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.

Dr. Greene’s Answer:

I can imagine how worrisome it would be to have concerns about your son’s development and then to be told he should be evaluated by a neurologist. I have a few thoughts on this matter.

First, crawling is not a major developmental milestone. The timing on crawling is so variable and many kids skip crawling altogether.

However, we do want to see kids begin to move across the floor, by rolling, commando-crawling, scooting, or inch-worming–however they want to do it–by around 9 months. When kids are not developing at the typical rate, it is wise to have them evaluated to see what is going on. It might be their unique style of development, or it might be something else that needs to be addressed.

The fact that he uses his arms but not his legs while scooting would make one want to look into whether the muscles in the legs are healthy, whether the nerves that control those nerves are functioning properly, and whether the parts of the brain that control those nerves are developing on schedule, as well as some other general developmental tests. This could be normal, but there could also be a problem anywhere along that path. Rather than focusing in on any one of the many possibilities, it’s wise to see the neurologist, who should be able to at least narrow it down quickly.

Dr. Greene’s Answer:

Your daughter could be perfectly normal, but this is worth discussing with your pediatrician.

In the United States, most kids start walking by about 12 to 14 months. Some kids skip crawling altogether and it can be normal not to walk until 18 months, but the combination of not crawling and not walking is worth looking into now to be sure there isn’t a problem.

Dr. Greene’s Answer:

When our darlings reach about six months old and the threat of SIDS is greatly reduced, we breathe a sigh of relief. We begin to think of their cribs as safe havens. While they may not always be happy in their cribs, they won’t be able to hurt themselves while in the protection of those four slatted walls.

Then it happens.

He learns to pull himself to standing. Soon he is cruising ’round and ’round the crib, instead of going down for a nap. Then he begins to bounce up and down. Before long, he catapults over the top — generally landing with a loud thud. A long silence follows, then a heart-stopping wail.

It’s high time for a big-boy bed.

Woody, your first task in this transition is to make his room as safe as his crib used to be. This means fresh, aggressive childproofing.

• Check furniture such as bookshelves for stability. If need be, fasten furniture to the wall.
• Put locks on dresser drawers — toddlers love to pull out drawers and use them as stair steps to the top of a piece of furniture.
• Replace standard electrical outlet covers with childproof covers. I prefer these to the plastic-cap-type that are inserted into the outlet. The plastic caps are easily removed by an adult and then lost, leaving the plug uncovered. Worse yet, the plugs can be removed by children who will put them in their mouths while exploring the outlet.
• Make sure mini-blind, drapery, and curtain cords are well out of reach
• Remove any toys or other small objects that could be a choking hazard.
• Put any potentially hazardous materials, such as disposable diapers, in the closet and install a childproof latch on the closet door.

Next, make his room a place where he feels safe — especially at night. Night lights are important, but at this age many kids want even more light than that. A 15- or 25-watt bulb in a lamp can keep the monsters that “live under his bed” at bay. Put the lamp on a timer so that it goes on at bedtime and off when it is time to wake up. This serves two very useful purposes. First if your son does wake up during the night — no — when your son does wake up during the night, he won’t be as frightened as he would be in the dark. Also, you can begin telling him that when he wakes up, if his lamp is still on, it’s still night-night time. Think about it — when we wake up in the middle of the night, we roll over and check the clock (usually hoping that we can get a few more hours of sleep before we have to face a new day). But when your son wakes up, he has no way of knowing what time it is. During the months when sunrise coincides with waking time, there’s no problem. But in many places that leaves two-thirds of the year when confusion can cause unrest (pun intended!).

Kids love stories at this age, so it’s a wonderful time to introduce a cassette tape player that your son can learn to turn on and off all by himself. There are lots of great story tapes available now for children. Investing in a few of these is smart. It’s an even better investment to make your own. There are no sounds in the world that are as comforting as mom’s and dad’s voices. At first you will need to help your son turn on the tape, but it won’t be long before you wake up in the night to hear your own voice coming from the tape player in the next room.

Finally, you might want to install a sturdy, metal child gate that swings open. Do not use a wooden, accordion style gate — both for your convenience and his safety. Let your son see you assembling the gate. When it’s in place, make a game of opening the gate and walking through it, then closing it and opening it again. Next close the door with you and your son inside. Explain to him that the gate is there to help him stay safely in his own room. When he’s comfortable with this, leave the room and stand just outside. Remind him that while he is in his room, he will be safe. Walk out of his sight and come back so that he gets used to being alone, inside his room, with the gate in place.

You have just re-created the safety of his crib — only larger.

Just before bedtime, tell him again that the lamp will be on as long as it’s nighttime. Remind him that while it is on he needs to stay in his room. When you put him to bed, help him turn on his tape player and, after your normal good night hugs and kisses, leave closing the gate behind you.

Your son will undoubtedly test you to see if you will enforce the “night-night time in your room” rule. He will probably stand at the gate and call for you to come and let him out — if you are lucky. (He also might cry mercilessly and try to make you feel guilty for confining him to his room). When this does happen, check on him to make sure he has not been awakened by a bad dream or he is not sick. Feel free to go into his room and help him get comfortable again so that he can go back to sleep. Let him know that he can read a book, listen to a tape, or play with his toys (since you can’t stop it, don’t make a fuss over it). But he can’t leave his room till morning! Leave and be prepared for an unhappy boy. He will probably try to manipulate you into opening the gate and letting him come into your room. Children  will often respond to new rules by testing them. Don’t give in. Unless you have decided that you want to have a family bed, teaching your child to sleep through the night in his own room is a real gift to the whole family.

Before you know it your little guy will be asking for a bunk bed, and your new concerns will be keeping him safely in the top bunk. Tip — when that time comes, don’t buy him Superman pajamas