For years doctors have encouraged parents to store toxic household cleaning products in locked cabinets, out of sight and reach of children. While this advice may have helped considerably, with injury from cleaning products in children declining 46 percent since 1990, a new study demonstrates that children under age 6 years are still at high risk of poisoning and other injuries from cleaning products in the home.

Spray bottles are the most common source of injury, and bleach is the most common agent.

Despite our best efforts, exposures and injuries are still common. US poison control centers still receive hundreds of thousands of calls each year because of unintentional poisonings from cleaning products. Each call is more than a statistic; it’s an important moment in the life of a family. And nearly 12,000 children were sick enough to be treated in US hospital emergency departments in 2006 alone.

To me, the old childproofing strategy has become out of date. Children are still being harmed. We haven’t seen much improvement in overall injury rates since 1996, and injuries from cleaners in spray bottles have actually increased. Meanwhile, effective non-toxic cleaning products are now available to get the job done at home.

When it comes to childproofing, I now recommend that expectant mothers and parents of young children replace their toxic household cleaning products with safer alternatives – reducing the risk both of immediate injury and of ongoing low-level exposure to dangerous chemicals.

Who is at risk?

The Center for Injury Research and Policy reviewed 17 years of ER data for children under age 6 to analyze the landscape of injuries from household cleaners. The results will be published in the September 2010 Pediatrics.

• Children age 1 to 3 account for 72 percent of injuries.
• One-year-olds alone account for 46 percent of injuries.
• Boys (59 percent) are more likely affected than girls (41 percent).
• More than 80 percent of poisonings occur while at home.

How are they injured?

• Poisoning is the most common (68 percent), followed by chemical burns (16 percent) and other injuries to the skin or eyes (10 percent).
• Spray bottles are the most common source (40 percent), followed by regular containers 30 percent), kitchenware (14 percent) and recently cleaned items (8 percent).
• Bleach is the most common product ingredient (37 percent), followed by hydrocarbons, acids/alkalis, detergents, and ammonia.

What’s the Solution?

None of the children’s injuries that resulted in the 267,269 emergency department trips in the study was necessary. Effective, safer ingredients are now available for every common household cleaning job.

Why should a parent who drives with a car seat clean with out-of-date chemistry?

For parents of children age 6 or under, doctors’ advice to lock-up toxic cleaners is no longer adequate. Instead, childproof by replacing products whose labels must say Danger, Warning, Harmful if Swallowed, or Use in a Well-Ventilated Space. If the label gives instructions for calling poison control or for emergency treatment, the product is dangerous.

Poisonings, burns, or other injuries from household cleaning products never need to happen again. Any injury to a child from a household cleaning product is one too many.

For the population as a whole, falls are the most common cause of unintentional injuries requiring medical care, the leading cause of hospital admissions for trauma, and the second leading cause (after motor vehicle collisions) of unintentional-injury-related deaths.

While older kids do sometimes fall while walking down the street or across a room, most of the time their falls include items that propel them through space – bicycles, skateboards, rollerblades and snowboards, to name a few. In other words, older kids don’t usually just fall, they crash! Some kids love to go, to move, travel. For those who do, teach them to use these devices safely, at the right time, in the right place and with the right people.

Teach your children not to ride at dusk or after dark, since most serious injuries happen then. When they do ride, it should be in the same direction as traffic, and they should stop wherever a blind driveway or alley intersects the street. One out of six kids killed in motor vehicle collisions is riding a bicycle, usually riding against traffic or crossing a driveway.

The most important preventive measure you can take, however, is to build the habit of using proper safety equipment. Helmets are the most important, for the simple reason that the brain is the most important. Helmets reduce the risk of brain injury by 90%. Use only helmets approved by the American National Standards Institute (ANSI), the Snell Memorial Foundation, the American Society for Testing and Materials or the Consumer Product Safety Commission.

Making helmets natural and fun is easiest if you start young. Along with the first tricycle comes the first helmet, preferably gift-wrapped to make it fun. Through the years, with each new vehicle comes the proper safety equipment, gift-wrapped and festive. Helmets can be decorated with stickers or glow-in-the-dark-paint. Safety should be seen for what it is – an exciting opportunity to make life even better – not a dull, boring restriction on fun.

When your kids are learning about helmets (or any safety measure) your example is critical. If you ride a bike, they need to see you in a helmet. This is hard for many adults, since most of us grew up before we learned that helmets save lives and brains. We’re used to riding without them, and the change is inconvenient and expensive. Don’t cop out by saying that since you aren’t riding in the street (just on a bike path) that you don’t need a helmet. You do. And so do your kids. Every time that you ride, on the road or off, a helmet protects your head and helps prevent the second leading cause of death from unintentional injury.

Your example is critical. Also point out examples of other cool helmet wearers – football players, firemen, baseball batters, construction workers, astronauts, etc. Talk about how cool the helmets are and speculate about why they wear them.

For kids on rollerblades or skateboards, wrist guards, elbow pads, knee pads and helmets have all been proven to reduce injury. Wrist injuries are the most common rollerblading, skateboarding, and snowboarding injuries, and those wearing wrist guards are more than 10 times as likely to avoid injury.

Falling Down: Infants and Small Children

Most parents are surprised at the ease with which small children can fall from beds, changing tables, and high chairs.  Even before they can roll over, they have a remarkable knack for propelling themselves off an elevated surface to land, thud, on the floor.  Cats land on their feet.  Babies land on their heads.

This is not just to frighten their parents – it turns out that their center of gravity is in their heads (ours is in our bottoms).  Those relatively large heads enable them to learn at a pace unequaled in the rest of their lives (except during medical internship, for those of us so inclined – a kind of second infancy, where we’re up all night, cry a lot, think we’re the center of the universe, and aren’t capable of doing much on our own).  Those same large heads can get them in trouble when they fall.

Part of my job as a pediatrician is to warn new parents, not used to baby behavior, of this risk of falling.  Most of these falls can be prevented by attention – and staying between your baby and the floor.  Still, most of us parents experience a baby falling at some point.  Thankfully most of these early falls have happy endings. A fall from the height of a bed or a crib may crack a collar bone, or even a skull, but is extremely unlikely to result in a serious, debilitating, or life-threatening injury.

The danger increases when children begin crawling and walking.  Often they have no sense of fear.  The greatest dangers come from falling down stairs, falling out of windows, out of shopping carts, and off buildings or playground equipment.  The severity of playground injuries correlates primarily with the height of climbing equipment – not with safety regulations or types of playground surfaces.

Your child’s days of innocent exploration can be prolonged (and his or her life saved) by your installing protective gates at the top and bottom of stairways.  Even more important is installing window guards or locks on all windows above the ground floor.  The same advice goes for grandparents’ homes.  Most fatal falls in children are from windows or other structures more than one story tall.

The risk of this type of fall decreases as the child gets more coordinated and more cautious about heights (usually from a few painful, short falls).  At the same time, though, the risk for another type of fall increases.

I wept again this morning when I stood with my family at the spot in our neighborhood where 7-year-old Alana Pack and her 10 year-old brother Troy were killed. This was an entirely preventable tragedy, but I can’t think of a single thing the parents or the children could have done to prevent it.

Alana and Troy were with their mother on a sidewalk near their home on their way to the local Cold Stone Creamery to celebrate with ice cream a warm October evening. Soccer season had ended the night before. Suddenly a gold Mercedes jumped the curb and struck both children on the sidewalk.

The car was driven by a 45-year old nanny whose license had been taken away for drunk driving. Alana died quickly; Troy, her only brother, died later at the hospital. The Packs went in a tragic moment from a picture book family to suddenly childless.

The woman who hit the children tried to drive away – over the children, but Mrs. Pack had the presence of mind to wrestle the keys away from her. The hit-and-run driver escaped nonetheless, by flagging down a passing car.  She was captured after a 3-day statewide “man” hunt.

What can we learn from this exquisite pain?

The woman who struck the children had previously had her driving privileges suspended at least nine times, in more than one state. She had previously been put on probation for drunk driving, and had been sent to alcoholic rehab (twice). She was also on probation after having been found guilty of disorderly conduct while intoxicated. Clearly we need a system that won’t let people with this degree of impairment drive. And taking away the license is not enough to do this. At the minimum, real monitoring is required. And greater restriction, if monitoring is not practical. We want to help people get free of their dependencies, but at the same time protect the community from their lapses.

While we are working for the system to change, let’s take personal action. Let’s commit ourselves anew never to drive while intoxicated or while too drowsy. But beyond this, let’s commit ourselves to speak and act when someone we know might drive while impaired.

I expect that this woman never wanted to cause so much suffering. She may not have been able to see how seriously she was impaired. But I suspect that some of those who knew her were aware.

This is one situation where I hope we will be willing to be our brothers’ and our sisters’ keepers.

According to The National Highway Traffic Safety Administration (NHTSA), 17,419 people in the U.S. were killed in crashes involving alcohol in 2002 – an average of about one every half hour. The number continues to go up each year. On average, about 5,800 Americans were killed in combat each year during the ten years of the Vietnam War.  The NHTSA reports that motor vehicle crashes remain the leading cause of death at all ages from 2 to 14 years old – more than half of them with vehicles where the driver had been drinking!

Standing with my family at the spontaneous collection of hundreds of flowers, notes, stuffed animals, candles, toys, baseball bats and soccer balls at the spot where the collision occurred, I felt like I was standing at an outpost of the Vietnam War Memorial in Washington, D.C. – a hallowed place that honors those who lost their lives and those left behind who mourn them.

Note: Mothers Against Drunk Driving has resources to help victims and their families and for those wanting to make a difference.

A young doctor named Hitoshi Nikaidoh graduated from the University of Texas-Houston Medical School in June 2003. He began work as a surgical intern in July. In August he stepped into a second-floor elevator in his hospital just as the doors were closing. We all expect that the doors will bounce back open if we dash in at the last moment. This time they didn’t.

They pinned his shoulders and trapped him in the doorway. But the elevator moved upward anyway, tearing off his head. He was 35 years old, with years of training behind him, and years of service ahead. The built-in failsafe mechanisms failed him when he needed them.

This type of tragic accident is unusual. Federal statistics estimate that elevators kill about 27 people per year and seriously injure another 11,000 in the U.S., making them one of the safest forms of travel.

I’m glad that the safety mechanisms in elevators usually work very well.  Nevertheless, let’s teach our kids to assume that elevator doors might keep closing. To try to open them, you might safely wave a hand in front of the photoelectric eye, or push on the door edge cushions, but only if there is plenty of time to remove your hand if the doors don’t respond.

The built-in mechanisms are an excellent safety net for when we misjudge the timing, but we should not routinely rely on them to work.

…to pursue CPR training. I salute you in your efforts to be trained to help save lives. In the United States, you can find a CPR event near you by just entering your zip code here. In any country you might be able to locate a class through the International Federation of Red Cross and Red Crescent Societies (http://www.ifrc.org/ ) by searching on CPR.

To keep your skills sharp, I encourage you to attend training at least once every two years.

On August 3, 2003 James Safar, a man whose work saved many, many lives, died quietly at his home in Pennsylvania. He was 79 years old. He started the nation’s first physician – staffed ICU, but it was another innovation that was his biggest legacy. Dr. Safar pioneered a life-saving technique that can be used at home, at a playground, in a restaurant, or at a swimming pool.

Today we call it CPR. It requires no special equipment, and can be learned in hours.

I believe every parent and everyone who works with children should be trained in child CPR. I believe that CPR of adults and children should be taught in schools.

In an emergency, the earlier someone starts CPR, the more likely the victim will survive.  The city of Seattle has the highest “save” rate among major cities in the U.S. About 45 percent of people who suffer complete cardiac arrest are saved. One reason for this is that Seattle has one of the highest bystander CPR rates of any city. When a bystander – whether friend, family, or stranger – starts CPR before emergency support arrives, the chance of surviving a cardiac arrest is tripled!

Nevertheless, in most cities, when emergency workers arrive at a cardiac arrest, they find no one giving CPR.

In honor of Dr. Safar, in honor of those you love, this would be a good month to find  a convenient CPR class and learn how to save lives.

A major change in lifesaving recommendations was made in July 2003. Amazing machines called automated external defibrillators or AEDs can be found in an increasing number of public places. These machines have pads or paddles that can be placed on the chest during a life threatening emergency. They use sophisticated computer algorithms to automatically determine the type of heart rhythm and to administer a sudden shock if, and only if, that shock is needed to get the heart back into the right rhythm.

How great that these machines are becoming more widespread! Most people in ventricular fibrillation cardiac arrest will survive if shocked within 3 minutes. By 12 minutes, fewer than 5 percent survive. The machines are now available for as little as $1000. But these lifesaving machines were originally designed for adults, not for children.

What happens if a tragedy sends a 7-year old into cardiac arrest? Or a preschool child falls in a pool? Or a toddler chokes? Will these machines correctly determine heart rhythms in a child? And what if they do? We know that too much electricity can permanently damage the heart muscle. If the pads do administer a shock, will the adult-sized shock do more harm than good?   Because of these concerns, AEDs have not been recommended for children under age 8 – until now!

After examining all of the available data on what happens when a child goes into cardiac arrest, the Pediatric Advanced Life Support (PALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) came out with dramatic new 2003 guidelines. Ideally, AEDs should be designed to detect pediatric rhythms and to deliver child-size shocks to children when needed.

Nevertheless, available AEDs should be used for all children past the first birthday who have no pulse or other sign of circulation (currently there is not enough data to recommend for or against their use in children under age 1). If a lone rescuer is caring for the child, the task force recommends 1 minute of CPR before any other action, including calling 911 or using the AED.

I hope that AEDs soon become even more common in public places, and eventually in homes. I hope that more and more of these have pediatric pad/cable systems. And in the meantime, I urge parents to take the time to learn child CPR if they haven’t already. This jewel of knowledge is something no parent should be without.

Related concepts:
Head injury

Introduction to concussion:

Children’s energetic exploration of life often results in head “bonks.” Fortunately, most of them are not serious. Nevertheless, when we hear the awful thud of a child’s head, our breath catches for a moment…

What is concussion?

A brief, temporary loss of consciousness following a blow to the head is called a concussion. It is possible to have a mild concussion without losing consciousness completely. Any brief alteration in consciousness, vision, and balance following a head injury could be a mild concussion.

Who gets concussion?

Is toddlerhood a contact sport?
Almost every child experiences minor head injuries. They occur throughout childhood and adolescence. They are most common in infants and toddlers and then later when children engage in contact sports.

What are the symptoms of concussion?

The classic symptom of a concussion is a brief loss of consciousness. A mild concussion might only cause brief confusion or momentary amnesia. It can be normal to have a headache, feel sleepy, or vomit once or twice afterwards.
In a baby or toddler, a prompt cry after a head injury is reassuring. The following is a list of signals that tell you that you need to talk with your pediatrician, either initially, or again if they develop after the first conversation:
If your child is (or has):

• Under 6 months of age
• Unconscious, even briefly
• Crying for longer than 10 minutes
• Vomiting repeatedly
• Bleeding or clear liquid from the ears or nose
• Rapid swelling just above the ear
• Unable to walk or talk normally
• Unequal pupil size
• Severe, worsening headache (or irritability before a child can talk)
• Neck pain
• Seizures
• Skull indentation or large bump
• Great force of injury (car accident, long fall, baseball bat, etc.)
• Changes in behaviour, such as being sleepy and difficult to arouse>

If any of these symptoms or situations is present, call your physician right away. Your child may be fine but you should be in touch with an expert. If your child is unable to get up by himself immediately after the head injury, there may also be a neck injury. It might be best not to move him. Call 911 and wait for emergency help to arrive.

Is concussion contagious?

Concussions and head injuries are not contagious, although the risk-taking behavior that leads to them can be.

How long does concussion last?

The loss of consciousness from a concussion may last only a few seconds, but it can last considerably longer. If it lasts a few minutes or longer, the child will likely need to be hospitalized for observation or treatment.
New symptoms can develop after a head injury during the next 24 to 48 hours, especially if there is some internal bleeding.

How is concussion diagnosed?

The nature and extent of a head injury is first assessed based on the story and on the physical exam. If there is any concern that a serious injury may be present, additional studies, such as a head CT, may be needed.

How is concussion treated?

For most concussions, observation and rest is all the treatment that is needed. During the first night afterward, you’ll want to try to awaken your child once or twice to be sure that he awakens normally.
Some children need definitive treatment at a hospital or even in a pediatric ICU for severe head injuries.
With any concussion, the risk is much higher from a second concussion soon after the first one (called the second impact syndrome) because the healing brain is not able to regulate blood flow as well.
The Colorado Medical Society has developed guidelines for return to contact sports (or practice) following a concussion. In these guidelines, a Grade III concussion involves a complete loss of consciousness, a Grade II concussion involves only confusion and brief amnesia surrounding the injury, and Grade I involves a player who is only confused after a head blow.
A player with a Grade I concussion, and no symptoms when examined, may return to play after 20 minutes. A player with a Grade II concussion may return to play after there has been one week with no symptoms. A player with a Grade III concussion should not return for a full month (including no symptoms in the last week before returning).
Repeated concussions increase the risks of acute or ongoing problems. After a second Grade I concussion, the player should avoid contact sports for at least two weeks; after the second Grade II, for one month; and after the second Grade III, the season is over.

How can concussion be prevented?

Helmets for using a bicycle, scooter, or roller-blades, and helmets for contact sports can help prevent many serious head injuries. Make sure your child is properly equipped for his activities.
Stair gates for infants and toddlers and car seats or seat belts for everyone in the car are also important safety equipment.
“Rock-a-Bye Baby,” the lullaby about a baby toppling from a poorly placed cradle, warns parents of a real danger. Falls from open windows, rooftops, balconies, play structures, and other heights injure more children than any other cause.
Summertime is the greatest danger period, with more open windows and more outdoor play. Children love to climb, so furniture is best kept back from windowsills and balcony railings. Window guards and window stops can let fresh air in but keep a child from falling out. Don’t rely on ordinary window screens to keep your children safe. In addition, placing shrubbery or something soft under danger areas can lesson the injury if a child does fall.

Related A-to-Z Information:

Head Banging, Headache, Hemophilia, Vomiting

Roller coasters are fun! Nevertheless, a study in the January 2002 issue of the Annals of Emergency Medicine reported a disturbing trend in the rate of thrill ride injuries.

Overall, the risk of injury is low. Of the 900 million rides taken in the US each year, about 1 in 124,000 result in a significant injury that is detected. Only about 1 in 15 million require hospitalization and 1 in 150 million rides taken results in a death. Most of the worst injuries are from internal bleeding or from brain damage.

As my own children learned while playing Roller Coaster Tycoon, the fastest rides often have the longest lines, creating a strong incentive to build them bigger, faster, scarier.

Each time the G forces are increased, the risk of injury (detected and undetected) also increases. And thus the rate of injuries is going up each year.