Introduction

Falling is a normal part of the way a child develops – learning to walk, climb, run, jump and explore the physical environment. Fortunately, most falls are of little consequence and most children fall many times in their lives without incurring damage, other than a few cuts and bruises. All the same, some falls are beyond both the resilience of the human body and the capacity of the contact surface to absorb the energy transferred. Falls are thus an important cause of childhood injuries, including those resulting in permanent disability or death. Falls of this degree of seriousness are not randomly distributed, either globally or within single countries. To understand why this should be one needs to examine the built environment and the social conditions in which children live.

This chapter focuses on the main ideas underlying the prevention of unintentional falls in childhood, using a public health approach. The extent and characteristics of the problem are first identified and after that the types of exposure that are linked to a risk of injury. Intervention strategies to prevent such injuries and their disabling consequences are examined for their effectiveness and cost-effectiveness. Finally, consideration is given as to how the most promising strategies can be successfully implemented on a wider scale.

Falls have been defined and recorded in sever always. This chapter adopts the World Health Organization’s definition, according to which falls are “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (2). In the WHO database of injuries, fall-related deaths and non-fatal injuries exclude those due to assault and intentional self-harm. Injuries and deaths resulting from falls from animals, burning buildings and vehicles, as well as falls into water and machinery, are also not coded as falls. Instead, they are recorded, respectively, as injuries due to animals, fire, transport, submersion and machinery.

An expert group convened by the National Institute of Child Health and Human Development defined falls as an external cause or type of exposure, the impact of which is “to come down by force of gravity suddenly; to tumble, topple, and forcibly lose balance” (3). The group listed the main factors relating to falls in childhood. These included:

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social and demographic factors, such as the child’s age, gender, ethnicity and socioeconomic status;

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the physical development of the child;

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activity taking place before the fall – such as running, walking or climbing;

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the location of the fall;

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the height from which the fall occurs;

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characteristics of the surfaces with which contact is made – such as texture, smoothness and deformability.

All this information, if available, taken together with information on risk factors, can provide valuable clues as to how and why fall-related injuries occur, and greatly help efforts to prevent them.

Epidemiology of falls

According to the WHO Global Burden of Disease project for 2004, an estimated 424 000 people of all ages died from falls worldwide. Although the majority of fall-related deaths were among adults, they ranked as the twelfth leading cause of death among 5 to 9-year-olds and 15 to 19-year-olds (see Table 1.1 in Chapter 1). Morbidity from falls is much more common and represents a significant burden on health-care facilities around the world. Among children under 15 years, non-fatal falls were the 13th leading cause of disability-adjusted life years (DALYs) lost. In most countries, falls are the most common type of childhood injury seen in emergency departments, accounting for between 25% and 52% of assessments (4, 5).

The published literature on the incidence and patterns of fall-related injuries among children relates largely to high-income countries, where just 10% of the world’s children live. In many of these countries, deaths from all types of injury are estimated to have dropped by over 50% over the past three decades (6, 7).

A systematic review of the literature from mainly low-income and middle-income countries in Africa, Asia and Central and South America on the incidence of unintentional childhood falls resulting in death or needing medical care, found the following.

• In Africa, the median incidence of falls among children and youth aged less than 22 years was 41 per 100 000 population (8).
• In Central and South America, the rate varied from 1378 to 2700 per 100 000 population aged less than 20 years (9, 10).
• In Asia, the median incidence was 170 per 100 000 population aged less than 18 years (43% of all injuries).
• The highest rate on the Asian continent was recorded in the United Arab Emirates with an incidence of some 1923 per 100 000 population (11–14).

The UNICEF–TASC surveys have also found falls to be a leading cause of morbidity and disability in children, resulting in high social and economic costs (15).

The studies reviewed suggest a substantial variability in the incidence of falls between regions – and sometimes within regions. In the absence of a common methodology and standard definition, however, data from different studies and settings cannot be compared directly and are potentially misleading. Less than a fifth of the studies documented deaths due to falls, only 12% used standardized or formal definitions for falls, and none provided reliable data on the severity of injuries or consequent disability resulting.

Mortality

In 2004, nearly 47 000 children and youth under the age of 20 years died as a result of a fall. Fall-related mortality data compiled by WHO reveal important differences between regions, and between countries within regions (see Figure 5.1). High-income countries in the Americas, Europe and Western Pacific regions had average mortality rates of between 0.2 and 1.0 per 100 000 children aged less than 20 years. However, low-income and middle-income countries in the same regions reported rates up to three times higher. Low-income and middle-income countries in South-East Asia and the Eastern Mediterranean regions had the highest average rates – of 2.7 per 100 000 and 2.9 per 100 000, respectively. While it is quite possible that the levels are so much higher in some places, it is also possible that some misclassification of data has occurred. Child abuse, for instance, is sometimes wrongly classified in the category of falls (16, 17).

FIGURE 5.1

Fatal fall-related injury rates per 100 000 childrena by WHO region and country income level, 2004. ^a These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries.

Age

In high-income countries, the average fall mortality rates, by age, are similar over the first 20 years of life. However, in low-income and middle-income countries, infants less than one year of age have very high rates (see Figure 5.2).

FIGURE 5.2

Fatal fall-related injury rates per 100 000 children by age and country income level, World, 2004. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update.

Community surveys conducted in Asia highlight the high incidence of fall deaths in the region. In Bangladesh, the overall fall mortality rate for the 0–17-year age group was 2.8 per 100 000 (1), and falls were the second leading cause of death through injury among infants aged less than one year (24.7 per 100 000 population). In Viet Nam, falls were the sixth leading cause of childhood death (4.7 per 100 000 aged 0–17 years) (18). In Jiangxi province in China, falls were the fourth leading cause of death (3.1 per 100 000 aged 0–17 years). Higher rates were reported in rural areas than in urban areas (19).

Falls are still an important cause of death in children in high-income countries, even though the incidence rates are considerably less than in low-income and middle-income countries. Falls are the fourth leading cause of trauma deaths in childhood in the United States (20) and the sixth leading external cause of death among Australian children aged 0–14 years (21).

Gender

Boys are overrepresented in fall mortality statistics (see Table 5.1), with the male-to-female ratio varying from 1.2:1 (in low-income and middle-income countries in South-East Asia) to 12:1 (in high-income countries in the Eastern Mediterranean region).

TABLE 5.1

Fatal fall injury rates per 100 000 children by sex, country income level and WHO region, 2004.

Type of fall

Based on data from the Global Burden of Disease project, which includes the fourth ICD coding digit from 70 mainly middle-income and high-income Member States, 66% of fatal falls among children occurred from a height, while 8% resulted from falls on the same level. Unfortunately, the relevant information was unavailable for a quarter of the reported falls (22).

Morbidity

Extent of the problem

Global statistics on non-fatal injury are not readily available, though the incidence of non-fatal falls is clearly much higher than that of fatal cases. Data that are available indicate that falls are a leading, if not in fact the most common, type of injury resulting in hospitalization or emergency room attendance in most high-income countries (20, 23–28). Falls were also cited as the leading cause of injury among 13–15-year-olds in the Global School Health Survey, covering 26 countries (see Statistical Annex, Table A.3).

Most published studies of non-fatal injury in low-income and middle-income countries are hospital-based and may fail to capture data on children who are unable to access medical care (29, 30). Community-based studies suggest that there are many more significant fall-related injuries than just those seen at health-care facilities (14, 31).

The Asian community surveys recorded injury events that were serious enough to warrant seeking medical attention or that resulted in school days missed. Injuries not meeting these criteria were deemed insignificant in terms of health-care costs and social costs (29, 31). In the injury survey in Jiangxi province, China (19), for every one death due to a fall, there were 4 cases of permanent disability, 13 cases requiring hospitalization for 10 or more days, 24 cases requiring hospitalization for between 1 and 9 days, and 690 cases where care was sought or where at least 1 day of work or school was missed (see Figure 5.3). The survey highlighted the substantial cost of non-fatal injuries due to falls and the small proportion of cases seen in hospital settings – cases which, taken together, must contribute considerably to the overall cost of falls.

FIGURE 5.3

Inury pyramid for falls among children 0–17 years, Jiangxi province, China. Source: Reference .

Similar patterns of injury were observed in Uganda, where there were higher rates of falls among children in rural than in urban areas (32). Data from various countries in Latin America and from Pakistan also reveal that falls are a common cause of non-fatal injury among children (9, 33–36).

Globally, 50% of the total number of DALYs lost due to falls occur in children less than 15 years of age. However, the burden of childhood falls is largely explained by the morbidity and disabilities that may persist for life. The skewed distribution of this burden geographically and the relative scarcity of statistics on non-fatal injury events make it more difficult to describe and address the problem of childhood falls.

Severity of falls

The severity of a fall-related injury is determined by the anatomy of the human body and the impact force to which the body is subjected – in the absence of any special protection on the body or impact-absorbing materials in the landing or contact surfaces (37–41). The impact force itself depends, among other things, on the height from which the fall occurs. These relationships are well described in high-income countries in relation to falls from playground equipment (42–46) and from windows and roofs (47–49).

The proportions of injuries due to falls, as well as the patterns of injury from falls generally, can differ considerably in developing countries from those in developed countries (50). For instance, a recent study conducted in four low-income and middle-income countries found that falls were the leading cause of unintentional injury among children under the age of 12 years. The types of injuries sustained were largely cuts and scrapes, fractures of the upper and lower extremities and contusions. In half of all cases, the children were left with some form of disability – in 41% of cases with a temporary disability of less than six weeks (see Statistical Annex, Table C.1).

Generally, the greater the height from which a child falls, the more severe the injury (51). The Jiangxi survey found that about 18% of falls were from heights of five metres or more and two thirds involved heights of between one and five metres (19). The Jiangxi and Beijing surveys (19, 52) revealed that as children grew older, an increasing proportion of falls were from greater heights – such as trees and rooftops, frequently, in the case of adolescents. A Nigerian study, on the other hand, found that only 25% of falls in childhood leading to hospitalization were from heights, the remainder occurring at ground level (53).

Injuries from falls from heights of more than two storeys typically involve falls from windows, balconies and roofs (41, 51). Falls from stairs and trees are also common, as are falls into ditches, wells, shafts and other holes in the ground (19). Trees are particularly hazardous, especially in some tropical countries where children are employed to harvest high tree crops (50) (see Box 5.1).

BOX 5.1

Falls from trees in Mozambique. In 2006, an injury and violence survey was conducted in Mozambique. The study covered 179 households from the urban district of Matola and 162 from the rural district of Boane, both areas in the southernmost part of the (more...)

In the United States, many of the fall fatalities among children involve falls from poor-quality housing in low-income urban areas, typically from the second floor or higher (51). Falls from greater heights tend to occur more in the summer months. This is presumably because windows – the usual site for falls of pre-school-age children – are more likely to be open at that time of year, and older children are more likely to be outdoors playing on fire escapes, roofs and balconies (47–49).

A case–control study from New Zealand has shown that the risk of injury in a fall from playground equipment increases dramatically for heights of over 1.5 metres (54). After adjusting for various factors such as the child’s age and weight and the presence of impact absorbing surfaces, children falling from over 1.5 metres were found to have four times the risk of injury compared to those falling from below that height. The risk of injury rose with increasing fall height, with children who fell from over 2.25 metres having 13 times the risk of injury compared to those who fell from 0.75 metres or below.

The extent to which falls from low heights result in life-threatening injuries, especially head injuries, has generated considerable controversy, largely in relation to suspected child abuse (55–57). What evidence there is on this does tend to point in the direction of possible abuse. Reported fatalities following short or minor falls are more common in situations where there are no unrelated witnesses who can confirm the history of events (55–57). When making clinical decisions, therefore, the height of a fall should not be the only criterion used to determine the threat to life that a particular injury poses (58).

Consequences of falls

Falls are the leading cause of traumatic brain injury, especially in young children, with a significant risk of long term consequences (20, 59–61). In the United States, about one third of the 1.4 million people suffering traumatic brain injuries are children aged 0 to 14 years, who have disproportionately high rates of falls compared with other age groups (62).

A Canadian study noted that 36% of infants aged less than one year presenting to an emergency department following a fall had significant head injuries, and that falls were responsible for 90% of all head injuries seen in the emergency department (20). Falls are also the most common cause of fatal and serious head injuries among children in France and the United Kingdom (63–65).

While the incidence of spinal-cord injuries following a fall is generally low, most spinal-cord injuries, resulting in quadriplegia or paraplegia, are attributed to falls (66–68). A case study from Nigeria describes the lifelong disability resulting from such injuries, often the result of falls from tall palm trees (69).

Children tend to use their arms to protect their heads when falling from a height. Limb fractures, particularly of the forearm, are therefore the most common type of fall-related injury in children beyond the age of infancy (37, 70–73). An analysis in Australia of children falling from playground equipment showed that fractures accounted for 85% of playground injuries (74). There have been suggestions that the incidence of upper limb fractures has increased in recent years, while that of serious head injuries has declined. This claim needs to be investigated further in relation to safety standards in playgrounds (75, 76).

Even after incurring open or complex fractures, children in low-income countries can make a good recovery if they receive proper care (77). All the same, permanent disfigurement and functional impairment from such fractures are frequently seen in poorer settings (5, 9, 78, 79). Growth-plate fractures are particularly liable to result in permanent disability (79). Abdominal and chest injuries are uncommon in falls from one or two storeys, but more frequent in falls from greater heights (47, 72, 80).

The UNICEF–TASC survey in Jiangxi province, China, found that falls were the leading cause of permanent disability in young people aged 0–17 years, primarily due to the long-term consequences of brain and cervical spine injury. Such disability was estimated to be 3.5 times more frequent in boys than in girls (19). A study in Nicaragua also found that falls were the leading cause of permanent disability in young people less than 15 years of age (33). In Thailand (81) and Viet Nam (18), falls accounted for 1% and 4% of the total burden of permanent disability, respectively. Permanent disability in these surveys referred to the loss of a physical sense – such as sight or hearing – loss of mobility or loss of the ability to speak. However, emotional, psychological and cognitive long term consequences were not included because of the difficulty in measuring them (19). As a result, the overall amount of permanent disability is likely to be considerably greater than the survey estimates suggest.

Risk factors

As already mentioned, the incidence and patterns of fall injuries among children depend to a great extent on contextual factors. A systematic review of the published literature on risk factors for unintentional injuries due to falls in children identified age, sex and poverty as consistent independent risk factors (4). Other major risk factors influencing the incidence and severity of fall injuries were: the height of the fall; the type of surface; the mechanism (whether dropped, falling down stairs or falling using a baby walker); and the setting (whether day care or home care).

Drawing on these studies and other epidemiological findings, Table 5.2 shows the major factors influencing the incidence of unintentional childhood falls and their consequences.

TABLE 5.2

Haddon Matrix applied to the risk factors for childhood falls.

Agent factors

Consumer products

In surveys of product safety in high-income countries, falls – generally involving infants in the first year of life – are among the most common non-fatal injuries. Such falls are associated with pushchairs (known as strollers in North America), prams, baby walkers, high chairs, changing-tables, cots (excluding portable cots) and baby exercisers (119, 120). A study from the state of Victoria, Australia, suggests that baby bouncers (also called baby exercisers) are involved in the most severe non-fatal injuries related to products, with almost one in three injuries resulting in hospital admission. After baby bouncers, high chairs and pushchairs are the products linked to the most severe injuries from falls (120, 121).

A review of fall-related risk factors in the 0–6-year age group found that among children using bunk beds, the risk of a fall injury is greater for younger children, children from poorer families, children in newer beds, and children who fall onto non-carpeted floors (4, 122). Other reports suggest that while bunk beds and conventional beds may cause almost the same number of fall injuries among 5–9-year-olds, injuries from bunk bed falls are more severe than those from conventional bed falls as the fall is from a greater height (120).

Many products for leisure activities – such as skateboards, in-line skates, Heelys (a popular brand of shoes that convert from sports to roller shoes), ice-skates, swing ropes and trampolines – can result in fall-related injuries, particularly limb fractures, sprains and head injuries (123–129) (see Box 5.2). The European Union’s injury database has identified children’s bicycles, roller skates and swings as the three leading consumer products implicated in home and leisure activity injuries, most of which are from falls (130).

BOX 5.2

Protective equipment to prevent wrist fractures. Falls are a common form of sport and recreational injury in children and adolescents. Activities that are associated with “outreach” falls – where the person falls forward and lands (more...)

Despite the virtual absence of data on the issue, product safety is considered to be a significant problem for children in developing countries. In addition to product-related risks in occupational settings, globalization has led to the widespread use in developing countries of potentially dangerous products that are not always accompanied by the safety features or regulations generally found in developed countries. Heelys are one such case of increasing concern, as falls involving their use can result in significant head and limb fractures (124, 131, 132).

Playground equipment

Falls from playground equipment can lead to severe injuries and are commonly seen in hospital admission statistics in high-income countries (120, 133–135). A study from Victoria, Australia, found that falls from playground equipment accounted for 83% of emergency department admissions. Of these cases, 39% were related to falls from climbing equipment, 18% from slides and 14% from swings (120).

Several studies have discovered significant associations between certain structural features of playgrounds and fall injuries (45, 54, 136–139). A New Zealand study has shown that lowering the height of equipment to 1.5 metres could reduce the risk of children having to attend emergency departments following playground falls by 45% (42). Studies from Canada (45) and Greece (138) have found high risks of injury, particularly from falls, in playgrounds lacking the proper safety standards – such as having appropriate and sufficiently thick surface materials, and adequate handrails or guardrails.

Animals

Studies from several developing countries point to the increasing number of cases in recent years of children and young people presenting to hospital as a result of falling from a horse. This may be due to the growing popularity of horse riding as a recreational sport, as well as to larger numbers of children working on farms (143–145). While most injuries from falls from horses are minor ones, a study from the Netherlands estimated that up to 40% of children and adolescents treated in hospital after falling from a horse still suffered a disability four years later (146).

Animal racing also poses significant risks of childhood falls (147–150). Camel racing is a popular spectator sport, whose origins lie in the desert culture of West Asia and North Africa (150). Traditionally, race camels were ridden by young children from the family of the camel owner. In recent decades, though, migrant children as young as three or four years of age have performed as camel jockeys, sometimes trafficked for that purpose (150, 151). Falls are the commonest type of injury in camel racing, frequently resulting in head injuries, including fractures of the skull (148, 149).

Interventions

The prevention of fall-related injuries among children is of paramount importance worldwide, given the large amount of resulting morbidity, the high costs of health care and the significant risk of death, particularly from head injuries. The measures employed must strike a careful balance between, on the one hand, promoting the healthy development of children – allowing them to play, explore and be physically active – and, on the other hand, recognizing the vulnerability of children living in environments designed primarily for adults.

The Child safety good practice guide (180) is one of several national or regional policy documents describing practical approaches for preventing fall-related injuries among children. The following section considers the most promising such interventions in a global context.

Engineering measures

Identifying, replacing or modifying unsafe products has been a leading strategy to prevent injuries from falls in many high-income countries. Major reductions in the incidence of childhood fall injuries have been achieved by removing or redesigning nursery furniture (see Box 5.3), playground equipment, sports and recreational equipment, and other items such as shopping carts and wheelchairs (180, 181). In some instances, a complete ban on a product has ensued. In other cases, there has been substantial modification of the original design – such as the introduction of a new braking mechanism for baby walkers (182). To be effective, such measures generally require continuous enforcement (180, 182, 183).

BOX 5.3

Product safety and falls from nursery furniture. Many countries have found injuries associated with nursery furniture to be an important issue in children under the age of five years. In the first year of a child’s life, these injuries may represent (more...)

In some cases, sufficient evidence has accumulated from other situations for devices to be recommended to protect against fall-related injuries. Thus, despite a lack of intervention studies relating to horse riding, helmets are now recommended to reduce the risk of serious head injuries among young riders (144). All the same, studies from Australia, Canada, New Zealand and the United States suggest that rates of wearing helmets remain relatively low in these countries (184–186). Helmets and wrist guards are also strongly recommended for children engaging in ice skating, in-line skating and roller skating (126).

Environmental measures

Modifying the environment to make it more “child-friendly” is a passive intervention approach that benefits people of all ages. Major changes in the design and maintenance of playgrounds have substantially reduced the number of playground injuries in many high-income countries (180). Such modifications included laying rubber or bark ground surfacing of sufficient depth, and making equipment, such as slides, safer in terms of height and structure.

A community-based programme in the United States has demonstrated how modifying buildings can achieve substantial reductions in fall-related injuries among children. The “Children Can’t Fly” programme (49) (see Box 5.4), combining individual counselling and a mass media campaign with the free distribution and installation of window guards, has proved effective in cutting the incidence of falls from high-rise buildings in low-income areas. How this strategy might be transferred to other settings depends on the structure of dwellings, the resources available and other factors. However, the use of window guards in many parts of Africa and other developing regions (187) suggests that this approach might be useful, if implemented along with other measures, such as the enforcement of building regulations.

BOX 5.4

Children Can’t Fly. “Children Can’t Fly” was a programme developed by the New York City Department of Health in the early 1970s, to counter the high rates of death and injury among children following falls from windows. (more...)

Conclusions and recommendations

Falls are the most common cause in many countries of injury-related hospital stays and emergency department visits involving children. Limb fractures and head injuries are common and traumatic brain injuries are most likely to result in lifelong disability. The predisposing factors and the types of fall vary considerably across different settings. Developing countries have a disproportionately high rate of fall-related injuries among children, and efforts to prevent these injuries are hampered by the lack of evaluative evidence of interventions that have been tried in these countries. Furthermore, although it is clear that the health-care sector has a pivotal role to play in preventing childhood injury, injury prevention in many countries often does not figure among the priorities for health.

Table 5.3 summarizes the main approaches to addressing childhood falls. The most effective strategies, in all countries, are those that combine proven or promising measures.

TABLE 5.3

Key strategies to prevent falls among children.

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