Monash University Accident Research Centre - Report #123 - 1997
Authors: W. Watson, J. Ozanne-Smith, S. Begg, A. Imberger, K. Ashby & V. Stahakis
Full report in .pdf format [641KB]
This publication reports on research undertaken into the safety of nursery furniture to underpin a proposed injury reduction program for these products. It contains a review of recent Australian and international literature on nursery furniture and bunk bed safety providing an overview of the injury issues involved and a review of the relevant standards. Major sources of Australian and international data relevant to this area were identified and the available data summarised. An in-depth analysis of Victorian data was undertaken to identify the relevant nursery furniture products, the nature and severity of injuries sustained and any patterns or trends including age profiles.
The major items of nursery furniture associated with injury, in the 0-4 year olds, in Australia are: prams, cots, high chairs, baby walkers, strollers, change tables and baby bouncers. Injury associated with nursery furniture is most likely to occur in the first year of life. Cots have the highest mortality with all identified deaths occurring as the result of asphyxia. In terms of non-fatal injury the picture is less clear with the incidence of injuries associated with different products varying between States. A comparison of hospital admission rates in Victoria for injuries related to the different products suggest that baby bouncers are associated with the most severe non-fatal injuries with almost one-third resulting in hospital admission. Falls were the most common cause of non-fatal injury in every product category with injuries to the face and head being the most prevalent. For at least four of the products (cots, prams, strollers and high chairs) about 6 percent of cases could be clearly identified as product failure (collapse, malfunction or entrapment hazard).
Victorian injury surveillance data shows that 86 percent of bunk bed related injuries in the under fifteen age group occur in children under the age of ten. While bunk-bed injuries peak in the 5-9 year age group, they still account for similar numbers of injuries as individual nursery products in the 0-4 year age group. No deaths related to bunk-beds could be identified in the available Australian data, however, information from the United States suggest that at least 38 children (mainly under 3 years) have died of asphyxia due to entrapment in the bunk structure, since 1990. The main cause of non-fatal injury is due to falls from the top bunk resulting in a fracture (33 percent), mainly to the upper extremity (75 percent).
On the basis of this research a number of recommendations have been made regarding product standards, injury data collection, research and evaluation and the dissemination of information. In particular, it is recommended that standards be developed for baby walkers, high chairs and change tables, that mandation of standards in Australia should occur when voluntary standards and the market place are ineffective in achieving compliance and evidence warrants it and that there is sufficient evidence and lack of compliance to mandate standards for household and portable cots.
Certain items of nursery furniture have been identified as potentially hazardous to children under five years of age. Bunk beds have also been shown to pose risks to children under ten years. The Monash University Accident Research Centre (MUARC) was invited by the Consumer Affairs Division of the Department of Industry, Science and Tourism to provide information on the hazards associated with nursery furniture and bunk beds to underpin a proposal for an injury reduction program in this area.
To undertake research into the safety of nursery furniture and bunk beds to underpin a proposed injury reduction program for these products.
1. Undertake a review of recent Australian and international literature on nursery furniture and bunk bed safety to:
(a) identify the relevant nursery furniture products;
(b) provide an overview of nursery furniture and bunk bed injury issues;
(c) review nursery furniture standards
2. Identify the major data sources and provide, to the extent possible, a summary of data available in Australia and internationally.
3. Undertake data analysis, to the extent possible (given the limitations of available data), including : nature of injuries and possible product involvement;
SUMMARY OF FINDINGS
An analysis of injury surveillance data revealed that the major nursery furniture products associated with injury in Australia are : prams, cots, high chairs, baby walkers, strollers, change tables and baby exercisers (bouncers). While injuries in the under five age-group peak at around one to two years of age, injuries associated with nursery furniture are most likely to occur in the first year of life.
It is estimated that, in Australia, at least 6,540 injuries associated with nursery furniture (and treated in hospital Emergency Departments or by general practitioners) occur annually in the under five age group. Of these, it is estimated that at least 540 cases result in hospital admission. Over 3,500 of these cases are aged under one year and of these, at least 270 result in hospital admission.
The estimated injury rate of 508 per 100,000 population for all medically treated (Emergency Department and general practitioner treated) nursery furniture-related injuries in the under five age-group is not too dissimilar from the U.S. injury rate of 431 per 100,000 population which only applies to treatments in hospital Emergency Departments.
In terms of injury severity, cots have the highest mortality. Of the 13 nursery furniture-related deaths identified in Victoria between 1985 and 1994, 10 (over 75 percent) were associated with cots. This is consistent with U.S. figures which show that almost 70 percent of nursery furniture-related deaths, identified by the CPSC, were associated with cots. All but one of the deaths associated with cots in Victoria were due to asphyxia and involved entrapment hazards directly related to cot design or modification (6) or to the cot environment (2 accessed blind cords, 1 strangled on the elastic attached to a toy). The other death resulted from a fall from a cot, though the actual mechanism of death was again asphyxia, due to the child falling into a clothes basket and suffocating in the contents. Strollers, high chairs and change tables have also been implicated in at least one death each in Victoria since 1985.
In terms of non-fatal injury, the picture is less clear cut with the frequency of injuries associated with the different nursery products varying between States. Baby walkers, high chairs and strollers were the three nursery furniture products most frequently associated with injury nationally while prams, cots and high chairs were most prominent in Victoria. A comparison between the national (NISPP) and Victorian (VISS) data sets suggests that this difference does not reflect demographic variations between the two collections. Rather, it may suggest different patterns of usage or changes over time since the collections represent different time periods. For example, the fall in baby walker injuries recorded by VISS over the period 1989-93 appears to coincide with a strong intervention program in Victoria to discourage the use of baby walkers. The proportion of baby walker injuries recorded in the new VEMD collection in 1996 (ranked sixth compared to fourth in VISS) suggests that such injuries are still declining in relation to injuries associated with other nursery furniture products.
A comparison of hospital admission rates in the Victorian collection for the different products suggest that baby exercisers or bouncers are associated with the most severe non-fatal injuries with almost one in three injuries resulting in hospital admission. This is due to the fact that falls from bouncers are usually from a height when care-givers place the bouncer on an elevated surface such as a bench-top. These are followed by high chairs and strollers both of which have admission rates equal to, or higher than, the overall admission rate for children under 5 years of age.
Falls were the most common cause of non-fatal injury in every product category (65 percent overall) ranging from 43 percent in the case of baby bouncers to 77.5 percent in the case of change tables. Injuries to the head and face were most prevalent in all product categories accounting for 63.5 percent overall (and up to 82 percent for stroller-related injuries). Injuries to the upper extremities were next at 15.3 percent of injuries recorded (and up to 22.3 percent for cots). Bruising, inflammation and/or swelling was the most common type of injury (31.3 percent), followed by lacerations (16.1 percent), concussion (11.2 percent) and fractures (8.3 percent).
For at least four of the nursery furniture products (cots, prams, strollers and high chairs) a small percentage of product failure was indicated as causal. For this group of products about 6 percent of cases could be clearly identified as product failure (collapse, malfunction or entrapment hazard). High chairs had the greatest percentage of identified product failure (8 percent) due mainly to the tray falling off allowing the baby to fall out. Seven percent of cot injuries were attributed to failure on the part of the product, mainly entrapment hazards. The main problem identified for prams and strollers was collapse of the product resulting in it folding up on the child. Almost half of identified malfunctions in prams involved the restraint breaking or coming undone.
Injury surveillance data (VISS) shows that eighty-six percent of bunk bed-related injuries in children under fifteen years of age occur in children under ten years. While bunk bed injuries peak in the 5-9 year age group, they still account for similar numbers of injuries as individual nursery furniture products in the 0-4 year age-group.
It is estimated that, in Australia, there are at least 3,850 injuries annually, in the under fifteen age-group, associated with bunk beds, that are treated by hospital Emergency Departments or by general practitioners. Of these, it is estimated that about 390 cases result in hospital admission. Almost half of all bunk bed injury cases occur (1900) in the 5-9 year age group and, of these, at least 180 result in hospital admission.
No deaths associated with bunk beds have been identified in the Victorian data. However, the U.S. Consumer Product Safety Commission has identified 38 cases, since 1990, in which children (mainly aged under 3 years) have died of asphyxia due to entrapment in the bunk structure. Based on NEISS data, it was estimated that there were at least 17 bunk bed-related deaths in the U.S. in 1995.
The main cause of non-fatal injury associated with bunk beds is a fall from the top bunk (80 percent of cases). The most common activity associated with a fall is playing (32 percent of falls). Over half of these falls occur in the under five age group (55 percent), with about 40 percent in the 5-9 age group and only 4 percent in the 10-14 year age-group. Jumping from bunks (7 percent of all injury) as a cause of injury also decreases with age. After playing, sleeping is the next most common activity associated with falls. The pattern is somewhat different in this instance with the majority of injuries (64 percent) occurring in the 5-9 year age-group, 19 percent in the 10-14 year age-group and the remainder (17 percent) in the under fives. One would expect that the lower involvement of under fives is due to the fact that they are less likely to sleep in a bunk bed. However, the high proportion of 5-9 year olds falling from bunks while sleeping suggests that children of this age may not be ready to sleep in a top bunk.
Because only 5 percent of narratives specified the presence or absence of a safety rail, little can be inferred about the usefulness of these in preventing falls. In at least 10 cases (1.6 percent), the injury can be directly attributed to a failure of the product or its design. Nine of these cases involved a collapse of part of the bunk (7 safety rails, one ladder and one base) resulting in a fall. The other case involved entrapment of the childs arm in part of the bunk.
Of the five-year age-groups, the admission rate is highest for 10-14 year olds at 22 percent which is substantially higher than the overall admission rate for the age-group. While the admission rate for under fives is similar to the overall admission rate for the age group, the admission rate for one-year olds is particularly high at 27.5 percent.
The most common non-fatal injuries associated with bunk beds are fractures (33 percent), three-quarters of which are upper extremity fractures. Bruising (21 percent) is the next most prevalent type of injury followed by lacerations (17 percent) and concussion (10 percent). These types of injury are most commonly associated with falls. Fractures and concussion result in the greatest number of hospitalisations (fractures accounting for 48 percent of admissions and concussion 20 percent). Injuries to the upper extremities are most common (38 percent) followed by injuries to the face (27 percent) and the head (13.5 percent).
1. Action should be taken by the Federal Bureau of Consumer Affairs and other responsible authorities to reduce deaths and injuries related to nursery furniture and bunk beds.
2. A general product safety directive should be adopted and enforced in Australia/New Zealand.
3. Safety guidelines for standardisation such as ISO/IEC Guides 50 and 51 should be actively promoted in Australia/New Zealand.
4. Where necessary to inform and monitor policy and action on product safety, research and evaluation studies should be commissioned.
5. Resources should be allocated, where required to meet the recommendations which follow.
6. Standards should be developed for baby walkers, high chairs and change tables. No Australian/New Zealand standards exist. These standards should be based on the best available international standards or draft standards.
7. Childrens furniture safety standards should be reviewed and, if necessary, modified at least once every five years, to ensure that new requirements or revision of existing requirements occurs as new substantive information becomes available.
8. Compliance with voluntary nursery furniture and bunk bed standards should be actively improved by measures such as: seeking industry co-operation, public education by means of media and hot-lines and a policy of mandation if necessary.
9. As in the United States, mandation of standards should occur in Australia where voluntary standards and the marketplace are ineffective in achieving compliance and evidence warrants it.
10. There is currently sufficient evidence, at least in the case of household cots and portable cots to mandate standards. Both of these items are involved in deaths (at a rate of about 9 times that for other nursery furniture) and studies by the Australian Consumers Association have repeatedly shown lack of compliance in the marketplace.
11. To avoid unacceptable "non-tariff" barriers to trade, Australia/New Zealand should focus initially on improving its safety requirements for nursery furniture in-line with other major importers of nursery equipment, particularly the United States.
Injury data collection
12. Hospital based injury surveillance should be implemented nationally to collect product-related injury data in sufficient detail and sufficient numbers to provide useful in-depth analyses and reliable secular trend data. It should contain sufficient cases by state to allow comparisons to identify best practice and effective interventions. There is potential for state support for options which would involve adequate numbers of cases to be collected to meet state needs.
13. Linkage of emergency department injury surveillance and hospital admission datasets should be undertaken to provide reasonably comprehensive information on moderate and severe injury cases (admissions).
14. The national coroners data and information system, currently under development, should identify products and their involvement in deaths.
Research and evaluation
15. Household surveys should be undertaken to collect additional information with regard to nursery furniture, bunk beds and possibly other products of interest. It is recommended that the surveys be undertaken collaboratively with other sectors or state departments interested in further exposure issues
16. Retail outlet observations of compliance of nursery furniture and bunk beds with Australian or overseas standards (where there are no Australian standards) should be conducted.
17. Studies should be undertaken to investigate second hand marketing. Compliance with standards, modifications to design, maintenance and general condition should be assessed.
18. In depth studies are required to conduct detailed tests of nursery furniture performance against test procedures, detailed in relevant standards, for current models in the market place.
19. A relative risk study should be undertaken for cots versus beds by age to determine the safest sleeping environment for children of different ages.
20. Follow-up case studies should be undertaken to determine whether child injuries associated with nursery furniture involve a range of factors which should be further investigated.
21. In depth investigations should be undertaken as coronial inquiries for all deaths involving nursery furniture.
22. Interventions should be evaluated:
Dissemination of information
23. The findings of this report should be published in formats accessible to government, industry and other relevant professionals as journal articles on each of the major products and in Victorian Injury Surveillance System publications.
24. Point of sale information about the correct use of products and the associated hazards should be provided for parents and care-givers.
25. Community service TV advertisements should be produced to alert parents and care givers to nursery furniture risks at the time of implementing preventive measures such as mandatory standards or new voluntary standards.
This project was funded through the Consumer Affairs Division of the Commonwealth Department of Industry, Science and Tourism