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Toddler Safety: Injury Prevention for Children Ages Two to Four
When your child reaches the toddler age, it is an exciting time in not only his or her life, but also for the parents. A child between the ages of two and four is a discovering machine. Developmentally, children now can run, jump, climb stairs, ride a tricycle, throw a ball, and play with toys that may have many small, intricate parts. Having two children in this age range, I have found that watching them grow through these years is a wonderful and gratifying experience. Because of this curious and rambunctious nature, the toddler does not understand the inherent dangers of their playful and exploring environments. Parents often are not aware of what their children can do. Nearly 300 children younger than four years old die every month in the United States because of unintentional injuries. Most of these injuries can be prevented with good parental supervision.
Burn injury is a leading cause of death in children under the age of five. Having an increased surface area (the amount of skin that covers a child's body is proportionately larger when compared to adults) and thinner skin, children are more easily burned than adults.
Hot water scalds cause a majority of burns. A common reason for the scald burns in our emergency department is that parents do not test the temperature of the water prior to placing their children in a bathtub. Water heaters in apartments and houses have a factory setting at 140 to 150 degrees Fahrenheit. Only two seconds is required for a child to receive a third-degree burn from water set at 150 degrees. It takes four seconds if the water is at 140 degrees, and 30 seconds at 130 degrees. Therefore, it is best to turn the water heater thermostat down to between 120 and 130 degrees to prevent these burns. You should always test the water before placing your child in the bathtub: if it is too hot for you, the water will burn your child. Children should be placed with their backs to the faucet so that they cannot turn the water on.
A child that plays in the kitchen when a parent is cooking and preparing food is a dangerous combination. Spillage of hot liquids, grease, and hot food is an unfortunate yet preventable cause of burns. Your child will undoubtedly reach for your hot food or hot cup of coffee. Never leave these hot items within their reach. Also, never hold a child and hot liquids at the same time, as you cannot handle both. Finding a safer place out of the kitchen for your child to play is the remedy to this potential hazard. Remember other kitchen appliances and hot surfaces such as irons and wall heaters can still be hot enough to burn your children long after they have been shut off.
First aid for burns
If your child is burned, immediately put cold water on the burned area. A bandage or clean cloth should be loosely applied. Never place ointments, powder, or any other substances to the burn, as this may make it difficult to treat. It is often difficult to remove these substances and clean the burn, which results in great pain and distress to the burned child. All burns require medical attention.
As a parent, you should take measures to protect your family and home against fires. These would include installing fire and smoke detectors in sleeping areas and near the furnace. The smoke detectors should be tested once a month and the batteries changed once a year. (Set a memorable date such as your child's birthday.) Conduct home fire drills with several planned escaped routes. Disposal of ashes, cigarette butts, and matches should be done carefully. Never smoke in bed. Fire extinguishers should be placed in areas of higher risk of fire such as the kitchen, furnace room, and near the fireplace.
Of the gunshot wound victims that arrive in Childrens Hospital Los Angeles Emergency Department, I have found that almost all are not a result of an intruder. Children have either been shot by themselves, by their friends, or by family members. All guns should be kept out of the household, as their presence increases the incidence of toddler gunshot victims exponentially. A gun, if needed in the house, should be unloaded and in a locked location separate from the ammunition.
Motor vehicle accidents are the number-one cause of preventable deaths in children at every age level. Many head injuries result from automobile accidents because of improperly restrained children. Every child who weighs less than 40 pounds needs to be in an approved car seat. Some parents try to rush the child from the car seat to the seat belt. But from 40 to about 80 pounds, and up to 4' 9" tall, children should always be seated in a belt-positioning booster seat. This allows the older child to be elevated so that the adult shoulder and lap belts are positioned correctly across the shoulder, with the lap belt lying low and flat across the hips. Children also experience better visibility and comfort with the booster seat.
The safest place in the car is the backseat, and that is where a child should ride. The front seat should be avoided because of the potential dangers of air bag deployment. Fatal injuries have resulted from children being struck by an air bag triggered by an accident. Air bags are released at speeds upwards of 150 mph and can cause significant brain injury. If a child needs to sit in the front seat, the car seat must be moved as far back as it can go to put as much distance between the child and the air bag. The air bag should be turned off or disengaged.
Remember that you, as a parent, are a role model for your child. You must wear a seat belt every time you drive. Your children will copy your actions. My children always say, "Daddy--don't go! You need to buckle me up!" on those occasions I forget to strap them in their car seats. And if you and your children are unfortunate victims of an automobile accident--the car seats should be replaced with brand new ones.
Curious toddlers are able to open any drawer within their reach. Furthermore, their inquisitive minds lead them to climb to discover "untapped" areas of the household. They may taste or swallow their newfound "treasures." Almost half of all pediatric poisonings occur in children five years old and younger.
To prevent childhood ingestions, poison-proofing your home is prudent. It is important to realize that anything in your house can be poisonous. All medications should be in child-resistant packaging and placed in an area beyond your child's reach. Many medications do look like candy--they should be out of reach and out of sight of children. Pills should be kept in their original container. Medicines should never be left on a countertop or bedside table. Accidental poisoning from an overdose or misdoses can be avoided by carefully reading the medicine label directions. Household products such as bleach, soap, cleaners, and detergent should be kept away from children. These items should be behind cabinet doors fitted with child-restraint latches. Hazardous material such as paint thinner, drain cleaners, and other chemicals should be locked up in cabinets out of reach.
If your child puts something poisonous in his or her mouth, call your local poison center or doctor immediately. Time is of the essence--the number of the poison center should be attached to your phone.
Be prepared to tell the poison center what was ingested and the current symptoms your child may have.
If an unrecognizable tablet was ingested, the poison center may ask you to describe the characteristics of the tablet, and more importantly, the imprinted code. The imprinted code is found directly on the tablet or capsule. It can be either scored or printed directly on the medication itself.
Be sure to look at all sides of the tablet or capsule, as all letters or numbers are helpful. The poison center can input the code into a computer program that can identify the medication.
Syrup of Ipecac should be on hand to make your child vomit, but it should only be used if the poison center or your doctor instructs you to do so.
If you are instructed to go to your nearest emergency department, be sure to bring the ingested poison. In my practice, I have found it frustrating to treat children with an "unknown poison." Their caretakers have either forgotten to bring in the ingested agent or do not know the medication's purpose. This missing information only delays the treatment of those poisons that have a definitive antidote.
Choking on food and small objects by children account for a large number of deaths per year. Foods notorious for choking include hot dogs, nuts, popcorn, and grapes. All food should be cut into thin slices or small pieces to prevent choking. Small hard candy should not be given to toddlers. Marbles, beads, thumbtacks, and other small objects should be kept out of reach of a toddler's hand. Children walking, running, or playing with food or toys in their mouths should never be permitted. The worst type of aspirations that I have encountered in my experience as an emergency medicine physician are those that involve latex balloons. A latex balloon will burst into many small pieces. The aspirated balloon sticks to the walls of the trachea so tightly, it is very difficult to remove even with specialized equipment.
The best way to deal with a choking child is to be prepared. A basic life support class should be taken so that a parent can recognize a choking child and apply proper technique to help remove the foreign body that may be stuck in a child's throat. Never place your finger in the child's throat to grasp an object you cannot see--this may push the object farther down the airway and worsen your child's condition.
Choking hazards table
||Pins and safety pins
|Any toy less than 1 1/2 inches in diameter
||Carrots, celery, and other raw vegetables
|Game tokens and pieces
|Toy chest with no air holes
||Pencils and pens
||Hard candy and lemon drops
Falls are one of the most common causes of emergency department visits. By now, your toddler has discovered the exhilarating talent of climbing stairs and furniture. As a parent, you may believe that your home is a safe haven; however, it can be a place of potentially dangerous falls.
Stairway falls make up a large percentage of home falls. The stairs should be always cleared of toys and clutter, as your toddler is still mastering the art of stair climbing. A trip down the stairs may end up as a trip to the emergency department at the hospital. Gates at the top and bottom of the stairway should be placed to restrict access to doorless rooms. A hardware gate that requires screws to install is recommended at the top of the stairs. These gates can swing open like doors. A pressure gate, on the other hand, requires no hardware to install. They should never be used at the top of the stairs because they are easily toppled over by young children. Avoid using accordion gates with large openings because a child's neck can become entrapped.
Doors to any dangerous areas should be locked. Children should never be allowed to play on fire escapes, high porches, or balconies. Windows need to be closed and locked when children are around. If the room needs ventilation, open those windows that a child cannot reach. Furniture or anything a child can climb should be kept away from windows. Do not depend on window screens to keep your child from falling out of a window. Install window guards on windows that are above the first floor.
Drowning is second only to motor vehicle accidents as a cause of preventable death. A child can drown in only one or two inches of water. Therefore, it is very important to recognize the many different water hazards that exist in and around your home. These include toilets, bathtubs, buckets, pails, swimming pools, hot tubs, whirlpools, and wells. A toddler's head is relatively large in proportion to rest of his or her body. Being "top heavy," they can easily fall over into a container of water leading to catastrophic results.
Prevention is the key to avoid these dangers. Buckets, pails, and bathtubs should all be emptied completely after each use. Children should never be left unattended in the bathtub. Toddlers should never be allowed to be in the bathroom unless they are closely supervised. Installation of a doorknob cover helps thwart a child looking for trouble in the bathroom. The toilet seat can be secured down with a childproof latch.
Swimming pools should not be installed in your yard until your children are at least five years of age. If you already have a pool, a five-foot fence should be installed on all four sides with gates that self-close and self-latch. The latches should be higher than your child's reach. Rescue and first aid equipment as well as a telephone should be kept at poolside. Toys need to be taken out of the pool after use so that your child will not be tempted to reach for them. Air-filled "floaties" and toys do not make your child waterproof. Most important, you as the child supervisor should learn CPR (cardiopulmonary resuscitation) and know how to get emergency help.
Your toddler is at the age where his or her motor development is rapid and has great potential for injury. Children learn through experience, and injuries are inevitable, but anticipatory guidance and prevention is key to decrease the risk of serious injury. As an emergency medicine physician, I am always ready for any situation that may come through the hospital doors. You, as a parent, can also be prepared by using common sense, providing good parental supervision, effectively communicating to your child, and learning life-saving techniques such as CPR and basic first aid. All of these can lead you to enjoy watching your toddler grow safely and securely.
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