https://www.ncbi.nlm.nih.

gov/pmc/articles/PMC5893510/
Pediatric unintentional falls are the leading cause of injury-related emergency visits for children
< 5 years old. The purpose of this study was to identify population characteristics, injury
mechanisms, and injury severities and patterns among children < 5 years to better inform age-
appropriate falls prevention strategies.
Background
Unintentional falls were the leading cause of nonfatal injury among children 0–4 years old from
2000 to 2015 in the United States (Centers for Disease Control and Prevention, 2017a). Over the
past decades, both national and local childhood injury prevention efforts have provided
education and interventions in an effort to reduce these injuries. Amongst the successful local
programs were the “Children Can’t Fly” and “Kids Can’t Fly” campaigns in New York City and
Boston, respectively. Within the first 10 years of implementation, these public health campaigns
resulted in up to a 96% reduction of window falls for children < 5-years-old (Harris et al., 2011).
Nationally, the American Academy of Pediatrics (AAP) has been at the forefront of providing
pediatric caregiver and community education as well as fall prevention strategies through
Council on Injury, Violence, and Poison Prevention (COIVPP) policy statements about injuries
associated with infant walkers, shopping carts, trampolines, and falls from heights (American
Academy of Pediatrics, 2001a; American Academy of Pediatrics, 2006; American Academy of
Pediatrics, 2012; American Academy of Pediatrics, 2001b). Despite these injury prevention
efforts, unintentional pediatric falls have remained a significant cause of injury, medical
morbidity, and cost to the healthcare system in the youngest population. According to the
Centers for Disease Control and Prevention, in 2010, unintentional falls in children < 5 years led
to 1,077,652 emergency department (ED) visits with lifetime medical costs of over 2.5 billion
dollars as well as 22,451 hospitalizations with lifetime medical costs of over 750 million dollars
(Centers for Disease Control and Prevention, 2017b). These data exemplify the magnitude of the
financial and medical burdens caused by pediatric fall-related injuries.

Prior studies on pediatric falls have evaluated specific mechanisms of falls (windows, stairs,
furniture) (Harris et al., 2011; Pressley & Barlow, 2005; Zielinski et al., 2012; Pomerantz et al.,
2012; Kendrick et al., 2015; Kendrick et al., 2016) or specific injuries sustained (head injury)
(Love et al., 2009; Ibrahim et al., 2012). Few population-based studies have examined overall
risk factors and injury mechanisms for falls as a function of age (Khambalia et al., 2006; Pitone
& Attia, 2006; Unni et al., 2012; Wang et al., 2013). Fall injury prevention efforts are enhanced
when population risk factors, typical injury mechanisms, and injury patterns according to
developmental age are used to provide targeted recommendations. Better understanding of
expected injury patterns from fall mechanisms can guide clinicians to distinguish between child
abuse and unintentional injuries (Thompson et al., 2013).

The primary objectives of our study were to examine population characteristics, mechanisms of
injury (MOI), injury patterns, and injury severities from falls among children < 5-years-old. The
secondary objectives were to identify trends and patterns from these data to make
recommendations for age-directed fall prevention education and interventions.

INTRODUCTION
Falls are the most common cause of pediatric injury. In infants under age 1, falls account for
over half of all sustained injuries (Pickett et al., 2003) and are more often associated with head
and facial injuries (Flavin et al., 2006). Across all childhood age groups, children 3 to 17 months
old exhibit the highest rate of injury, and falls are the leading cause.
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 sustaining much more than a few cuts and bruises.
But some falls go beyond the resilience of a child’s body, making them the fourth largest cause
of unintentional injury death for children.
Falls are the most common cause of paediatric injury leading to emergency department visits. It
is widely acknowledged that children are at risk of falls in the community and with many
education programs supporting prevention, it is important that this education is reflected in the
hospital environment. Children fall as they grow, develop coordination and new skills.and are
often unaware of their limitations. Therefore one could conclude that all children are at some risk
of falling.
Aim
The intention of this guideline is to raise awareness and educate nursing staff and the
multidisciplinary team of the importance of maintaining a safe environment for all patients;
assist with identifying patients who are high risk of fall; provide the tools to educate families and
carers of the potential risk of falls and outline strategies to develop individualised management
plans of care to reduce risk for high risk patients
Falls can be classified into three types:
Physiological (anticipated). Most in-hospital falls belong to this category. These are falls that
occur in patients who have risk factors for falls that can be identified in advance, such as altered
mental status, abnormal gait, frequent toileting needs, or high-risk medications. Key actions to
take for prevention include close supervision of the patient (go to section 3.2) coupled with
attempts to address the patient's risk factors (go to sections 3.3 and 3.4).

Physiological (unanticipated). These are falls that occur in a patient who is otherwise at low fall
risk, because of an event whose timing could not be anticipated, such as a seizure, stroke, or
syncopal episode. Appropriate postfall care (go to section 3.5), coupled with injury prevention
measures in the case of recurrence (go to section 3.4), are key for these patients.

Accidental. These falls occur in otherwise low-risk patients due to an environmental hazard.
Improving environmental safety will help reduce fall risk in these patients but is helpful for all
patients (go to section 3.2). Occur when a patient falls unintentionally, usually as a result of
tripping or slipping, as a result of equipment failure or other environmental factors. Patients
cannot be identified as being at risk for falls prior to this type of fall.
Nursing responsibilities
 Orientate all patients, parents to room and ward
 Keep side rails up on the bed and keep the bed in the lowest position
 Side rails and cot sides are raised for appropriate age and patient groups
 Appropriate non slip footwear for ambulating patients
 Maintain adequate lighting in child's room; low level lighting at night.
 Keep floors clear of clutter including equipment and toys
 Secure and supervise all children with a safety belt or harness in wheelchairs, highchairs,
strollers, infant seats and any specialist seating (e.g. Tumbleforms)
 Children on trolleys are always under the immediate and direct supervision of a staff
member or a caregiver
 Infants in an incubator have portholes securely fastened and door closed unless directly
attended
 Hourly rounding will support the provision of proactive care such as the need for
assistance to the bathroom
 Place necessary items a patient may need within reach (drinking water, etc)
 Patients who have received sedation or general anaesthetic may be unsteady and require
supervision
 Nurses work with families to ensure they understand the risk of falls and how to help
prevent them.
Other ways to prevent falls

If your child is an inpatient, these guidelines can help prevent falls:

 Make sure the nurse call light, bedside table, telephone, or anything else your child may
need is within easy reach.
 Let the nurse know if you are leaving and your child is on falls precautions.
 All children who fall asleep outside their beds or cribs should be returned to their beds or
cribs. Please do this before you get tired and are ready for sleep.
 Make sure the nurse call light works and your child knows how to use it.
 Ask the nurse or doctor how much activity is safe for your child at this time.
 Encourage your child to move slowly, especially when getting up from the bed and after
receiving sedation.
 Have your child sit up on the side of the bed and wait to see how he feels before standing.
 If your child feels weak, lightheaded, or dizzy, he should ask for help before getting out
of bed.
 Use a wheelchair or wagon if your child’s gait (walk) is unsteady after sedation or
anesthesia.
 Your child should not lean on or use anything with wheels for support, such as an IV
pole.
  Ask your child to call for you or the nurse when there is a need to get out of bed for any
reason.
 Your child should not get out of bed at night alone. Patients who try to walk in the dark
often fall.
 Bending over may cause your child to feel dizzy. Your child should not lean out of bed to
pick up something off the floor.
 Your child should avoid wearing long nightgowns and robes that could cause tripping.
 Ask your child not to wait until he must hurry to the bathroom. Help him use the toilet
often. If your child is too weak to go into the bathroom, ask the nurse for a bedside
commode.
 If your child uses a cane, crutches, or a walker at home, he should do the same in the
hospital.
 If foot braces have been prescribed, encourage your child to wear them.
 If your child wears glasses, they should be on before getting up to walk.
 Please tell the staff if you see a slippery area that could cause your child or someone else
to fall.
 Talk to your child’s doctor, pharmacist, or nurse about medicines that could increase the
risk of falls.
 Talk about preventing your child from falling while talking about your child’s care in the
nursing bedside report.

Management 
Standard safety measures should be put in place for all patients regardless of the risk identified.

Falls score equal to or greater than 3 necessitates the implementation of a Falls High Risk
Management Plan which is located in the Primary Assessment flowsheet within the EMR.

For all patients identified as high risk, i.e., those with a falls risk score of 3 or greater; a Falls
High Risk Management Plan must be commenced. The plan will be developed in collaboration
with the child's parent and will be specific to the patient's individual needs.

The plan will remain in use until the patient's falls risk score changes. If the falls risk score alters
a new plan will be implemented as the patients needs may have changed. Patient risk should
continue to be assessed daily, once the patient's risk score is less than 3 and the patient's risk of
falling is reduced, a management plan is no longer required; however it is important that a safe
environment is always maintained.

A physiotherapist can advise as to how to safely support the patient during positioning, transfers,
standing, walking and use of mobility aids.

An occupational therapist can ensure safe setup of the ward bedroom, bathroom and toilet to
minimize falls risks and recommend management techniques/assistive equipment for self-care
tasks.
In the event of the occurrence of a fall:

 Ensure patient safety

 Provide immediate supportive action for the child
 Conduct a physical examination, measure and document vital signs
 Commence neurological observation if the child's head was the first point of impact
 Do not move the patient until injuries are identified
 Notify appropriate medical staff
 Ensure safe transfer back to bed, consider using a hoist if necessary

Documentation of a fall event

 Record the incident in the EMR, including: description of event (location, activity
occurring, time, who was present), assessment findings, interventions and patient
outcomes, notification of the incident to the parent.
 Report the incident through the hospital incident reporting system, VHIMs. All falls,
including near misses should be reported. The information from reported falls is used to
gain insight of the causes of falls for patients at the RCH and continuously improve the
local falls prevention program   
 The Medical staff/AUM or NUM to inform the parents if they are not present that: 

o A fall has occurred:

 What factors contributed to the fall

 Outcome of post-fall assessment
 What additional protective measures have been put in place

Key Prevention Tips

Play safely.
Falls on the playground are a common cause of injury. Check to make sure that the surfaces
under playground equipment are safe, soft, and consist of appropriate materials (such as wood
chips or sand, not dirt or grass). The surface materials should be an appropriate depth and well-
maintained.

Make your home safer.

Use home safety devices, such as guards on windows that are above ground level, stair gates, and
guard rails. These devices can help keep a busy, active child from taking a dangerous tumble.

Keep sports safe.

Make sure your child wears protective gear during sports and recreation. For example, when in-
line skating, use wrist guards, knee and elbow pads, and a helmet.
Supervision is key.
Supervise young children at all times around fall hazards, such as stairs and playground
equipment, whether you’re at home or out to play.

Treatment
https://www.nichd.nih.gov/health/topics/pediatric/conditioninfo

What are emergency medical services for children (EMSC)?

EMSC is care that aims to reduce children’s disability and death from severe illness
or injury by increasing awareness and enhancing capabilities among pre-hospital,
health systems, healthcare providers, and the general public of the special
(physiological and psychological) needs of children receiving emergency medical
care.

What is pediatric critical care?

Children who have severe or life-threatening injuries need critical care, which
includes constant monitoring and specialized treatments. Critical care happens in
hospital pediatric intensive care units (PICUs). PICUs are staffed by physicians with
specialized training to care for children with traumatic injuries; these specialists are
often called pediatric intensivists.

Because injuries can affect many parts of the body at once, PICUs have access to
many healthcare providers who specialize in many types of medicine. These
specialists may include emergency medicine physicians, surgeons,
anesthesiologists, cardiologists, neurologists, and others. PICUs may also have
access to pediatricians, nurses, social workers, psychologists, physical and
occupational therapists, speech therapists, pharmacists, and others who help
injured children and their families heal and recover. 2
Predisposing factors Precipitating factors

Age (<5 years old) Environmental conditions

Hospital environment
Medications (seizure)
Immobility
ASSESSMENT NURSING OUTCOME PLANNING INTERVENTION EVALUATION
DIANOSIS IDENTIFICATION
Subjective Acute pain At the end of nursing Short Term: Independent: Short Term:
data: related to intervention, the After 15-20 minutes
tissue patient’s: of nursing  Discuss the prevention After 15-20
“Simula po trauma and intervention, the measures. (Rationale: For minutes of
nung nahulog reflex  Mother will client’s mother will patient’s mother education.) nursing
siya sa kama, di muscle implement be able to know and  See to it that the beds are at intervention, the
na po tumigil spasms strategies to understand the fall the lowest possible position. client’s mother
kakaiyak.” As secondary increase safety prevention If needed, set the patient’s was able to
verbalized by to fall as and prevent falls measures. sleeping surface as adjacent know and
the mother of 2 evidence by in the home. to the floor as possible. understand the
years old client. excessive Long Term: (Rationale: Keeping the fall prevention
crying  Patient displays After 3 weeks of beds closer to the floor measures. Goal
improved well- nursing reduces the risk of falls and was met.
Objective data: being such as intervention, the serious injury. In some
baseline levels client will be able healthcare settings, placing Long Term:
 Weak in the mattress on the floor
appearance for pulse, BP, to regain and
respirations, and maintain mobility at significantly reduces fall After 3 weeks of
V/S taken as relaxed muscle the highest possible risk.) nursing
follows: tone or body level.  Put side rails up. intervention, the
(Rationale: To reduce the client regain and
T: 37.6 posture.
risk of falling.) maintain
HR: 155  Reduce or eliminate factors mobility at the
 Patient that precipitate or increase highest possible
RR: 28 displays pain experience (e.g., fear) level. Goal was
improvement (Rationale: Personal met.
in mood, factors can influence pain
and pain tolerance.)
coping.
 Investigate signs and
symptoms related to pain.
 (Rationale: Bringing
attention to associated signs
and symptoms may help the
nurse in evaluating the
pain. In some instances, the
existence of pain is
disregarded by the patient.)

Dependent:
 Administer medication as
prescribed by the physician.
(Rationale: Benefits are
effective management of the
illness/disease, slowed
progression of the disease,
and improved patient
outcomes.)