From Crib to Kindergarten The Essential Child Safety Guide

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Contents

Preface vii

1 Keeping Your Child Safe from Injury: An Introduction 1

2 Good Night, Sleep Tight: Sleep Safety 23

3 Splish Splash: Bathing and Dressing 43

4 Peter, Peter, Pumpkin Eater: Food Safety 58

5 It’s Playtime! Toys, Games, and Playgrounds 76

6 Are We There Yet? Traveling Near and Far 107

7 Upstairs, Downstairs, and All Around the House 123

8 Safety, Room by Room 145

Appendix: Injury Prevention Summary Charts 167

Resources 185

Bibliography 189

Index 193
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Preface

You are almost certainly reading this book because you have children
in your life who mean the world to you. Your children or grandchil-
dren or nieces or nephews or next-door neighbors light up the lives of
everyone they touch, and you want to keep those precious children
safe from all harm.
As an injury prevention specialist, I, too, care very deeply about
keeping children safe. I study injury trends, identify the causes of in-
juries, and recommend ways to prevent injury. I wrote this book to
give you the benefit of my work and my experience.
Before I describe what this book is about and how it is organized,
let me say a few words about what it is not. Above all, this is not a
book meant to instill fear or anxiety. By helping you understand how
to keep your child safe, I hope to make you feel more confident as you
and your child go about your daily lives. Nor is this a book about
childhood development, although it does touch on developmental
milestones to explain how and why children are at risk for different
injuries at different developmental stages. Finally, this is not a guide
to buying specific products, although it does discuss hazards, regula-
tions, and labeling information for most of the kinds of products used
around babies and children. This is a book that will help you recog-
nize and reduce hazards so that your children can be as safe from in-
jury as possible.

Injury can be defined simply as physical damage to the body. In the

past, the word accident was used to describe an event that resulted in
injury, but over time the scientific study of injury has revealed that
there are underlying factors that can predict injury, and thus it has be-
come clear that injuries are not random or chance events, as the word
accident suggests. Now we use the term unintentional injury. It is un-
settling at the least to realize that unintentional injury is the leading
viii PREFACE

cause of death among children. Happily, the study of injury has also
revealed that steps can be taken to prevent or minimize injury.
A hazard can also be defined simply as any condition that has the
potential to cause injury. Recognizing hazards (called “hazard identi-
fication”), like any other skill, requires education, training, and ex-
perience. In reading this book, you are educating yourself in how to
identify hazards and eliminate them. As you gain experience in iden-
tifying and eliminating hazards, you will reap the huge benefit of pro-
viding a safer environment for your child.
Children aged newborn to five years old spend most of their time
at home, and they are most likely to be injured in and around the
home. That’s why this book focuses on young children within the
home setting. One purpose of this book is to communicate the mes-
sage that children are vulnerable to different injuries at different ages.
The changes in children’s vulnerability to injury are related to changes
in their size, shape, physical and cognitive abilities, and behavior pat-
terns.
Another purpose of this book is to provide specific information
about how to reduce hazards and create a safer home environment
for your children. To that end, each chapter
• explains and illustrates injury patterns and describes when chil-
dren are at risk for these injuries;
• lists key prevention methods; and concludes with
• a safety checklist.
Charts that summarize key injury prevention information from
each chapter can be found in the appendix at the end of the text. The
checklists and summary charts provide quick access to key informa-
tion that is relevant for your child’s age.

▲
Throughout this book, you will see illustrations that are labeled
! with a special symbol—a triangle containing an exclamation point.
This symbol means, “Watch out! This is not safe!”
In the first chapter, I provide more information about injury and
injury prevention and begin to describe why children are at risk for
specific injuries at specific ages. The core of the book is organized by
the daily routines in a child’s life: sleeping, bathing and dressing, eat-
ing, playing, and travel. Again, in describing the hazards in these rou-
tines I do not mean to scare readers but rather to help readers reduce
or eliminate the hazards (which, as noted, have the potential to cause
serious injury and death). The last two chapters focus on the physical
household environment, from the backyard to the family room, to
PREFACE ix

help you recognize the hazards all around the home. Following the
appendix of charts is a list of useful resources you may want to con-
sult to keep current on safety issues.
I encourage you to use this book as a resource and reference guide
throughout the first five years of your child’s life, referring to specific
sections as often as you need to. Use the charts and checklists as quick
reminders of when (at what age) children are at greatest risk for cer-
tain injuries, and for reminders about key prevention measures you
can take. Share your knowledge with anyone who is involved in your
children’s care, from sitters and other caregivers to grandparents and
others.
What I want more than anything is for this book to help you keep
your children as injury free as possible through their first five years of
life.
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The Myths and Realities of Childhood Injury
Many people have beliefs about how injuries occur and how they can
be prevented. Often, however, these beliefs reflect myths rather than
reality. One common myth is that an injury is a random event—the
result of chance, bad luck, or something else over which we have no
control. This myth has had a long life, in part because the word acci-
dent perpetuates the notion that injuries occur in unpredictable ways.
Today, injury prevention specialists have replaced accident with un-
intentional injury. Injuries are either intentional (the result of a delib-
erate act, such as abuse or violence) or unintentional (the result of a
person’s interacting with a product or condition in a particular envi-
ronment). The reality is this: we can predict and, therefore, can pre-
vent unintentional injury.
Another myth is that injury prevention is just a matter of common
sense. Although common sense can help prevent injuries, effective in-
jury prevention strategies are based on scientific principles. Many dis-
ciplines are involved in injury prevention, including epidemiology,
hazard analysis, human factors analysis, engineering, biology, phys-
ics, biomechanics, and communication science.
Think of an unintentional injury as an event that occurs on a time-
line. That is, some scenario—events, personal characteristics, prod-
ucts, or environmental conditions—sets the stage for an injury to be
possible. If these events, characteristics, or conditions interact in a cer-
tain way, a predictable injury could occur. Once an injury has oc-
curred, further events are set in motion. For example, a bystander re-
2 FROM CRIB TO KINDERGARTEN

acts, someone calls 911, or someone rescues the injured person from
more serious injury.
Here’s an example of a timeline of an unintentional injury:
On a warm day, a backyard above-ground swimming pool has just
been used by a family taking a swim before lunch. The pool does
not have a pool cover. The family consists of a mother, a father, and
three children, aged eight, five, and two years. The eight-year-old
is the last one to leave the pool area. His hands are full—he is car-
rying shoes, towels, and goggles—so he can’t get a good grip on
the gate when he closes it. As a result the latch does not lock, and
the gate stays ajar.
Inside the house, the father prepares lunch while the mother gets
the two-year-old into dry clothes. The older children take care of
themselves and play a video game in the den until lunch is ready.
The mother sends her youngest child into the den with one of his
toys, telling the older children to keep an eye on him while she takes
a quick shower. The older children, however, get involved in their
game and do not realize that their brother has left the den and
headed for the pool.
When the mother gets out of the shower and goes to check on
the children, she realizes the youngster is missing. Her instinct is to
call for him and hurry to the pool. She sees him floating face down
and immediately pulls him out of the water and begins CPR. The
father, alerted to what has happened, calls 911. Paramedics arrive
in two minutes and take over the mother’s efforts.
This child is fortunate and survives because he was found in time
and because his mother knew CPR.
You can see that pre-injury events—those that set the stage for an
injury—may unfold over time, but the injury itself happens in an in-
stant. The outcome of the injury depends on how quickly rescue ef-
forts begin and how effective they are.
You can also see that even though the stage had been set for an in-
jury, if the two-year-old boy had not gone outside, he would not have
almost drowned. Or had he gone outside but found the pool gate
locked, he would not have ended up in the pool. Changing even one
aspect of the scenario leads to a different outcome.
Here’s another example:
A grandmother visits her daughter and two-year-old grandson for
the weekend. The grandmother takes blood pressure medication
and keeps it in her purse when she travels. For convenience, she
AN INTRODUCTION 3

has transferred a weekend’s worth of medication from its child-

resistant package to a pillbox with a simple lid.
When she arrives at her daughter’s home and settles into the
guest room, she sets her purse on the bed. Later on, she comes
across her grandson looking in her purse. She sees that the pillbox
has been opened and is empty.
The boy’s mother calls a poison hotline. Based on the type of
medication, she is instructed to take her son to the local emergency
department. There the medical staff monitor and treat him, and he
is released the next morning.
From both of these examples, you can appreciate why we prefer in-
jury prevention efforts—those that interrupt the pre-injury scenario
so that an injury never occurs—to injury control efforts, those that
help minimize the consequences of an injury once it has occurred. But
because it is not always possible to prevent injury, it is also important
to control injury. In both of the scenarios above, the injury preven-
tion effort (the locking gate and the child-resistant cap) failed because
of human error. In both cases, the injury control effort worked, be-
cause the injury was reversed by immediate and appropriate actions
(CPR and emergency department treatment).
Human error is not a negative term. We all make mistakes: we all
get fatigued, stressed, distracted, or confused at times, or we fail to
communicate with each other, and any of these conditions can lead to
our making mistakes. Good injury prevention solutions always con-
sider human factors, including what a person may do wrong and what
the consequences could be.

What Defines an Injury?

People recognize an injury when they see one—a cut, a scrape, blood,
swelling, redness, loss of consciousness, and so on. People may even
recognize an injury when visual clues are missing, for example when
someone has experienced hearing damage, hyperthermia (excessive
heat), or a closed head injury (a blow to the head that doesn’t break
the skin). But what’s the underlying cause—the biological basis—of
injury? Put simply, injury results when the body’s tolerance to absorb
energy is exceeded.
Intuitively, you know that energy is associated with moving objects,
like a car, a train, or a thrown baseball, and that if a person were
struck by any of these objects, the energy in the moving object would
4 FROM CRIB TO KINDERGARTEN

be greater than the body’s ability to absorb it without injury. The en-
ergy associated with moving objects or physical force is called kinetic
or mechanical energy. Other kinds of energy are thermal (related to
temperature), electrical (related to electric current), chemical (related
to chemical substances and drugs), and radiation (related to changes
in atomic structure; examples are the production of radon gas and x-
rays). All of these five types of energy can cause injury. Another cause
of injury is an absence of or interference with life requirements—
something a person needs to live, such as oxygen. Examples of these
injuries include drowning and suffocation.
There are only six possible causes of injury, then: five kinds of en-
ergy and the lack of a life requirement. The potential for injury from
any of these types of energy or from lacking a life requirement is called
a hazard. So there are mechanical hazards, thermal hazards, electri-
cal hazards, chemical hazards, radiation hazards, and hazards that re-
move or interrupt life requirements. A classic approach to injury pre-
vention is to identify hazards associated with a product or an activity
and eliminate or reduce those hazards. Removing a hazard is a great
way to prevent injuries.
Mechanical hazards have to do with the potential for injury from
physical forces, like pushing, pulling, compressing, obstructing, twist-
ing, falling, and colliding. Here are examples of injuries from me-
chanical hazards:
cuts, bruises, and abrasions
broken bones
traumatic amputation
choking
foreign objects in the eye, ear, or nose
Thermal hazards have to do with temperature, either hot or cold.
Injuries from thermal hazards include the following:
burns from contact with hot surfaces or open flames
scalds from contact with hot liquids or steam
hypothermia from exposure to excessive cold (a child who falls
through thin ice while skating can suffer hypothermia)
hyperthermia from exposure to excessive heat (a child left in a
closed vehicle on a hot day can suffer hyperthermia)
Electrical hazards have to do with electric current. Examples of in-
juries from electrical hazards include shocks and burns from contact-
ing “live” wires (a child who sticks a key into an electrical outlet will
AN INTRODUCTION 5

receive a shock or jolt of electricity through his body). Lightning is

natural electricity and is also an electrical hazard, though your chance
of being struck by lightning is small.
Chemical hazards have to do with chemical substances in their
solid, liquid, or gaseous states. For the focus of this book, chemical
substances include medicines and pharmaceuticals, household clean-
ing agents, batteries, toxic gases, heavy metals (like lead, arsenic, and
chromium), and automotive products (like antifreeze and motor oil).
These are examples of injuries from chemical hazards:
poisoning
respiratory distress
chemical burns
Radiation hazards have to do with changes in molecular structure
that result in the emission of heat or light. Most commonly, we asso-
ciate exposure to radiation with long-term illness, such as leukemia,
rather than with acute, or short-term, injury. You are unlikely to en-
counter a radiation hazard in your home that will result in acute in-
jury.
Hazards that remove or interrupt life requirements have to do with
the cutting off of a person’s oxygen supply. Such hazards may cause
injuries such as these:
suffocating
drowning
breathing air with insufficient oxygen (for example, the air in a
house fire)

What Determines Whether an Injury Will Occur?

You interact with energy and hazards every day. Every time you cook,
you are exposed to a thermal hazard and the potential for a burn, but
only rarely do you get burned. When you do get burned, it might be
a minor burn that you treat at home or a severe burn that requires a
doctor’s treatment. Whether an injury occurs depends on two things:
1. The amount of energy. Was it a warm cookie sheet or a hot
cookie sheet that had just come out of a 400⬚ F oven?
2. The ability of the body, or body part, to absorb that energy.
Did you touch the hot pan with one finger, or did your tod-
dler put his hand on the pan?
6 FROM CRIB TO KINDERGARTEN

The energy can be delivered in a single exposure, like touching the

hot cookie sheet, or over a number of exposures, for example eating
lead-based paint chips every day for a month.
The ability of the body or body part to absorb the energy has to do
with
• composition of the affected area: is it muscle, fat, bone, or an
internal organ?
• size of the affected area: is it a fingertip, a hand, or an arm?
• biological maturity of the affected area: is it newly formed
skin, a developing organ, or a mature bone structure?
The severity of an injury depends on the balance between the en-
ergy delivered and the energy one’s body is able to safely absorb. To
gain a sense of the relative severity of injuries, consider the following
comparisons:
• injury from being hit by a toy car pushed along the floor ver-
sus injury from being hit by a real car traveling on a road at
40 mph
• injury from spilling a cup of hot soup versus injury from
spilling a pot of boiling pasta
• injury from touching a household outlet wire versus injury
from touching a high-voltage wire
• injury from drinking acetic acid (vinegar) versus injury from
drinking sulfuric acid
• injury from a routine x-ray versus injury from an atomic bomb
Different parts of the body have different abilities to absorb energy,
as illustrated by the severity of injury we would expect in the follow-
ing situations:
• being struck by a hard ball in the eye as opposed to the thigh
• spilling hot tea on the fingers as opposed to the lap
• splashing drain cleaner on the forearm as opposed to drinking
it
• an adult’s taking five baby aspirins by mistake as opposed to a
baby’s being given five adult aspirins by mistake
From these examples, you can see that there is a broad range of in-
jury possibilities, from no or minor injury at one extreme to death at
the other. You also get a sense of how many variables come into play
in determining if an injury will occur.
Injury prevention professionals study all the factors associated with
AN INTRODUCTION 7

an injury, including the person, the product, and the environment, to

identify what can be changed to prevent or minimize the injury. The
first choice is for the manufacturer to change the product, ideally in
a way that does not require the person to do anything. We call this a
passive intervention. If changing the product is not possible, another
choice is to change the environment. An example of this would be to
install a fence around a swimming pool. A third choice is to change
the person’s behavior, such as getting her to wear a bike helmet on a
regular basis. This last choice is usually the least preferred, however,
because it’s quite difficult to change behavior, regardless of whether
the person is a child or an adult.

A Brief History of Product Safety

We all use numerous consumer products in our daily lives, and we
don’t often give a lot of thought to the risks of their use. Today’s con-
sumer products are, on the whole, safe for their intended use, thanks
to stringent safety measures. These safety measures haven’t always
been in place, however. The 1970s became a turning point for con-
sumer product safety when Congress determined three things: (1) in
the U.S. marketplace, there was an unacceptable number of consumer
products that posed unreasonable risks of injury; (2) consumers were
not able to anticipate the risks of using those products; and (3) the
public needed to be protected. In 1972, therefore, Congress passed
the Consumer Product Safety Act, which created the U.S. Consumer
Product Safety Commission, an independent federal regulatory agency.
The Commission was directed to collect injury data and investigate
the causes and prevention of consumer product–related injuries, ill-
nesses, and deaths. The Commission was given the authority to make
rules and regulations, test products, recall or ban products, and im-
pose civil and criminal penalties. The Commission was also given the
responsibility to carry out some preexisting regulations, including the
Flammable Fabrics Act (passed in 1953), the Refrigerator Safety Act
(1956), the Federal Hazardous Substances Act (1960), and the Poi-
son Prevention Packaging Act (1970).
Some of the earliest mandatory regulations the Commission put in
place were for children’s products, including cribs (effective in 1973),
pacifiers (1977), rattles (1978), and small parts (1978). If you are
thinking, “When I was a kid we didn’t have all this protection, and I
survived just fine,” and if you are wondering why regulations are nec-
8 FROM CRIB TO KINDERGARTEN

essary at all, consider that many children did get injured or die when
you were a child. Those injuries and deaths were never systematically
reported or studied before the 1970s. The absence of regulatory pro-
tection was really a reflection of how little we knew about injury. The
facts about injuries to children are disturbing.
Before the crib regulation, many infants died when they became
trapped between slats or between a crib’s side rail and mattress.
Among other things, the regulation mandated that the spacing be-
tween crib slats be no greater than 2³⁄₈ inches—this space is narrow
enough to prevent an infant’s being trapped between slats. The crib
regulation forbade the use of wood screws, because they loosen over
time and lead to gaps in a crib’s frame in which an infant can become
trapped. Later amendments to the crib regulation forbade dangerous
cutouts in headboards and footboards, for these had been the cause
of serious head- and neck-trapping incidents. Also, a voluntary stan-
dard among crib manufacturers did away with tall corner posts,
which had created a strangling hazard, because clothing and cord
loops were easily hooked over them or became caught on them, es-
pecially as children tried to climb out of the crib.
Before the pacifier regulation, infants and young children had
choked on pacifiers that fit entirely into the mouth, and they were
hanged by pacifier cords that caught on other items, like crib corner
posts. Among other things, the regulation mandated that pacifier
shields be large enough not to fit inside the mouth and that pacifiers
not be sold with ribbons or other strings attached.
Before the rattle regulation, infants choked when rattles reached
the back of the mouth and blocked the airway. One provision of the
regulation was that a rattle not be smaller than a certain size to pre-
vent this type of choking.
Before the small parts regulation, children choked on the small
parts of toys. The regulation required that parts in toys and products
intended for children younger than three years be too large to cause
choking.
Some of the Consumer Product Safety Commission’s more recent
regulations have been for child-resistant cigarette lighters (effective in
1993), child-resistant multipurpose lighters (1999), bike helmets
(1999) (bicycles have been regulated since 1978), and child-resistant
baby oil packaging (2002). The Commission has also banned certain
products for children younger than three years. These banned prod-
ucts include lawn darts, infant cushions, small balls, and dive sticks
(hard plastic toys about seven inches long that children throw into the