Chapter 1 Index

A. General Information about the well child examination

B. Nutrition Issues

C. Sleep Issues

D. Dental Issues

E. Anticipatory Guidance
--Discipline: Normal Toddlers
--Discipline: To Spank or Not to Spank
--Toilet Training: or Once Upon a Potty
--Reach Out and Read
--Anticipatory Guidance: Other Items to Ask Birth – 6 years of age
--Smoking: Adverse Effects on Children
--What’s New in Car Seats in 2002
--Water Safety: Prevention and Treatment of Drowning

Common Accidents

I. Infants and Toddlers:

1. Walkers: Walkers are one of the most common causes of injury in infants.  One in three children using mobile infant walkers suffer an injury. In 1997, walkers can be made in this country only if they are wider than a 36 inch doorway.  The AAP recommends a ban on the manufacture and sale of mobile infant walkers.  The most common severe injury is a child in a walker falling down steps (96% of children brought to ER with this injury), but can also occur when the walker is going over a door jam, over an uneven rug, when outside on the ground, or when on a deck or raised surface. The most common severe injury is to the skull, but broken bones, eye trauma, and less serious abrasions are also common.  Most common injuries: skull fx (10%), contusions (59%), concussions/head injuries (13%), nosebleeds (3%), avulsed teeth (1.5%).  Remember eye injuries as well. (Pediatrics August 97)

Anticipatory Guidance: At the 2-4 month check-up, ask parents if they plan to use a walker.  If they do, you should tell parents the dangers of them, and recommend only the stationery types.  Good news in 2001: incidence of accidents from walkers are down about 40%.

2. Motor Vehicle Accidents: Despite a lot of publicity about car seats, parents continue to drive their children in cars without them.  Also commonly seen when driving is an empty car seat in the back seat with a parent holding the infant in their arms.  You must advise parents that this is a dangerous practice.

Anticipatory Guidance: All children should face backward in the back seat until 1 year of age; if child is 20-40 lbs.: use convertible safety seat facing forward in back seat; 40-60 lbs: bigger booster seat; 60-70 lbs.: lap/shoulder belt.  Encourage your local hospital to insist that all newborns be driven home in a car seat.  See car seat discussion page 22.

3. Burns: Burns are very common in crawling infants and in toddlers.  The most common sources of these burns are mother’s curling iron, wood stove, hot liquid spills, reaching and touching the oven, stove or fireplace, as well as burns made intentionally on children.

Anticipatory Guidance: Warn parents at the 4-6 month checkup about this source of injury to their children.  Warn parents to not apply butter or other ointments on a burn.

4. Bicycle Injuries in toddlers: Are often taken on bicycle rides by their parents.  Separate seats are available for the children.  Common sources of injury from this cause include motor vehicle injuries, and children getting their legs caught in the spokes of the bicycle wheel.  Everyone riding on a bike should wear a helmet.

Anticipatory Guidance: If the parents of your patient do ride bikes, be sure and counsel them of the potential dangers and how they should minimize them.

5. Ingestions or Poisonings: All medications look good to infants and toddlers and they like to sample them.  Putting locks on cabinets is not enough.  Parents must be careful that visitors, relatives with medications never leave them in sight of the children. 

Anticipatory Guidance: Should we advise Ipecac?  In 2002, this is still debated.  Emergency Physicians prefer the use of activated charcoal, but when families do not have immediate access to emergency rooms, Ipecac may still be important to have at home.  The parents should be advised that this vomiting inducer should not be given until after a doctor advises it.

6. Drowning: Either drowning or near drowning is the number one cause of accidental death in children under 5 years of age.  The age groups most involved are toddlers aged 1-2 and teenagers, males more than females 3:1.  There are a number of things we can do to try and prevent these tragedies:

Anticipatory Guidance:

1. Teach your children to swim and water safety by 18 months of age. Learning to swim helps prevent drownings and near drownings but part of learning to swim is developing a sense of danger.  For example, when storms come up, when lightning occurs, when it is particularly windy, if at the beach, waves become rough. 
2. Never leave your toddler alone in the bathtub or any body of water.  Many tragedies occur when parents go to answer the door, the phone, etc.  Take the child with you. Flotation devices such as water wings are not a substitute for adult supervision.
3. If you have a pool at your house, make sure there is a fence at least 5 feet high around it and    that it has a tamper proof pool cover. Many drownings occur when toddlers fall in an unprotected pool.
4. Always monitor the fatigue of your children in water. Colder waters are more dangerous.
5. Always remind your child that they should never swim alone.
6. Have all parents learn CPR. Treatment of drowning is difficult, but if parents have a pool at home, or the children are likely to be visiting a pool often, parents should learn CPR and be advised that the most important thing is for them to clear the airway and do mouth-to-mouth resuscitation until help arrives.

II.  Accidents in Older Children

1.  Bike Accidents: One in 80 children between 6 and 12 years of age requires hospital care for bike injuries each year.  Two-thirds are associated with head trauma, one-fifth with upper limb fractures and one-tenth with lower limb fractures.  Fatal bike accidents are usually due to brain trauma when a vehicle from the rear is overtaking a bike. 

Anticipatory Guidance: Parents should be encouraged to teach their children “rules of the road,” and of course to insist that their child always wear a helmet.  Some communities, particularly on the West Coast, have been successful in getting children to wear helmets.  Helmets do save lives.

2.  Skateboard, scooter, roller-blade accidents: An increasing source of injuries in children.  The same types of injuries, and the same recommendations hold for these injuries as for bike injuries.

3.  Playground Injuries:

Introduction: It is important to remember that young children need to play and that a large part of group exercises will occur on the playground.  We need to encourage children to exercise at least an hour a day.  Injuries that occur during play need to be evaluated with that background.

Common Facts About Playground Injuries:

1.  Most common group involved is elementary school boys.

2.  The most commonly seen injuries from playgrounds are:

a. Lacerations: 31%
b. Bumps and bruises 15%
c. Fractures 10%: most serious from falls involving lower extremities
d. Dental injuries: 8%

3.  The most commonly involved part of body is the head; fortunately, most injuries are not serious.

4.  The equipment that is most commonly associated with injuries include:

a. wooden plank swing with rope handles, (head injuries)
b. slides
c. climbing frames
d. metal bars
e. merry go-rounds

5.  The most common surfaces involved with injuries:

a. bark surface is associated with fractures;
b. cement surface is associated more with scrapes and abrasions; if used for biking and skateboarding, head injuries as well.

Anticipatory Guidance:

1. Make sure that playground equipment is not too high: the higher the elevation of the equipment, the more likely the injury, and the more serious the injury.
2. Develop an all-purpose helmet that children can wear when playing on the playground, as well as when riding a bike or skateboarding.
3. Help encourage research into new and more resilient surfaces.
4. Be aware of what causes the most injuries: swings and slides: encourage parents to supervise children more closely when involved in these activities.

4.  Firearm Injuries: In rural communities suicide is the leading cause of firearm deaths in children.  African American children are more likely to be involved in homicides, white children more likely in suicides.  In fact, 15-19 year old males do 88% of homicides. In addition, 25% of the victims of nonfatal injuries end up with a permanent neurologic disability.  Of course, many tragedies occur daily in this country when younger children accidentally play with loaded guns.

Recommendations: At the six-month checkup and periodically thereafter, ask parents if they lock up their guns and keep them unloaded.  This reminder could save a life.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004