Review of the Article Titled “Risk and

Protective Factors for Falls From

Furniture in Young Children: Multicenter
Case-Control Study”

Taslima Khanam
ID:1522028680
Submitted to Yamin Tauseef Jahangir
Application of Computer Software in Public Health (PBH 714)
Date: 31st March 2017
Reference:

Kendrick D, Maula A, Reading R, Hindmarsh P, Coupland C, Watson M, Hayes M, Deave T.

Risk and protective factors for falls from furniture in young children: multi center case-control
study. JAMA pediatrics. 2015 Feb 1; 169(2):145-53.

Summary:

In each year, more than 1 million children in US and 200000 children in UK attend emergency
departments (EDs) due to falls whose aged 0 to 4 years. Among total ED attended children in this
age group, 50% was the injury related to falls. US spent around $1082 million for treatment of
those children in 2005. This study aimed to estimate the associations for risk and protective
factors for falls from furniture in children aged 0 to 4 years. It was a multi center case-control
study at hospitals. It included 4 centers around UK. Total participants were 3320 children aged 0
to 4 years. Among them, 672 were case and 2648 were control participants match on age, sex,
calendar time and study center. The potential participants were invited to participate in the study
during medical attendance or by telephone or by mail. The participation rate for case was 35%
and for control was 33%. This study included an average of 4 controls per case. Case was
defined as falls from furnitures occurring at the child’s home resulting in attendance in the
selected hospitals. Control participants were medically attended without fall from furnitures. The
injuries of the control group was due to falls on 1 level, stair falls, poisoning and scalds. The
exposure variables included safety practices, safety equipment use and home hazards. The
outcome variables was fall from furnitures at child’s home.The confounding variables were age,
sex, calendar time, index of multiple deprivation (IMD) and distance from hospital. While
considering validity exposure measurement in the study, sensitivity, specificity and predictive
values of self reported and observed exposures were analyzed.The study demonstrated that
parents of case were significantly more likely not to use safety gates in the home compared with
parents of control participants. The adjusted odd ratio was 1.65 at 95% CI (1.29-2.12). They
were significantly more likely not to have taught their children about climbing on kitchen object
and the adjusted odd ratio is 1.58 (at 95% CI, 1.16-2.15). For the children aged 0 to 12 months,
the cases were significantly more likely to have been left on raised surfaces than control children
(AOR, 5.62, 95% CI, 3.62-8.72). They were significantly more like to have been had their
diapers changed on raised surfaces (AOR, 1.89; 95% CI, 1.24-3.27). Besides, They were
significantly more likely to have been put in car or bouncing seats on raised surface (AOR, 2.05;
95% CI, 1.29-3.27). For children aged 3 years and older, cases were significantly more likely to
have played or climbed on furniture and the adjusted odd ratio was 9.25 (at 95% CI, 1.22-70.07).
They were significantly less like to have played or climbed on garden furniture. The adjusted odd
ratio was 0.74 (at 95% CI, 0.56-0.97). This study suggested that some falls of young children
aged 0 to 4 years might be prevented by incorporating fall prevention advice into child health
surveillance programs, personal child health records, home safety assessments and other child
health contacts. However, further studies are need to find the casual relations between the safety
equipments and home hazard exposures and falls.

Critics:

The introduction of the article is very precise. It gave important facts about the falls of young
children aged 0 to 4 years old, but they did not give any evidences on the falls from furnitures of
this age group. The reason of focusing on falls from furnitures is also not being explained.
Therefore, the importance of the study remains unanswered to the readers and policy makers.

Even though this study focuses falls in young children, this study included new born, infants and
young children in the sample population. According to WHO studies, the age of young children
is defined from 2 to 5 years. The study did not include children who aged between 4 to 5 years.
Therefore, we can say the title of the study is misleading and the study also missed a portion of
the young children population. The sample might not fully present the targeted population.

The study protocol was approved by Nottinghamshire Research Ethics Committee. They have
tried to control most of the external and internal bias in the study. However, the participation rate
of cases was 35% and controls was 33%, which actually make this study more vulnerable to
selection bias. The participants of the study could be slightly different from the general
population. For example, they could be more serious than the other parents. That is called as
volunteer bias. Besides, the recruitment period of the case and control was different. Recruitment
of cases started on June 14, 2010, and ended on November 15, 2011. Recruitment of control
participants also started on June 14, 2010, but ended on April 27, 2012. This difference of timing
period in recruitment can also introduce bias in this study.

This study has a big sample population. They also had 4 controls per case, which make this case
control study more appreciable. The case were children who were medically attended due to falls
from furnitures. The control was children who were medically attended due to falls on 1 level,
stair falls, poisoning and scalds. That raises a question on the comparing these two groups of
children. The children in the control group that were injured due to poisoning and scalds might
have very different exposures than the cases. The response of these parents might differ from the
cases, since they are having different problem and might have high recall bias on exposures due
to having not similar issues. The study excluded falls from play equipment. and those living in
children’s homes. I would prefer having a control participants that included all kinds of falls
rather than including children having poisoning and scalds. Besides, this study is trying to find
risk and protective factors for falls from furnitures, keeping a control group in the community
level could make this study more representative sample to find the association between
exposures and falls.

Inclusion protocol of the cases and controls are different. “Cases were eligible to be recruited
once to the study.” However, “control participants were eligible to be recruited a second time to
the study as a case or additional control after at least 12 months from the first recruitment.” This
might increase the sample size, but it make authenticity of the data questionable. If a child
included as a control first and then 12 months later that child is also included as case. The
exposure of that child might not differ that much within 12 month interval. I think the study
should have similar inclusion protocol for both cases and controls.
Measuring the exposures of interest were safety behaviors, safety equipments and how hazards.
However, the measurement of those exposures were different among case and control. For case,
the exposures were measured 24 hours prior to the fall and for control, prior to questionnaire
completion. They also measured exposure of use of baby walkers, playpens/travel cots,
stationary activity centers for children aged 0 to 36 months. Children who are less than 9 months
do not learn even walking. Measuring their exposure to walker and stationary activity centers
seems unnecessary. Some for the definition of the exposures were not well defined. For example,
raise surface, rule about not climbing on objects and not jumping on furniture were not explained
in the article. The response options for some exposure variables were every, most, some days,
never and not applicable. These response were collected for a week prior to the falls and prior to
completing questionnaire. People might understand the options differently. This type of response
option should include number of days instead of subjective categories like most or some days.
Then, the inconsistent answers could be avoided. Therefore, the questionnaire is needed to be
redesigned to omit these type of errors.

The tables of the article included lots of variables that make the tables quiet long. Some of the
variable that defined the characteristics of the study population were confusing. For example, in
Table 1, maternal age is less than and equal 19 years at birth of first child does not have direct
connection with the falls of young children where only 45% children was first children in the
sample. The overcrowding variable was defined as more than 1 person per room which is little
bit misleading. The sample says 56% house are overcrowded which could be derived by how we
have actually defined our variable of overcrowding.

One of the main challenge for this study was having lots of missing values. They have excluded
missing data range from15% to 25% during multivariate analysis. They controlled the
confounders during the analytical statistics. Compare to the controls, cases were slightly
younger, had fewer hours of out-of-home child care per week, more of their parents were
unemployed, received state benefits, lived in nonowner-occupied housing, and lived in
neighborhoods with higher deprivation scores. For statistical analysis, “odds ratios (ORs) and
95% confidence intervals were estimated using conditional logistic regression adjusted for
neighborhood deprivation, distance from hospital, and confounders identified from DAGs.” The
study included lots of statistical analysis and reported most of their findings to the articles. The
analysis table was also very long, which makes the table less reader friendly.

It was found that the increase odds of falls is statistically significantly associated with not using
safety gates anywhere in the home, leaving children on raised surfaces, changing diapers on
raised surfaces, putting car or bouncing seats on raised surfaces, climbing or playing on
furniture, and not teaching children rules about things they should not climb on in the kitchen. It
was largest case control study on fall from furniture in young children. However, the study
cannot confirm that the association is causal. Therefore, further studies are needed to find the
casual relation between risk and protective exposures and the falls from furnitures.