcare of Atlanta; CI: Confidence interval; Texas A&M School of Public Health, College Station, TX, USA. 9Department of
COIVPP: Council on Injury, Violence, and Poison Prevention; E-code: External Health Promotion and Behavior, College of Public Health, The University of
cause of injury code; ED: Emergency department; GCTR: Georgia Central Georgia, Athens, GA, USA. 10Department of Emergency Medicine, Emory
Trauma Registry; ICD-9-CM: International classification of diseases, ninth University, Atlanta, GA, USA.
revision, clinical modification; ICU: Intensive care unit; ISS: Injury Severity
Score; LOS: Length of stay; MOI: Mechanism of injury; MRN: Medical record Published: 10 April 2018
number; NTDSD: National Trauma Data Standard Dataset; OR: Odds ratio;
SES: Socioeconomic status; WIC: Women Infant and Children
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