Case Review

Anotherbabywalker injuryvictim
Author: Carole C. A t k i n s o n , RN,C, MS, B o s t o n , M a s s a c h u s e t t s

1-year-old girl w a s b r o u g h t b y her p a r e n t s to t h e

e m e r g e n c y d e p a r t m e n t of our p e d i a t r i c h o s p i t a l
on C h r i s t m a s day. S h e h a d j u s t fallen d o w n one flight
of s t a i r s (12 to 13 s t e p s ) w h i l e in a b a b y walker.
A c c o r d i n g to t h e p a r e n t s , w h o h e a r d t h e n o i s e from
t h e fall, t h e b a b y c r i e d i m m e d i a t e l y a n d d i d n o t lose
c o n s c i o u s n e s s . T h e b a b y h a d no k n o w n h e a l t h p r o b lems, b u t t h e y k n e w t h a t h e r father a n d b r o t h e r h a d
t h a l a s s e m i a trait.
T h e t r i a g e n u r s e o b s e r v e d a c o n t u s i o n on the
b a b y ' s f o r e h e a d a n d e r y t h e m a of her r i g h t forearm.
The b a b y w a s a w a k e b u t irritable; h e r p u p i l s w e r e
e q u a l a n d r e a c t e d to light. Vital s i g n s w e r e as follows:
h e a r t r a t e 190 b e a t s / m i n , r e s p i r a t o r y r a t e 36 per
m i n u t e , b l o o d p r e s s u r e 84/56 m m Hg, axillary t e m p e r a t u r e 36 C, o x y g e n s a t u r a t i o n 99% on r o o m air,
a n d G l a s g o w C o m a Scale s c o r e 15.
T h e b a b y w a s i m m e d i a t e l y p l a c e d in a K e n d r i c k ' s
e x t r i c a t i o n d e v i c e ( F e r n o - W a s h i n g t o n ) w i t h a cervical
collar, a n d a portable, lateral cervical s p i n e r a d i o g r a p h
w a s o b t a i n e d . P h y s i c i a n e x a m i n a t i o n i d e n t i f i e d no injuries or a b n o r m a l i t i e s o t h e r t h a n t h e f o r e h e a d c o n t u sion. A n IV infusion of n o r m a l saline solution w a s
started. The baby was sedated with midazolam
(Versed) a n d f e n t a n y l a n d a c o m p u t e d t o m o g r a p h i c
(CT) s c a n of h e r h e a d Was p e r f o r m e d w ! t h ~ o r r n a l findings. Cervical s p i n e r a d i o g r a p h s also w ~ e - a o r m a l , after w h i c h t h e s p i n e i m m o b i l i z a t i o n w a s rer~oved.
T h e b a b y ' s h e m a t o c r i t w a s 28.4%. A s e c o n d
s p e c i m e n for h e m a t o c r i t d e t e r m i n a t i o n , s e n t a p p r o x i m a t e l y 3 h o u r s after t h e first, w a s 25.9%. A l t h o u g h
w e b e l i e v e d t h i s w a s p r o b a b l y a result of h e m o d i l u tion, t h e d e c i s i o n w a s m a d e to a d m i t t h e girl for
overnight observation, serial examinations, and
follow-up h e m a t o c r i t d e t e r m i n a t i o n s .

Carole c. Atkinson is trauma nurse coordinator, Childzen's

Hospitai, Boston, Massachusetts.
J Ernerg Nuts 1997;23:302-5.
Copyright 1997 by the Emergency Nurses Association.
0099-1767/97 $5.00 + 0 18/1/82631

302

Volume 23, Number 4

No a d d i t i o n a l injuries w e r e i d e n t i f i e d d u r i n g the
a d m i s s i o n . After a n u n e v e n t f u l night, t h e b a b y w a s
a w a k e , alert, a n d d e m o n s t r a t i n g a g e - a p p r o p r i a t e
behavior. She h a d full r a n g e of m o t i o n w i t h no deform i t i e s of her e x t r e m i t i e s ; s h e w a s w a l k i n g , playing,
a n d m o v i n g freely in t h e crib w i t h o u t discomfort. She
w a s d i s c h a r g e d h o m e in t h e m o r n i n g , w i t h a h e m a t ocrit of 29%. T h e p a r e n t s w e r e a d v i s e d to s e e k followu p w i t h her p e d i a t r i c i a n a s needed.

A c c o r d i n g to s t u d i e s , 25% t o
50% of all b a b y - w a l k e r u s e r s
w i l l s u s t a i n a r e l a t e d injury.

T h r e e d a y s later t h e b a b y w a s referred b a c k to us
b y h e r p e d i a t r i c i a n for a n o r t h o p e d i c e v a l u a t i o n . The
baby's mother had reported that the baby was not
g r a s p i n g o b j e c t s or u s i n g her h a n d s to pull herself u p
s i n c e t h e fall. F o r e a r m r a d i o g r a p h s r e v e a l e d bilateral,
h e a l i n g , n o n d i s p l a c e d , distal r a d i u s fractures. T h e
f r a c t u r e s w e r e i m m o b i l i z e d w i t h c a s t s for s e v e r a l
w e e k s , a n d t h e r e w e r e no r e p o r t e d a d v e r s e s e q u e l a e .

Baby walkers and related injuries

B a b y w a l k e r s a r e s e a t s s u s p e n d e d w i t h i n a frame
on w h e e l s , e n a b l i n g infants w h o are n o t y e t w a l k i n g
i n d e p e n d e n t l y to b e m o b i l e (Figure 1). T h e w a l k e r s
are q u i t e p o p u l a r in s p i t e of t h e fact t h a t t h e y s e r v e no
d e v e l o p m e n t a l or e d u c a t i o n a l p u r p o s e . A p p r o x i m a t e l y 3 million b a b y w a l k e r s are sold in t h e U n i t e d
S t a t e s e a c h year. A n a d d i t i o n a l I million u s e d w a l k e r s
a r e also in c i r c u l a t i o n annually. ~ A s m a n y a s 80% of all
b a b i e s from 4 to 15 m o n t h s of a g e u s e a walker. 2,3
B a b y w a l k e r u s e c a n b e d a n g e r o u s . A c c o r d i n g to
s t u d i e s , 25% to 50% of all b a b y - w a l k e r u s e r s will sust a i n a r e l a t e d injury. 4, s T h e C o n s u m e r P r o d u c t Safety
C o m m i s s i o n (CPSC) r e c e i v e s t w i c e a s m a n y r e p o r t s

Atkinson/JOURNAL OF EMERGENCY NURSING

Table i
Walker-related deaths: 1989-19931
Drownings
Suffocation (includes 1 walker seat failure)
Stair falls
Tip-over

Table 2
Walker-related m e c h a n i s m s of injury 8
Falls d o w n stairs
B e t w e e n levels
Basement stairs
Tip-overs
Burns
Other

Figure 1

Sketch of a mobile baby walker.

for w a l k e r - r e l a t e d injuries a s for injuries a s s o c i a t e d

w i t h b a b y strollers or c a r r i a g e s . In fact, r e p o r t s of
w a l k e r - r e l a t e d injuries are m o r e c o m m o n t h a n t h o s e
for all o t h e r b a b y furniture c o m b i n e d . T h e e s t i m a t e d
a n n u a l c o s t for t r e a t m e n t of w a l k e r - r e l a t e d injuries is
$90,000,000. I

Eleven baby walker-related

d e a t h s w e r e r e p o r t e d from
1989 to 1993.

Eleven baby walker-related deaths were reported

from 1989 to 1993 (Table 1). tn 1994, ED visits for
w a l k e r - r e l a t e d injuries w e r e e s t i m a t e d a t 27,000 b y
t h e N a t i o n a l E l e c t r o n i c Injury Surveillance S y s t e m of
t h e CPSC. P e r h a p s a n o t h e r 10,000 c h i l d r e n v i s i t e d
t h e i r p r i m a r y c a r e p r o v i d e r for less s e r i o u s injuries.
M a n y a d d i t i o n a l e p i s o d e s are p r o b a b l y n e v e r r e p o r t e d .
S e v e n t y - f i v e p e r c e n t of all w a l k e r - r e l a t e d injuries
o c c u r in t h e h o m e : I C o m m o n m e c h a n i s m s of injury
i n c l u d e falls d o w n stairs, tip-overs, c r u s h injuries
from o b j e c t s p u l l e d d o w n onto t h e child, burns, a n d
toxic i n g e s t i o n (Table 2). Walker-related s t a i r w a y falls
r e s u l t in t h e m o s t s e v e r e injuries. T h e b a b y r e m a i n s

40%
39%
3%
3%
15%

in t h e w a l k e r d u r i n g t h e fall, w i t h t h e h e a d e x p o s e d
a n d u n p r o t e c t e d . N i n e t y p e r c e n t of w a l k e r injuries
affect t h e h e a d or face. 5, 6 S i g n i f i c a n t h e a d t r a u m a ,
i n c l u d i n g skull fractures, i n t r a c r a n i a l h e m o r r h a g e s ,
a n d c o n c u s s i o n s , o c c u r s in o n e t h i r d of all walkerr e l a t e d injuries. T h e e x t r e m i t i e s w e r e i n j u r e d in 6% of
c a s e s , a n d t h e t r u n k in a p p r o x i m a t e l y 3% (Table 3). 6

Walker-related s t a i r w a y falls
result in t h e m o s t s e v e r e
injuries. T h e b a b y r e m a i n s
in t h e w a l k e r d u r i n g t h e fall,
with the head exposed and
unprotected. Ninety percent
of w a l k e r injuries affect t h e
h e a d or face.

T h e CPSC h a s m a n d a t e d d e s i g n m o d i f i c a t i o n s int e n d e d to m a k e b a b y w a l k e r s safer; p r o d u c t s t h a t do

n o t m e e t t h e r e q u i r e m e n t s a r e b a n n e d from d i s t r i b u tion. Also, m a n u f a c t u r e r s voluntarily p r o v i d e s a f e t y lite r a t u r e w i t h t h e walker. In C a n a d a , d e s i g n r e g u l a t i o n s
b e c a m e so rigid t h a t c o m p a n i e s s t o p p e d m a n u f a c t u r i n g t h e walkers. But in s p i t e of d e s i g n m o d i f i c a t i o n s ,
t h e w a l k e r s are still d a n g e r o u s ; a safer a l t e r n a t i v e to
m o b i l e b a b y w a l k e r s is t h e n o n m o b i l e a c t i v i t y s e a t
(Figure 2), T h e A m e r i c a n A c a d e m y of P e d i a t r i c s reco m m e n d s a b a n on t h e m a n u f a c t u r e a n d sale of b a b y
walkers2; t h e A m e r i c a n M e d i c a l A s s o c i a t i o n r e c o m -

August 1997 303

JOURNAL OF EMERGENCYNURSlNG/Atkinson

Table 3
Baby w a l k e r - r e l a t e d injuries reported to CPSC
in 19941
Cases
Body part injured

Head
Face
Mouth
Eyeball
Ear
Neck
Shoulder
Hand
Lower arm
Upper arm
Wrist

Elbow
Foot
Lower leg
Upper leg
Lower trunk
Upper trunk
Internal

More than one body part

Other/unknown
Total

No.

13376
8079
2297
211
17
17
335
311
269
68
60
42
192
187
43
184
164
173
671
307

50
30
9
<1
<0.5
<0.5
1.24
1.15
1.0
<0.5
<0.5
<O.5
<1
<1
<0.5
<1
<1
<1
2.5
1.14

27006

100%

m e n d s t h a t p h y s i c i a n s c o u n s e l p a r e n t s on the risk of
injury from u s e of b a b y walkers7 The 1996 ENA G e n eral A s s e m b l y p a s s e d a resolution to incorporate b a b y
w a l k e r - r e l a t e d injury risks into ENA's Injury P r e v e n t i o n Position S t a t e m e n t .
Discussion

T h e story of this 1-yea>old is n o t u n u s u a l for our

b u s y p e d i a t r i c e m e r g e n c y d e p a r t m e n t . In a r e c e n t 7m o n t h period, 27 b a b i e s w e r e t r e a t e d after walkerrelated s t a i r w a y falls; 7 r e q u i r e d a d m i s s i o n to t h e
hospital. We h a v e l e a r n e d t h a t injuries occur at t i m e s
of d i s t r a c t i o n for the family: d u r i n g a inogd, t h e arrival
of a n o t h e r child into t h e home, d u r i n g partii~s, a n d on
holidays, as w a s t h e s i t u a t i o n in this case.
T h e e m e r g e n c y n u r s e correctly identified this
p a t i e n t as h i g h risk b e c a u s e of t h e m e c h a n i s m of
injury a n d a s s e s s e d for s i g n i f i c a n t injuries. A l t h o u g h
t h e b a b y h a d n o r m a l vital s i g n s a n d w a s a w a k e a n d
alert, t h e i m p a c t i n c u r r e d b y t h e b l u n t t r a u m a to t h e
h e a d a n d a b d o m e n d u r i n g t h e fall i n c r e a s e d the probability of i n t r a c r a n i a l a n d i n t r a a b d o m i n a l bleeding.
T h e b a b y w a s r e a s s e s s e d frequently a n d carefully,
a n d t r e n d s of her vital s i g n s w e r e noted. T h r e e areas
of c o n c e r n e m e r g e d : t h e low h e m a t o c r i t finding,
i d e n t i f i c a t i o n of injuries, a n d t h e n e e d for injury prevention education.
The c o m p l e t e blood cell c o u n t in this c a s e w a s ab-

304

Volume 23, Number 4

Figure 2

Baby shown in nonmobile activity seat.

normal; t h e h e m o g l o b i n w a s 9.3 g m / d l a n d t h e h e m a tocrit 28.4%, w i t h a m e a n corpuscular v o l u m e of 62 fL.

The baseline hematocrit determination was repeated
a n d t h e s e c o n d h e m a t o c r i t value w a s 25.9%. T h e b a b y
h a d r e c e i v e d a b o u t 170 ml of IV fluid b y t h e t i m e of the
s e c o n d blood s a m p l i n g . A l t h o u g h t h e s e v a l u e s w e r e of
c o n c e r n , w e b e l i e v e d t h a t t h e family history of thala s s e m i a trait e x p l a i n e d the h y p o c h r o m i c / m i c r o c y t i c
a n e m i a a n d t h a t h e m o d i l u t i o n a c c o u n t e d for t h e seco n d h e m a t o c r i t reading. A c c o r d i n g to t h e family, t h e
b a b y ' s h e m a t o c r i t before t h e injury w a s a b o u t 27%.
G i v e n t h e a b s e n c e of a n y e v i d e n c e of i n t e r n a l
injury, w e were comfortable in our p e d i a t r i c t r a u m a
c e n t e r s e t t i n g w i t h a p l a n of close o b s e r v a t i o n rather
t h e n s u b j e c t i n g t h e b a b y to further d i a g n o s t i c testing. A n o n p e d i a t r i c facility m i g h t h a v e a lower
t h r e s h o l d for a b d o m i n a l CT s c r e e n i n g or transfer to a
p e d i a t r i c center.
H e a d injuries are s e e n frequently in i n f a n t s a n d
toddlers, b e c a u s e their h e a d s are p r o p o r t i o n a t e l y
h e a v i e r t h a n their torsos. If t h e r e are clinical f i n d i n g s
i n c o n j u n c t i o n w i t h a high~risk m e c h a n i s m of injury,
a CT s c a n is i n d i c a t e d . A b a b y / c h i l d w i t h a G l a s g o w
C o m a Scale score of 14 or less after s u s t a i n i n g h e a d
t r a u m a should h a v e a CT. S i g n i f i c a n t h e a d injuries
also carry a higher risk of a s s o c i a t e d n e c k injuries.
A l t h o u g h cervical s p i n e injuries occur i n less t h a n 2%
of all i n j u r e d children, it is i m p e r a t i v e t h a t this injury
b e ruled out. i n t h e p e d i a t r i c p o p u l a t i o n a n d i n the
u n c o n s c i o u s or u n c o o p e r a t i v e p a t i e n t , c l i n i c a l
a s s e s s m e n t for n e c k injury m a y b e impossible.

Atkinson/JOURNAL OF EMERGENCY NURSING

T h e r e d n e s s of t h e r i g h t forearm n o t e d b y t h e
t r i a g e n u r s e w a s n o t e v i d e n t on s u b s e q u e n t a s s e s s m e n t s a n d t h e r e f o r e w a s n o t followed u p w i t h r a d i o g raphy. T h e d i s c o v e r y of t h e b a b y ' s f o r e a r m f r a c t u r e s
c a u s e d us to r e v i e w our care. Should a f o r e a r m radiog r a p h h a v e b e e n o b t a i n e d ? If t h e p h y s i c a l a s s e s s ment had been more comprehensive, would the wrist
injuries h a v e b e e n d e t e c t e d ? W a s t h e b a b y ' s fussin e s s , i n t e r p r e t e d a s fear, a c t u a l l y p a i n ? Injuries m a y
b e m i s s e d in c h i l d r e n g i v e n their l i m i t e d ability to
c o m m u n i c a t e feelings a n d s e n s a t i o n s . It is p o s s i b l e
t h a t t h e f r a c t u r e s w o u l d h a v e b e e n m i s s e d , e v e n if
r a d i o g r a p h s h a d b e e n o b t a i n e d . Subtle c h a n g e s on
radiographs may be misinterpreted.

O n e m e t h o d of m i n i m i z i n g
m i s s e d injuries is to r o u t i n e l y
a s s e s s t h e b a b y ' s u s e of all
extremities as follows.
Observe the baby push the
u p p e r b o d y off t h e floor or
stretcher while prone.
O b s e r v e t h e b a b y ' s g r a s p of
a large, h e a v y o b j e c t , s u c h a s
a bottle; and a small light
o b j e c t , s u c h a s a rattle. N o t e
t h e b a b y ' s g r a s p of o b j e c t s
a n d t r a n s f e r f r o m h a n d to
h a n d . Pull a t o y f r o m e a c h of
the baby's clenched hands.

O n e m e t h o d of m i n i m i z i n g m i s s e d injuries is to
r o u t i n e l y a s s e s s t h e b a b y ' s u s e of all e x t r e m i t i e s a s
follows. O b s e r v e t h e b a b y p u s h t h e u p p e r b o d y off t h e
floor or s t r e t c h e r while prone. O b s e r v e t h e b a b y ' s
g r a s p of a large, h e a v y object, s u c h as a bottle; a n d a
small light object, s u c h a s a rattle. N o t e t h e b a b y ' s
g r a s p of o b j e c t s a n d transfer from h a n d to hand. Pull
a t o y from e a c h of t h e b a b y ' s c l e n c h e d h a n d s .
O b s e r v e t h e b a b y w i t h b o t h feet on a firm surface,
w h i l e g r a s p i n g t h e p a r e n t ' s fingers or t h e s i d e of a
crib or other safe, i m m o b i l e object. D o c u m e n t t h e
b a b y ' s p e r f o r m a n c e of e a c h activity. We r e v i e w e d this
e x p a n d e d a s s e s s m e n t w i t h our o w n staff after t h i s
case.

Injury p r e v e n t i o n e d u c a t i o n is v e r y i m p o r t a n t . A
crisis is n o t t h e m o s t effective t i m e to i n t r o d u c e inform a t i o n , so p r e p a r e a few h i g h - i m p a c t facts to deliver
in a n o n j u d g m e n t a l way. For e x a m p l e , d i s c u s s w i t h
t h e family t h e s u r p r i s i n g f a c t t h a t t h e r e are a n estim a t e d 30,000 ED visits a y e a r for b a b y w a l k e r - r e l a t e d
injuries. Tel1 t h e family t h a t t h e r e a r e s t a n d a r d s for
d e s i g n of b a b y w a l k e r s to p r e v e n t p i n c h e d fingers
a n d tip-overs, b u t no w a l k e r p r o t e c t s t h e b a b y from
falling over t h r e s h o l d s or d o w n stairs. R e m i n d t h e
family t h a t t h e r e is no p r o t e c t i o n for t h e b a b y w h e n
t h e w a l k e r e n a b l e s t h e b a b y to r e a c h u p a n d pull
d o w n h e a v y objects, t o u c h h o t objects, or i n g e s t toxic
s u b s t a n c e s , all of w h i c h w e r e p r e v i o u s l y i n a c c e s s i b l e .
Finally, tell families t h a t b a b i e s s h o u l d n e v e r b e left
u n a t t e n d e d in a w a l k e r a n d s t r o n g l y e n c o u r a g e families to d i s p o s e of t h e walker.
References
1. US Consumer Product Safety Commission. Baby Walkers;
Advance Notice of Proposed Rulemaking. Washington, DC;
1994; US Consumer Product Safety Commission 16 CFR part
1500.
2. American Academy of Pediatrics, Committee on Injury
and Poison Prevention. Injuries associated with walker falls.
Pediatrics 1995;5:778-80.
3. Chiavello CT, Christoph RA, Bond GB. Infant walkerrelated injuries: a prospective study of severity and incidence. Pediatrics 1994;6:974-6.
4. Parrington MD, Swanson JA, Meyer FM. Head injury and
the use of baby walkers: a continuing problem. Ann gmerg
Med 1991;6:652-4.
5. Trinkoff A, Parks PL. Prevention strategies for infant
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This section features actual emergency situations

with particular educational value for the emergency nurse. Contributions (four to six typed,
double-spaced pages) should include a case
summary focused on the emergency care phase,
accompanied by pertinent case commentary,
Submit to P a t t y Campbell, Section Editor,
c/o Managing Editor, 216 Higgins Rd., Park Ridge,
IL 60068-5736,. phone (847) 698-9400; E-maik
khalm@ena, org.

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