A systematic review of the risk factors and interventions for the prevention of playground injuries

Scoping review of children's and youth's outdoor play publications in Canada

INTRODUCTION

Since 2015, interest in the benefits of outdoor play for physical, emotional, social and environmental health, well-being and development has been growing in Canada and elsewhere.

METHODS

This scoping review aims to answer the question, "How, and in what context, is children's and youth's outdoor play being studied in Canada?" Included were studies of any type on outdoor play published after September 2015 in English or French by authors from Canadian institutions or assessing Canadian children and/or youth. Articles retrieved from MEDLINE, CINAHL and Scopus by March 2021 were organized according to eight priority areas: health, well-being and development; outdoor play environments; safety and outdoor play; cross-sectoral connections; equity, diversity and inclusion; professional development; Indigenous Peoples and land-based outdoor play; and COVID-19. Within each priority, study design and measurement method were tallied.

RESULTS

Of the 275 articles included, the most common priority area was health, wellbeing and development (n = 239). The least common priority areas were COVID-19 (n = 9) and Indigenous Peoples and land-based outdoor play (n = 14). Cross-sectional studies were the most common; the least common were rapid reviews. Sample sizes varied from one parent's reflections to 999 951 data points from health databases. More studies used subjective than objective measurement methods. Across priorities, physical health was the most examined outcome, and mental/emotional development the least.

CONCLUSION

A wealth of knowledge on outdoor play in Canada has been produced since 2015. Further research is needed on the relationship between outdoor play and mental/emotional development among children and youth.

Environmental and practice factors associated with children's device-measured physical activity and sedentary time in early childhood education and care centres: a systematic review

BACKGROUND

Early childhood education and care (ECEC) settings offer a potentially cost-effective and sustainable solution for ensuring children have opportunities to meet physical activity (PA) and sedentary time (ST) guidelines. This paper systematically reviewed the association between childcare environment and practice and children's PA and ST.

METHODS

Three electronic databases were searched, and citation tracking of eligible studies performed between June-July 2020 (updated March 2022). Studies were eligible when (i) participants attended ECEC settings, (ii) they reported the association between use of outdoor space, including factors of time, availability, play, size and equipment, and children's device-measured PA and ST, and (iii) where applicable, they compared the exposure to use of indoor space. Risk of bias was assessed using the Critical Appraisal Skills Program (CASP) tools. A synthesis was performed using effect direct plots and charts to visualise effect sizes.

RESULTS

Of 1617 reports screened, 29 studies met the inclusion criteria. Studies provided data on outdoor versus indoor time (n = 9; 960 children), outdoor versus indoor play (n = 3; 1104 children), outdoor play space (n = 19; 9596 children), outdoor space use external to ECEC (n = 2; 1148 children), and portable (n = 7; 2408 children) and fixed (n = 7; 2451 children) outdoor equipment. Time spent outdoors versus indoors was associated with increased moderate-to-vigorous PA (MVPA), light PA (LPA) and total PA, while the association with ST was inconclusive. The mean (standard deviation) levels of outdoor MVPA (4.0 ± 3.2 to 18.6 ± 5.6 min/h) and LPA (9.9 ± 2.6 to 30.8 ± 11.8 min/h) were low, and ST high (30.0 ± 6.5 to 46.1 ± 4.3 min/h). MVPA levels doubled when children played outdoors versus indoors. Outdoor play space, and outdoor portable equipment, were associated with increased MVPA. A dose-response relationship for outdoor play area size was observed, demonstrating increased MVPA with areas ≥505m2 (5436 ft2), but no further increases when areas were > 900m2 (9688 ft2). No studies reported on injuries in outdoor settings.

CONCLUSIONS

ECEC policies and practices should promote not only outdoor time but also the availability of resources such as portable play equipment and sufficient size of outdoor play areas that enable children to be physically active for sustained periods while outdoors.

SYSTEMATIC REVIEW REGISTRATION

International prospective register of systematic reviews (PROSPERO) Registration Number: CRD42020189886.

The Current Status of Public Playground Safety and Children’s Risk Taking Behavior in the Park: Nakhon Si Thammarat Province, Thailand

The playground is perhaps the one area where school children feel like they can roam free, and public playgrounds provide many learning opportunities through different types of play. A cross-sectional descriptive study is presented with the objective of studying playground safety and the play behavior of primary school children at a park in Nakhon Si Thammarat Province, Thailand. The total number of playground equipment pieces was 22, the sample group of children was 362 children, and the data were collected using a playground safety survey and an observation form on playground play behavior. Data were collected from 2017 to 2018 and were analyzed using descriptive statistics including frequency, average, and standard deviation. The research showed that: (1) the most common defects of playground equipment included the material selection, the distance of the stair steps, and the height of the playground equipment; (2) the lack of awareness of children in terms of using the playground equipment safely; and (3) the three top risks in the play behavior of children were not checking equipment or toys before play, playing on the equipment over-adventurously, and playing on the equipment carelessly with friends. Related government agencies should provide support and management for playground areas and playground equipment by continuously implementing equipment checks, improvements, and repairs.

Achieving gains in state and local child safety systems and workforce development: application of the framework for quality improvement and innovation in child safety

OBJECTIVE

This study investigated the application of the Children's Safety Network (CSN) Framework for Quality Improvement and Innovation in Child Safety through the Child Safety Learning Collaborative (CSLC).

METHODS

The CSN Framework was used by 26 state/jurisdiction teams that participated in cohort 1 of the CSLC, from November 2018 to April 2020. The aim was to strengthen child safety systems and the workforce to spread child safety evidence-based and evidence-informed strategies and programmes for children and adolescents ages <1-19 years.

PROCEDURES

Participating teams' child safety system development, workforce development, engagement in the CSLC, challenges encountered and overall satisfaction with the CSLC were assessed through ongoing CSLC participation records and an end-of-cohort survey (survey response rate: 73.1%).

RESULTS

Teams showed an average change of 2.4-fold increase in the spread of evidence-based and evidence-informed child safety strategies and programmes, indicating improvement in child safety systems. Knowledge development on CSLC tools and strategies was reported by 77.8% of teams, with 55.5% reporting CSLC tools and strategies contributed to workforce development. Over two-thirds (70.6%) reported being satisfied or very satisfied with the CSLC, but identified some challenges, including staff turnover and the need to strengthen partnerships. All teams demonstrated engagement in the CSLC, based on participation in a virtual meeting, learning session or a monthly report submission.

CONCLUSIONS

Despite challenges, teams continued to participate in the CSLC, recognising the importance of collaborative learning. The CSN Framework is helpful for state/jurisdiction teams to improve child safety systems and develop their workforce.

Epidemiology of child playground equipment-related injuries in the USA: Emergency department visits, 1995-2019

AIM

To analyse the most recent trends and characteristics of playground equipment-related injuries in children.

METHODS

We used the National Electronic Injury Surveillance System database to acquire cases of playground equipment-related injuries in children ≤17 years old between 1995 and 2019. A total of 184 580 unweighted cases met our study inclusion criteria.

RESULTS

A total of 5 356 703 (95% confidence interval 4 235 530-6 477 876) emergency department visits for playground-related injuries in the USA were estimated during the study period which was equal to an average of 29.4 annual injuries per 10 000 US population ≤17 years. The mean age was 6.5 (standard error 0.049) years. School-aged (42.7%) and pre-school children (35.3%) accounted for most playground injuries. More than half of the injuries were reported in males (53.6%). Most injuries occurred with climbing apparatuses (36%), followed by swings (25.9%) and slides (20.9%). Overall number of injuries (∆ - 22.3%, P = 0.01) and incidence (∆ - 21.6%, P = 0.01) had a declining trend after 2012. However, reported concussion injuries showed an increasing trend during the study (∆ + 28.3%, P < 0.001). A marked seasonal variation in number of injuries existed with most injuries in May and September.

CONCLUSIONS

Although injuries arising from playground equipment have decreased during the past 8 years, there was an increase in number of reported concussions. The outcomes of this study suggested that further efforts should be directed towards such serious injuries.

Paediatric playground and tree-related injuries: Hospital admissions in the Midland region of New Zealand

AIM

To examine the incidence and outcomes of paediatric playground and tree-related injuries in the Midland region of New Zealand.

METHODS

A retrospective review of Midland Trauma Registry hospitalisation data between January 2012 and December 2018 was undertaken. Cases included children aged 0-14 years hospitalised for playground and tree-related injuries. Demographic and event information, injury severity and hospital-related outcomes were examined.

RESULTS

Playground and tree-related hospitalisations (n = 1941) occurred with an age-standardised rate of 144.3/100 000 (confidence interval (CI) 127.3-161.3) and increased 1.4% (CI 1.3-4.2%) annually. The highest incidence was observed in 5-9-year olds (248.8/100 000) with 0-4 and 10-14-year olds at 86.0 and 89.2/100 000, respectively. Injuries most commonly occurred at home, school or pre-school (77.1%), 93.7% were due to falls and, the upper extremity was the most frequently injured body region (69.9%), particularly due to forearm (55.6%) and upper arm (34.7%) fractures. Tree-related incidents comprised 11.6% of all injuries and explained 57.1% of injuries classified as major severity. Fifty-eight percent of children were hospitalised for 1 day and 97.0% for less than 5 days. Estimated hospital costs were NZ$1.2 million annually with a median of NZ$3898 per incident. Injuries classified as minor severity accounted for 86.5% of the total estimated cost.

CONCLUSION

Children aged 5-9 years' experience high rates of costly hospitalisation for playground and tree-related injuries. Targeted injury prevention initiatives, particularly in the home and school environments, are imperative to reduce the incidence and burden of playground and tree-related injuries to affected children, their families and hospital resources.

The Role of Fall Biomechanics in the Cause and Prevention of Bone Fractures in Older Adults

PURPOSE OF REVIEW

Adults over age 65 experience the highest rates of bone fracture, and 90% of fractures in older adults are caused by falls from standing height or lower. Advances in fracture prevention rely on our ability to prevent falls, reduce the severity of falls, and enhance the resistance of bone to trauma. To help guide these efforts, we need improved understanding on the types of falls that cause fractures.

RECENT FINDINGS

In this review, we describe recent evidence on how the mechanics of falls in older adults influence the risk for fractures to the hip, wrist, vertebrae, and humerus. We discuss how fracture risk depends on fall height, fall direction, and landing configuration. We also review the benefits of exercise, wearable protective gear, and environmental modifications in preventing fractures in older adults. Our findings highlight promising new directions in fracture prevention, and the need for collaboration between the bone and falls research communities to implement proven strategies and generate new solutions.

Day care as a strategy for drowning prevention in children under 6 years of age in low- and middle-income countries

BACKGROUND

Drowning is responsible for an estimated 320,000 deaths a year, and over 90% of drowning mortality occurs in low- to middle-income countries (LMICs), with peak drowning rates among children aged 1 to 4 years. In this age group, mortality due to drowning is particularly common in rural settings and about 75% of drowning accidents happen in natural bodies of water close to the home. Providing adequate child supervision can protect children from drowning, and organized formal day care programs could offer a way to achieve this.

OBJECTIVES

Primary objective • To assess the effects of day care programs for children under 6 years of age on drowning-related mortality or morbidity, or on total drowning accidents (fatal and non-fatal), in LMICs, compared to no day care programs or other drowning prevention interventions Secondary objectives • To assess the effects of day care programs in LMICs for children under 6 years of age on unsafe water exposure • To assess safety within these programs (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) • To assess the incidence of unintentional injury within these programs • To describe the cost-effectiveness of such programs, in relation to averted drowning-related mortality or morbidity SEARCH METHODS: On November 23, 2019, and for an update on August 18, 2020, we searched MEDLINE (PubMed), Embase, CENTRAL, ERIC, and CINAHL, as well as two trial registries. On December 16, 2019, and for an update on February 9, 2021, we searched 12 other resources, including websites of organizations that develop programs targeted to children.

SELECTION CRITERIA

We included randomized, quasi-randomized, and non-randomized controlled studies (with explicitly listed specific study design features) that implemented formal day care programs as a single program or combined with additional out-of-day care components (such as educational activities aimed at preventing injury or drowning or early childhood development activities) for children of preschool age (below 6 years of age) in LMICs for comparison with no such programs or with other drowning prevention interventions. Studies had to report at least one outcome related to drowning or injury prevention for the children enrolled.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection and data extraction, as well as risk of bias and GRADE assessment.

MAIN RESULTS

Two non-randomized observational studies, conducted in rural Bangladesh, involving a total of 252,631 participants, met the inclusion criteria for this review. One of these studies compared a formal day care program combined with parent education, playpens provided to parents, and community-based activities as additional out-of-day care components versus no such program. Overall we assessed this study to be at moderate risk of bias (moderate risk of bias due to confounding, low risk of bias for other domains). This study showed that implementation of a formal day care program combined with parent education, provision of playpens to parents, and community-based activities, in a rural area with a high drowning incidence, likely reduces the risk of death from drowning over the study period of 4 years and 8 months compared to no day care program (hazard ratio 0.18, 95% confidence interval [CI] 0.06 to 0.58; 1 study, 136,577 participants; moderate-certainty evidence). Drowning morbidity (non-fatal drowning resulting in complications), total drowning (fatal and non-fatal), unsafe water exposure, and program safety (e.g. transmission of infection within day care, physical or sexual abuse of children within day care) were not reported, nor was the incidence of other unintentional injuries. Cost-effectiveness was reported as 812 USD (95% CI 589 to 1777) per disability-adjusted life-year averted as a consequence of drowning (moderate-certainty evidence). The second study compared day care programs with or without playpens provided to parents as an additional component versus only playpens provided to parents as an alternative drowning prevention intervention. Overall we assessed the study to be at critical risk of bias because we judged bias due to confounding to be at critical risk. As the certainty of evidence was very low, we are uncertain about the effects on drowning mortality rate of implementing a day care program compared to providing playpens (rate ratio 0.25, 95% CI 0.15 to 0.41; 1 study; 76,575 participants; very low-certainty evidence). Likewise, we are uncertain about the effects of a day care program with playpens provided as an additional component versus playpens provided alone (rate ratio 0.06, 95% CI 0.02 to 0.12; 1 study, 45,460 participants; very low-certainty evidence). The other outcomes of interest - drowning morbidity, total drowning, unsafe water exposure, program safety, incidence of other unintentional injuries, and cost-effectiveness - were not reported.

AUTHORS' CONCLUSIONS

This review provides evidence suggesting that a day care program with additional out-of-day care components such as community-based education, parent education, and playpens provided to parents likely reduces the drowning mortality risk in regions with a high burden of drowning compared to no intervention.

Playground equipment-related extremity fractures in children presenting to US emergency departments, 2006-2016

Background

Despite updated playground equipment and improved industry standards, playgrounds remain a common source of childhood injury. Fractures account for 35% of all playground injuries presenting to emergency departments (EDs). We aimed to examine the time trends and epidemiologic patterns of playground equipment-related extremity fractures in children in the United States.

Methods

We analyzed data from the National Electronic Injury Surveillance System. Children ≤14 years presenting to US emergency departments from 2006 to 2016 with playground equipment-related injuries were included. We used weighted complex survey analysis to describe the epidemiologic patterns and severity of playground equipment-related extremity fractures and Joinpoint linear weighted regression analysis to determine trends in extremity fractures.

Results

An annual average of 72,889 children were treated in US EDs for playground equipment-related extremity fractures, yielding a national annual incidence rate of 119.2 per 100,000 children. Playground equipment-related extremity fractures accounted for 33.9% of ED presentations and 78.7% of hospitalizations for playground equipment-related injuries. Of patients with playground equipment-related extremity fractures, 11.2% had severe fractures requiring hospitalization. The annual rate of ED visits due to playground equipment-related extremity fractures remained stable (annual rate of change = 0.74, p = 0.14) from 2006 to 2016. Adjusted for age, injuries on monkey bars or climbing gyms were associated with significantly increased odds of extremity fractures in comparison to injuries from other playground equipment (adjusted odds ratio [aOR]: 2.0; 95% CI: 1.9–2.1). Overall, 49.8% of extremity fractures and 54.7% of severe extremity fractures (i.e. those requiring hospitalization) occurred on monkey bars or climbing gyms.

Conclusions

Despite enhanced playground safety standards, national rates of playground equipment-related extremity fractures have remained stable in the US. Extremity fractures remain the most common type of playground injury presenting to EDs and most commonly occur on monkey bars and climbing gyms.

'Active & Safe Central': development of an online resource for the prevention of injury in sport and recreational activity

BACKGROUND

Sport and recreation related injuries exert a significant cost on the healthcare system. As prevention researchers and practitioners, we have a responsibility to provide guidance towards prevention to those who participate in sport and recreation, and those that coach, treat and parent children that participate. The objective of this project was to use an integrated knowledge translation approach to develop an end user-driven digital platform that provides injury prevention information and resources across 51 sport and recreational activities.

DESIGN

We used an integrated knowledge translation approach to scope and develop an online sport and recreational injury prevention resource. A project team was formed that included end users-coaches, parents and athletes, injury researchers and practitioners, as well as members of a digital design team. All members of the project team informed the development process, including a review of literature and existing resources, the translation of evidence and development of the platform. At all stages of development, members of the project team cocreated knowledge for the tool, including forming the research questions, the approach, feasibility and development of outcomes.

CONCLUSION

The 'Active & Safe Central' (https://activesafe.ca/) platform provides web-based sport injury and prevention information. This user-friendly, web and mobile accessible platform can increase the reach, awareness and implementation of prevention programming in sport and recreational activity.

Epidemiology of playground equipment related/unrelated injuries to children: A registry-based cohort study from 6 emergency departments in Korea

The aim of study was to understand the epidemiology of playground injury and to find the factors related to the clinically significant injuries. This retrospective observational study enrolled children (age 0-18 years old) who visited the emergency departments (ED) of 6 hospitals in Korea.We obtained and analyzed the data from the ED injury surveillance system, which was supported by the Korea Centers for Disease Control. Clinically significant injury (Cs injury) was defined as the injuries that caused hospital admission for more than one day. The factors associated with injury and clinical outcome were compared between admitted and discharged patient groups. Multivariable logistic regression and the population attributable fraction were used to identify significant factors for hospitalization.A total of 1458 patients were enrolled. The proportion of patients who visited ED due to injuries unrelated to the playground equipment use was 57.8%. The majority of Cs injury was upper extremity fractures (68.1%). The risk factors for admission were the 6- to 11-year old age group (OR 5.7, 95% CI 1.3-25.0) and public playground (OR 2.4, 95% CI 1.1-5.3); the population attributable factor of these factors was 51.3% and 36.0%, respectively.This study shows that approximately 60% of the patients visited ED due to injury unrelated to the playground equipment use. The risk factors of Cs injuries were ages 6 to 11 and public playgrounds. The results of the study can be helpful to formulate the prevention policy against playground injury.