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A review of stroller-related and pram-related injuries to children in Singapore
  1. Manasvin Tripathi1,
  2. Arif Tyebally1,2,
  3. Jasmine Xun Yi Feng1,
  4. Shu-Ling Chong1,2
  1. 1Department of Emergency Medicine, KK Woman's and Children's Hospital, Singapore, Singapore
  2. 2Duke-NUS medical school, Singapore
  1. Correspondence to : Manasvin Tripathi, Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore; manasvintripathi{at}gmail.com

Abstract

Prams and strollers are commonly used in daily childcare. We aim to study the type and severity of injuries associated with prams and strollers in an Asian population. We performed a retrospective review of children below the age of 6 who presented to a tertiary paediatric hospital in Singapore, from January 2012 to June 2015, with such injuries. There were 248 pram-related and stroller-related injuries. The median age was 12.5 months old. 69 (27.8%) sustained open wounds, 17 (6.9%) suffered fractures or dislocations and 2 children had significant head injuries. 29 patients (11.7%) sustained injuries while on stairs or escalators. Most of the injuries (197 cases, 79.4%) occurred despite adult supervision. The need for intervention was associated with older age and entrapment injuries (p<0.001). Only appropriately sized prams and strollers without exposed hinges should be used. These should not be deployed on stairs and escalators.

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Introduction

Prams (also known as perambulators or baby carriages) and strollers (also known as push chairs or buggies) are small manually propelled vehicles with three or four wheels designed for caregivers to transport infants and toddlers on foot.

Prams are made for infants and are designed to accommodate them in a horizontal lying position. They have carriages to accommodate the sleeping infant and often have a canopy to cover part of the carriage. Strollers are designed to transport babies and children over the age of 6 months, in an upright or semi-upright seated position. They tend to be lighter and more often of a collapsible construction. Side-by-side and long front-back tandem strollers are also available for transporting more than one child by a single parent or caregiver.1 ,2

Prams and strollers have been associated with falls and entrapment injuries in young children.3 ,4 Injuries often result from the equipment falling over, unintentional rolling away of the equipment, mechanical defects or the very act of deploying the equipment. Analysis of data from multicentre studies done in USA and Australia have led to the creation of well-defined safety standards for marketed prams and strollers.5–8 Despite these standards, injuries still occur; the majority of which are preventable. Recently, in Singapore, a baby who was sitting in a stroller pushed by his 21-month-old cousin sustained a major head injury after the pram he was in folded inwards and fell to the ground. He died from intracranial bleeding.9

Though similar injuries have been studied in other populations, there is currently a lack of such literature in the Asian population. Even though the equipment itself is largely the same, the manner of use (or inappropriate use) may differ between different populations and cultures. We aim to (1) describe pram and stroller injuries in our population and identify possible risk factors associated with severe injuries and (2) compare our injured population with those reported in other countries.

Methods

This study was a retrospective review of data from the injury surveillance database of KK Women's and Children's Hospital (KKH), Singapore, from January 2012 to June 2015. We included children aged <6 years old. KKH is the main paediatric tertiary hospital in Singapore and sees an annual attendance of about 175 000 children, including patients from neighbouring countries.

The injury surveillance database consists of prospectively collected data that include patient demographics, mechanism of injury, object(s) associated with injury and location of the injury. The details surrounding each injury are documented during the consultation in the emergency department (ED). MT and JFXY searched the database using the key words ‘pram’ and ‘stroller’ under objects associated with injuries. All other types of baby care products were reviewed manually to look for any missed stroller-related and pram-related injuries. Information was also collected about the type of injury and the interventions performed for the children.

We looked specifically at these injuries which were associated with staircases or escalators. Data were collected on the adult supervision during the injury.

We separately analysed injuries that required procedural intervention in the hospital. These included toilet and suture for open wounds, dental procedures for dental injuries, manipulation and reduction for fractures or dislocations, cast immobilisation and surgery under general anaesthesia.

We used SPSS V.19.0 (PC statistical package, SPSS, Chicago, Illinois, USA) for statistical analysis. Categorical variables were described by frequency (numbers and percentages) while continuous variables were described using medians and IQRs. We performed a univariable logistic regression to study the association between the need for intervention and presenting variables. A p value of <0.05 was used to define statistical significance.

This study was given ethics approval by the local institutional review board.

Results

There were 248 pram-related and stroller-related injuries among children <6 years of age during the study period (refer figure 1). Out of all the injuries, 111 were associated with strollers and 136 with prams. There were unclear data on one injury.

Figure 1

Flowchart describing the derived numbers of pram and stroller injuries from injury surveillance database.

The median age of presentation was 12.5 months (refer table 1).

Table 1

Demographics, circumstances and description of injury of study subjects (n=248)

While the most common diagnosis was that of minor head injury, a few head and face injuries were severe and required intervention. A 1-year-old sustained multiple facial lacerations and a head injury after falling from the pram while on an escalator. Toilet and suturing of the lacerations were performed. Another 8-month-old infant suffered an unwitnessed fall from the stroller. This child presented with inconsolable crying and was noted to have a palpable depression on the scalp. The patient was diagnosed to have a depressed skull fracture on CT and underwent elevation of the depressed fracture under general anaesthesia.

The majority of injuries (242 cases, 97.6%) were caused by blunt trauma and six patients (2.4%) sustained injuries as a result of a crushing injury. Of all the injuries seen, 29 cases (11.7%) were documented to have resulted from the use of prams or strollers on stairs or escalators.

Most of the injured children (197 patients, 79.4%) were accompanied and supervised by an adult. In 15 cases (6%), there was no clear documentation whether adult supervision was present.

Most of the injuries happened in and around the home (116 cases, 46.8%). Among 131 injuries (52.8%) that occurred outside the home, 11 (8.4%) occurred in shopping malls.

A total of 50 (20.1%) patients required procedural intervention (refer table 2). Forty-four patients (17.7%) were admitted for inpatient observation, for head injury. Four patients (1.6%) were admitted for a procedure under General Anaesthesia. Two patients required toilet and suture to repair gingival lacerations, one patient required repair of a large tongue laceration by the surgeons and the last patient underwent neurosurgery for elevation of a depressed skull fracture under general anaesthesia (refer table 2).

Table 2

Outcomes

On univariable logistic regression, we found a statistically significant association between injuries that required procedural intervention and older age (p<0.001). We found that entrapment injuries were more often associated with the need for intervention in the ED (p<0.001). There was no significant association between injuries that occurred on stairs or escalators and the need for intervention (p=0.161).

Discussion

It has been suggested that stroller and pram injuries constitute the most common baby care product-related injuries.10–12 In our experience, stroller-related and pram-related injuries are more common when compared with infant walkers, high chairs, changing tables and infant exercisers.

The mean age of the injured children in our study was 12.5 months, similar to the previous study by Powell et al3 on National Electronic Injury Surveillance System data (NEISS) in the USA (mean age of 11 months). In our study, most of the injuries (223 patients, 89.9%) occurred on the head and neck region, also similar to the NEISS data (87%). We found that those with injuries to their limbs and digits from entrapment injuries were more likely to require intervention.

The older children were more likely to sustain injuries that required procedures to be done in the hospital. We postulate that older children are heavier and are more likely to tilt the stroller or pram off balance, resulting in a fall. Also, older children tend to exhibit more exploratory behaviour and may stand or climb out of the pram.

There was no statistically significant association between the need for intervention and whether prams versus strollers were involved during the injury (p=0.606). We noted 29 (11.7%) patients who sustained injuries while the strollers and prams were on escalators and stairs, which was similar to the 10% reported in a study conducted in Australia.13 There was, however, no statistically significant association between the need for intervention and whether stairs/escalators were involved. This could be due to the small numbers that required intervention. Of special interest, injuries that occurred in shopping malls contributed to 11 patients (8.4%) of those injured outside the home. We specifically looked at shopping malls because young parents in our population frequently bring their children to shopping malls. It is common practice to hang heavy shopping bags on the stroller handles—this could lead to the loss of balance of the pram or stroller.

We were unable to determine the exact number of injuries associated with unfastened belts/harnesses. The lack of proper restraint use while in the stroller has also been previously reported.14 ,15

We recognise the limitations in our study. Milder injuries could have been seen in other primary care facilities—this could have led to an underestimation of the size of the problem. Also, the number of injuries that required intervention was small. This would affect the statistical significance when studying the association with relevant details in the mechanism of injury (eg, location and supervision).

Recommendations

Parents should make sure that the prams and strollers (with their corresponding restraints and safety harnesses) are appropriate for the age and size of the child.

Children should not be allowed to stand in or lean out of a pram or stroller. Adult supervision is mandatory at all times. After opening the pram, caregivers should check and adjust the pram prior to putting the child in the pram or stroller. The harness should be secured as soon as the child is placed inside.

While choosing a pram, parents must make sure that there are no exposed hinges and joints, which may trap or crush the digits. The pram structure must be stable, balance well and have safety features like effective locks, brakes and safety harnesses/belts.

Parents must ensure that their prams or strollers have the mandatory standard safety features according to one of the guidelines like Mandatory Australian Standard AS/NZS 2088:2000.16 ,17

Reminders and labels can be placed near injury prone areas such as escalators and stairs (figure 2). Barriers can be installed at the foot of escalators to prevent prams and strollers from being pushed onto them.

Figure 2

Suggested caution labels for escalators.

What is already known on the subject

  • Pram and strollers are common baby care products that cause injuries.

  • Majority of the injuries are caused by falls from the pram/stroller.

What this study adds

  • In our Asian population, those with injuries to their limbs and digits were likely due to entrapment injuries in the stroller structure. This type of injury was associated with the need for procedural intervention.

  • Older children were more likely to sustain pram-related or stroller-related injuries that required intervention.

  • Pram and stroller injuries continue to occur on escalators and stairs. Injury prevention efforts should focus on these high-risk areas.

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References

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Footnotes

  • Contributors MT, CS-L, AT and JFXY contributed to the conception and design of the study, analysis and interpretation of the data. MT and JFXY were directly involved in data acquisition. All the authors were involved in drafting the article and revising it critically at every step for important intellectual content. All authors have read the manuscript and have approved its submission. The material submitted is original and has not been submitted or published elsewhere.

  • Competing interests None declared.

  • Ethics approval Centralised Institutional Review Board (CIRB)—SingHealth Research, Singapore.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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