Article

Unintentional injuries in child care centers in the United States: A systematic review

Journal of Child Health Care 1–13 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513501020 chc.sagepub.com

Andrew N. Hashikawa, Manya F. Newton and Rebecca M. Cunningham University of Michigan Medical School, USA

Martha W. Stevens Johns Hopkins School of Medicine, USA

Abstract The study systematically reviewed all types of unintentional injury and injury prevention research studies occurring within child care centers in the United States. A total of 2 reviewers searched 11 electronic databases to identify 53 articles meeting inclusion criteria. No studies used trauma registries or randomized control trials. Data were not pooled for further analysis because studies lacked standardized definitions for injury, rates, severity, exposure, and demographics. The following child care center injury rates were reported: (0.25–5.31 injuries per 100,000 child-hours); (11.3–18 injuries per 100 children per year); (6–49 injuries per 1000 child-years); (2.5–8.29 injuries per child-year); (2.6–3.3 injuries per child); (3.3–6.3 injuries per 100 observations); (635–835 medically attended injuries per year per 100,000 children and 271–364 child care center playground injuries per year per 100,000 children); and (3.8 injuries per child per 2000 exposure hours). Child care center injury rates were comparable to injury rates published for schools, playground, and summer camp. Most injuries were minor, while most severe injuries (fractures and concussions) were falls from playground structures. Future studies need to use standardized injury definitions and injury severity scales, focus efforts on preventing severe playground injuries in child care centers, and report child care parameters for inclusion in national injury databases. Keywords Accident and emergency, childhood, pediatric

Corresponding author: Andrew N. Hashikawa, Department of Emergency Medicine, Children’s Emergency Services, 24 Frank Lloyd Wright Suite H-3200, Ann Arbor, MI 48105, USA. Email: [email protected]

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Introduction Pediatric unintentional injuries are currently the leading cause of morbidity and mortality among children nationally and the Centers for Disease Control and Prevention (CDC) calls pediatric injuries ‘‘among the most under-recognized public health problems facing the United States’’ (Borse, 2009). In 2009 alone, there were greater than 2.7 million nonfatal unintentional injuries in the 0- to 5-year age group, with the estimated cost of related medical spending in the billions of dollars (American Academy of Pediatrics (AAP), 2011; Borse, 2009; Dowd, 2002; Schwebel et al., 2006b; Shope and Aronson, 2005). A majority of these injuries are classified as minor (not requiring hospital admission), but it is precisely these minor injuries that account for the vast majority of both the functional and financial health care burden of unintentional injury (Danseco, 2000; McClure, 1996; Polinder, 2005). Poor and minority families, many who lack paid sick leave, are disproportionately affected when they miss work to care for their injured or ill children (Heymann and Earle, 1999; Heymann et al., 1996, 1999). Following World War II, children requiring nonparental child care services rose dramatically and has continued to rise, now with more than two out of every three children requiring child care (Zigler, 2009). A substantial proportion of children between 0 and 5 years are cared for in child care centers settings, typically defined as a facility that cares for 13 or more children, and so the prevention of unintentional injury in the child care centers becomes paramount (National Survey of Children’s Health, 2003). Nationally, an estimated 211,000 children per year received medical care in the emergency department for injuries sustained on playground equipment and more than 25% occurred among children of 0–5 years age (Vollman et al., 2009). The National Survey of Children’s Health (2007) estimates that among preschool age children, 10% of injuries requiring medical attention occur in the child care setting. Child care playground safety is one of the 13 national indicators of child care quality, but little is known about the epidemiology of injury in child care settings (Dowd, 2002; Fiene, 2002; Gratz, 1992b; Snow et al., 1992). A systematic review was conducted to examine the rates, patterns, and interventions of all types of unintentional injuries in child care center settings. The review also summarizes child care center injury prevention studies over the time period with the most rapid increase in child care centers (post–World War to present), calls attention to the gaps within the literature, and makes specific recommendations for improving child care center injury prevention research.

Methods Identification of the literature The systematic review used a series of child care- and injury-related key words, including child care, day care, child day care centers, nursery, nursery schools, Montessori, and preschools combined with accident, wound, injury, child, and infant. A total of 11 electronic databases were searched through December 2011: CINAHL, Embase (1946–2011), Family and Society Studies Worldwide, Health and Safety Science Abstracts, JSTOR, Ovid Medline (1946–2011), PubMed, PsycINFO, Popline, Sociological Abstracts, and Web of Knowledge. An experienced university librarian validated the search strategy. Reference lists of studies and review articles were handsearched for studies potentially missed by database searches. The search methods to identify relevant studies were based on the same search strategy used by the same coauthors in a different published review (Newton et al., 2008). 2

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Selection strategy and data abstraction Investigators found early in the search process that injury studies in only family-based child care settings were exceedingly limited. A study of a family-based child care analyzed illness and injury, with a single injury occurring during the entire study (Taras and Bassoff, 1993). Another study described potential safety hazards in 73 Philadelphia, PA, family-based child care homes, but did not study injury directly (Perez et al., 2011). Three studies, included in this review, reported separate injury rates for family-based child care settings in addition to child care centers (Cummings et al., 1996; Turner et al., 1993; Wrigley and Dreby, 2005). The severe lack of studies in family-based settings affected the reviewers’ abilities to draw any substantial conclusions, so this review elected to report on studies in child care center settings only. Articles describing a primary published research study (including abstracts, state reports, consumer product safety reports, and case reports) examining all types of unintentional injuries within child care centers were included. Analysis was limited to studies of ‘‘child care centers,’’ ‘‘day care centers,’’ ‘‘nurseries,’’ or ‘‘preschool’’ settings, or as currently defined as a facility providing care of any number of children in a nonresidential setting or 13 or more children in any setting if the facility is open on a regular basis (AAP, 2011). Studies of both center child care and home/family-based care settings were included if centers were grouped and analyzed separately. Only articles that defined ‘injuries’ in the methods sections were kept. Definitions included injuries in child care centers causing absence from child care, warranting medical attention or treatment (school nurse, medical doctor, and emergency department), generating an injury report, or deemed reportable by school policy or state law. Studies focusing on injury prevention interventions directly within the child care center settings were included. Articles were limited to studies conducted in the United States and available in English. All types of injuries occurring in child care centers were included except for sudden infant death syndrome (SIDS) cases, which were excluded because they are classified as natural deaths and not from injury and thus were beyond the scope of the analysis (Wrigley and Dreby, 2005). Articles were excluded if the child care center was used only as a recruitment center and did not directly relate to research within the child care center itself. Dates of publication year were limited by electronic database dates beginning in 1946 (post World War II). Authors (ANH and MFN) independently screened and selected all articles for inclusion. Authors (ANH and MFN) abstracted the following data into Microsoft Excel (Microsoft, Redmond, Washington, USA): Authors, publication date, study objective, design, time period, data collection method, subject characteristics, sample size, child care type, response rate, injury characteristics (sex, age, time, definition, severity, rate, type, location, mechanism, treatment, and intervention), outcomes, conclusions, and limitations. One reviewer (ANH) extracted data into the spreadsheet and a second reviewer (MFN) checked data for quality, accuracy, and completeness.

Results The search and selection strategy, outlined in Figure 1, yielded 53 articles that were included in the final review. Articles were sorted and presented based upon three categories: (1) studies describing rates or patterns of unintentional injuries in child care center settings (Supplement Table 1); (2) studies of injury prevention interventions in child care center settings (Supplement Table 2); (3) studies describing the state of unintentional injury prevention in child care center settings (Supplement Table 3).

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Figure 1. Search and selection strategy.

Rates or patterns of unintentional injuries occurring in child care center settings The search identified 26 studies reporting injury rates or patterns of injury, with each study described in Table 1. Of them, 20 studies reported specific injury rates, but definitions of injury, injury rate, and injury severity varied widely. One study, using a systematic media search, legal records, and state records analyzed fatalities related to unintentional injuries in child care settings 4

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Injury rate

Rate Definition

Study Authors

0.25-5.31

Injuries per 100,000 child-hours

(Briss et al., 1994; Briss et al., 1995; Cummings et al., 1996; Sacks et al., 1989; Waibel and Misra, 2003)

11.3-18

Injuries per 100 children per year

(Landman and Landman, 1987; Lee and Bass, 1990; Turner et al., 1993)

6-49

Injuries per 1000 child-years

(Chang et al., 1989; Leland et al., 1993)

2.5-8.29

Injuries per child-year

(Alkon et al., 1994; Leland et al., 1994)

2.6-3.3

Injuries per child

(Bitner, 1964)

3.3-6.3

Injuries per 100 observations

(Federer, 1964)

635-835

Injuries per year per 100,000 children

(Kotch et al., 2003)

Figure 2. Overall injury rates in child care centers.

and found an unintentional injury fatality rate (excluding SIDS) of less than 0.23 fatal injuries per 100,000 children in children 5 minutes);

3.8

Injuries (median) per 2000 exposure time (1 year full time)

Male

N¼1886 injuries Scrapes – 36.5% Bumps/bruises – 34.5% Lacerations – 5.8% Crush – 2.8% Burns – 0.4% Dental – 0.4%

NA

Playground – 74%

(continued)

Table 1. (continued)

Author

Child care setting

Injury definition

Injury rate

Rate definition

Sex

Injury number and type

Injury treatment

Injury mechanisms

Kotch et al., 2003

Center

Incident receiving medical treatment

Overall: 835 (‘97); 806 (’98); 635 (’99) Playground: 364 (’97); 336 (’98); 271 (’99)

Injuries per year per 100,000 enrollees

NA

N ¼ 5402 injuries

NA

NA

Waibel and Misra, 2003

Center

Accident medically attended by staff only;

5.31

Injuries per 100,000 child hours

Male

N ¼ 897 injuries Bites – 39% Fall – 23% Bump/Bruise – 22% Cuts, fracture – 16%

First Aid – 87%

Falls – 23%

Wrigley and Dreby, 2005

Center and family care

Fatalities from unintentional injuries