Using Home Safety Checklists to Identify Potential...

Using Home Safety

Checklists to Identify

Potential Hazards

Bruce J. McIntosh, M.D.Statewide Medical Director

Child Protection Team System

September 6, 2018

Preventing Unintentional InjuriesTake-Home Points

▪ Most injuries and injury-related deaths

in children could be prevented by better

supervision by parents and other caretakers

▪ Sometimes hazardous conditions in the home

and inadequate supervision are the result of

ignorance, sometimes of negligence

▪ Inadequate supervision and neglect are even

more dangerous to children than abuse

▪ Age-specific Home Safety Checklists can assist

in identifying hazards in the home

Deaths Due to Abuse and NeglectFlorida Death Review Program

Florida Child Abuse Death

Review Committee Annual

Reports

State of Florida Abuse Death Review Committee. Annual Report,

December 2017, page 18.

Deaths Due to Abuse and NeglectFlorida Death Review Program, 2011 - 2016

Abuse and Neglect in FloridaDistribution of 68 Verified Deaths in 2016

State of Florida Abuse Death Review Committee. Annual Report,

December 2017, page 17.

Abuse and Neglect National Reporting Trends 1990 - 2005

Home Safety ChecklistsAn Approach to Reducing Deaths and Injuries

▪ Age-specific

▪ Birth – 6 months

▪ 6 – 12 months

▪ 12 – 24 months

▪ 2 – 6 years

▪ To provide guidance to

those visiting homes in

identifying hazardous

conditions and behaviors

Preventable Deaths and InjuriesSeldom Is There a Single Cause

▪ Child Medical problems, disability,

prematurity, one of too many

▪ Parent Alcohol or other substance

abuse, mental health issues, ignorance,

low IQ, non-nurturing childhood

▪ Family Domestic violence, criminal history, too

many kids

▪ Society Poverty, lack of health insurance,

isolation, lack of community supports

Dubowitz H. Child Neglect: A Child’s Perspective. First Coast

Conference on Child Maltreatment, Jacksonville, FL, April 2001.

Supervision-Related Injuries and DeathsA Spectrum of Responsibility and Response

Accident

(Not avoidable

by reasonable

degrees of

supervision)

Culpable Negligence

(Resulting from an

“utter disregard” for

supervision and

safety)

Simple Neglect

(Avoidable by

reasonable

degrees of

supervision)

Support, referral

for treatment or

grief counseling

Removal of other

children, arrest and

criminal prosecution

Services such as

home safety check,

parenting classes

Home Safety Checklist: Birth - 6 Months

Checking for Unsafe Sleep

Florida Child Abuse

Death Review Committee.

Annual Report, December

2017, page 21.

Florida Child Abuse Death CommitteeMost Common Causes of Preventable Deaths

85 sleep-related

asphyxia deaths

Safe Sleep for Infants: Crib SafetyCharacteristics of a Safe Crib

▪ Vertical slats no

more than 2 3/8

inches apart

▪ Corner posts flush

with end panels (or

very tall)

▪ Mattress should fit

snugly within sides

Bass M. Asphyxial Crib Death. NEJM 296, 555, 1977.

Safe Sleep for Infants: Crib SafetyCharacteristics of a Safe Crib

Safe Sleep for Infants: Crib SafetyAdditional Regulations - June 28, 2011

▪ Traditional drop-side

cribs cannot be

made or sold

▪ Repair kits are not

allowed to retrofit

older cribs

▪ Wood slats must be

made of stronger

wood to prevent

breakage

▪ Crib hardware must

have anti-loosening

devices to keep it

from coming loose

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 33.

Florida Child Abuse Death ReviewHow Old Are the Children Who Suffocate?

Florida Child Abuse Death Review

Committee. Annual Report,

December 2017, page 29.

Florida Child Abuse Death ReviewWhere Do Infants Suffocate?

Florida Child Abuse Death Review Committee. Annual Report, December

2017, page 29.

Florida Child Abuse Death ReviewWhere Do Infants Suffocate?

Terminology Is Important

“Co-Sleeping” vs “Bed-Sharing”

▪ Much of the confusion about the dangers of

sleeping with infants comes from inconsistent use

of terms

▪ To most people, Co-Sleeping means sleeping together on

the same bed or couch – which is very dangerous

▪ To others, Co-Sleeping means sleeping in the same room

– which is safe and a good thing

▪ To avoid confusion when speaking with families, it is

best to speak of “Bed-sharing” and discourage it, and

“Room-Sharing” which is fine

Advocates for Bed-SharingEncouraging a Dangerous Practice

1976 2002

Bed-Sharing Is on the RiseA Dangerous Trend

▪ In the United States the incidence of

bed-sharing has increased from 5.5%

in 1993 to 12.8% in 2000.

▪ Bed-sharing is most common in:

▪ Parents under 18 years old

▪ Low income parents

▪ Unmarried

▪ Trend accompanied by in increase in

the incidence of infant deaths from

asphyxia

Source: Archives of Pediatrics and Adolescent Medicine,

January 2003.

Safe Sleep for InfantsConsumer Product Safety Commission Study

▪ Comparing data from the 1980’s with that from the 1990’s researchers found that:

▪ Suffocation deaths in cribs fell from 192 to 107

▪ Suffocation deaths in adult beds rose from 152 to 391

▪ Suffocation deaths in chairs and sofas rose from 22 to 110

▪ The risk of suffocation for infants sleeping in adult beds was 40 times higher than for those sleeping in cribs.

Scheers et al. Where Should Infants Sleep? A Comparison of Risk for

Suffocation of Infants Sleeping in Cribs, Adult Beds,and Other Sleeping

Arrangements. Pediatrics 112:883, October 2003.

Should We Tell Parents Not To

Sleep with Their Infants?

Physician’s Weekly,

Vol. XVI, No. 5,

January 21, 2000.

Where Do Sleeping Babies Suffocate?42 Deaths in Florida in 2009

▪ 31 (74%) were co-sleeping

▪ 19 were co-sleeping in beds

▪ 5 were co-sleeping on sofas

▪ 4 were co-sleeping on a mattress or pallet

▪ 2 had no documentation as to type of bed

▪ 1 was co-sleeping in an over-sized chair

▪ 11 (26%) were placed in un-safe sleep environments

▪ 2 were placed in cribs or bassinet with pillows, blankets or other

unsafe items

▪ 3 were placed on adult beds with pillows surrounding

▪ 3 were placed on sofas or recliners

▪ 2 was placed on the floor with pillows surrounding

▪ 1 was placed on a bunk bed and found wedged against the wall

State of Florida Abuse Death Review Committee. Annual Report,

December 2010, page 74.

25 had cribs, bassinets or

playpens in the home that were

not being used.

Infant Death by SuffcationWhat Happens?

▪ Entrapment/wedging

▪ Overlying

▪ Bedding

▪ Plastic

▪ Stangulation

▪ Other and unknownScheers et al. Where Should Infants Sleep? A Comparison of Risk for

Suffocation of Infants Sleeping in Cribs, Adult Beds,and Other Sleeping

Arrangements. Pediatrics 112:883, October 2003.

▪ Parents should place healthy babies to sleep in

supine position (on their backs)

▪ Do not expose to cigarette smoke, either during

pregnancy or after birth

▪ Make sleep environment as safe as possible

▪ Use a safe crib

▪ Avoid soft bedding materials

▪ Keep plastic wrap and cords out of crib

▪ Breast feed rather than bottle feed

Carroll JL and Siska ES. SIDS: Counseling Parents

to Reduce the Risk. American Family Physician

57:1566, 1998.

Sudden Infant Death SyndromeNot Neglect or Abuse – But Preventable

Supine Sleeping CampaignEffect on SIDS Rate in the US

Trachtenberg FL, et.al. Risk Factor Changes for Sudden Infant Death Syndrome

After Initiation of Back to Sleep Campaign. Pediatrics 129:630, April 2012.

Back to Sleep Campaign

Jacksonville Times-Union,

July 20, 2000.

SIDS and RaceDisparities Persist

Safe Sleep for InfantsGood Advice for Parents

▪ Avoid soft bedding

▪ Comforters

▪ Sheepskins

▪ Pillows

▪ Large stuffed animals

▪ Extra padding

▪ Use only the mattress

and pad provided by the

manufacturer

Home Safety Checklist: Birth - 6 Months

Checking for Unsafe Sleep

Safe SleepInformation Available on DCF Website

Safe SleepInformation Available on DCF Website

National and Florida StatisticsDeaths and Injuries in Motor Vehicle Accidents

▪ Motor vehicle accidents are the leading cause of unintentional injury deaths in

children ages 5 – 14 years old in the United States and the second leading

cause of injury deaths in children ages 1 – 4, causing a total of 7,882 deaths

in those age groups in 2015

▪ In Florida in 2015 there were 666,091 motor vehicle accidents involving

children less than 18 years old, resulting in 35,992 injuries and 149 deaths

among children in that age group

▪ Injuries to children and teens in Florida due to motor vehicle accidents resulted

in costs of $339 million in 2013, with total injury costs in all age groups totaling

$3.02 billion, the largest total of any state in the Southeast

Centers for Disease Control: https://www.cdc.gov/injury/images/lc-

charts/leading_causes_of_injury_deaths_unintentional_injury_2015_1050w760h.gif

Florida Highway Safety and Motor Vehicles:

https://www.flhsmv.gov/pdf/childsafety/crashes-by-county.pdf

Centers for Disease Control: https://www.cdc.gov/motorvehiclesafety/pdf/statecosts/fl-

2015costofcrashdeaths-a.pdf

Home Safety Checklist: Birth - 6 Months

Checking for Safety in Vehicles

Accidents: DefinitionMost “Accidents” Are No Accident

Ac’ ci-dent: An event

that takes place without

one’s foresight or

expectation, especially

one of an unfortunate or

afflictive character.

Webster’s New Collegiate Dictionary, 1960, page 6.

Deaths

Injuries

Unintentional Deaths vs InjuriesThe Tip of the Iceberg for Children

Hazardous Conditions in the Home Common Cause of Death and Injury

Preventing Fall InjuriesSupervision for Injury Prevention

Preventing Fall Injuries

▪ Parents should never to leave infants of any age unattended on a changing table, bed or couch

▪ Fall injuries in infants too young to get themselves up onto beds and couches are the result of negligent care

▪ When toddler-aged children who can climb are injured in short-distance falls, the injuries can be considered accidental

“I Didn’t Know He Could Roll Over”

Failure to Supervise

Baby G

▪ Six week old infant

brought to ED by mom

with complaint of

swelling on side of head

▪ Infant alert an active, but

X-ray revealed linear

skull fracture

▪ Mom related baby was

on edge of bed and fell

off when she sat down

on bed

Home Safety Checklist: Birth - 6 MonthsPreventing Falls and Burns

Home Safety Checklist: 6 – 12 Months

Preventing Falls

Preventing Fall Injuries: WalkersOfficially Discouraged by the AAP

▪ Increase risk and

severity of injury

▪ Significant head

injuries common

▪ Delay walking

Fazen LE and Feliberto PI. Baby

Walker Injuries. Pediatrics

70:106, 1982.

Discourage WalkersEncourage Use of “Exercisers” Instead

Home Safety Checklist: 6 – 12 Months

Preventing Poisonings and Choking

Home Safety Checklist: 6 – 12 Months

Burn Prevention and Car Seat Use

Kitchen BurnsOften the Result of Negligent Supersion

Kitchen BurnsOften the Result of Negligent Supersion

Failure to Supervise

Baby W

▪ Eight and a half month old infant brought to ED with burns on hand

▪ Sixteen year old mom says that 4 days previously child had pulled up on edge of stove door and put arms and hands on hot inner surface

▪ Many abuse reports on mom as a victim when she was a child

Medical Neglect

Iron BurnsOften Result from Negligent Supervision

Home Safety Checklist: 12 – 24 Months

Preventing Burns

• Hot dogs

• Round candies

• Peanuts or nuts

• Grapes

Harris CS. JAMA 251:2231, 1984.

Supervision for Injury Prevention: Choking

Common Causes of Death by Asphyxiation

Keep floors clear of small

objects

Be especially careful of older

child’s toys

All parents should know how

to perform the Heimlich

maneuver

Allow Only Toys Too Big to Fit in Mouth

Supervision for Injury Prevention: Choking

• Assume everything will

go in the mouth

• Keep floors clear of

small objects

• Be especially careful of

older child’s toys

• All parents should know

how to perform the

Heimlich maneuver

Supervision for Injury Prevention

Preventing Choking

Home Safety Checklist: 12 – 24 Months

Choking Prevention

▪ Parents should keep medications in a locked cabinet

▪ Medications should be kept in child-proof containers

▪ Life-threatening ingestions often involve prescribed or recreationally-acquired opiates

▪ Many families of children with toxic ingestions have other problems requiring services

Toxic IngestionsMost Result From Caretaker Negligence

Supervision for Injury Prevention: Poisonings

Hazardous Substances in Food Containers

Home Safety Checklist: 12 – 24 Months

Poisoning Prevention

Supervision for Injury Prevention: Overview

Better Parents Know to Child-Proof the Home

▪ Keep small objects off floor

▪ Use safety latches on cabinets

▪ Put plug covers in electric outlets

▪ Run electric cords behind furniture

▪ Put breakable things out of reach

▪ Install barrier gates to limit access

▪ Crawl around to check work

Supervision for Injury Prevention: Overview

Child-Proofing the Home

Home Safety Checklist: 12 – 24 Months

Automobile Safety

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 24.

Florida Child Abuse Death ReviewLocation of Drownings and Barriers

Supervision for Injury Prevention: Bathtub Drownings

Parent Always Gone “Just a Minute”

Drowning: Bucket Hazards

160 Deaths in U.S. Over Six Year Period

Mann NC et al. Bucket-Related Drownings in the United States,

1984 Through 1990. Pediatrics 89:1068, 1992.

Home Safety Checklist: 6 – 12 Months

Preventing Drownings

Florida Child Abuse Death

Review Committee. Annual

Report, December 2017,

page 21.

Florida Child Abuse Death ReviewMost Common Causes of Preventable Deaths

63 Drownings Deaths

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 32.

Florida Child Abuse Death ReviewWhat Are Typical Ages for Drowning?

82% less than 6

years old

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 24.

Florida Child Abuse Death ReviewLocation of Drownings and Barriers

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 27.

Florida Child Abuse Death ReviewHow Did Barriers Fail?

▪ There were 91 drowning deaths reported, of which 42 were verified as due to neglect

▪ Number of cases reviewed indicates serious under-reporting to the registry

▪ “Adequate supervision is defined as an attentive person responsible for watching children and who is not under the influence of drugs or alcohol. The person must always be proximate to the child (eyes on) to provide continuous supervision.”

▪ According to caretakers, most child victims were missing from sight for less than five minutes.

Child Drownings in Florida - 2010Number One Cause of Preventable Death

State of Florida Abuse Death Review Committee. Annual Report,

December 2010, page 18.

Annual Report, December 2009, page 50.

Causes of Abuse and Neglect Deaths Role of Substance Abuse

State of Florida Abuse Death Review Committee. Annual Report,

December 2011, page 13.

Florida Child Abuse Death Review Committee. Annual Report,

December 2016, page 26.

Florida Child Abuse Death ReviewRisk Associated with Substance Abuse

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 41.

Florida Child Abuse Death ReviewRisk Associated with Substance Abuse

Home Safety Checklist: 12 – 24 Months

Drowning Prevention

▪ Consider every allegation or suspicion

of supervisory neglect individually

▪ Be aware of age-specific guidelines

enforced by child protective services

▪ Some child injury risks are unpredictable and

unavoidable

▪ Caretakers may already suffer an emotional

burden when a child suffers and avoidable injury

AAP Committee on Child Abuse and Neglect. Pediatrics 118:1296,

September 2006.

When Is Lack of Supervision Neglect?The American Academy of Pediatrics’ Answer

▪ How long and at what time of the day was

the child unsupervised?

▪ Does the child have any physical, emotional,

developmental, behavioral, psychiatric or

cognitive disabilities?

▪ Has the child previously shown an ability to

look after himself and make good judgments?

▪ What is the inherent danger in the environment

in which the child was left unsupervised?

AAP Committee on Child Abuse and Neglect. When Is Lack of

Supervision Neglect? Pediatrics 118:1296, September 2006.

When Is Lack of Supervision Neglect?Consider Each Case Individually

▪ Have there been past instances or allegations of

supervisory neglect?

▪ How many children of what ages and maturity

were under the caretaker’s supervision?

▪ Are there any physical, emotional or mental

limitations of the designated caretaker?

▪ Does the child have an adequate knowledge of

emergency telephone numbers and access to a

parent or other informed caretaker?

AAP Committee on Child Abuse and Neglect. When Is Lack of

Supervision Neglect? Pediatrics 118:1296, September 2006.

When Is Lack of Supervision Neglect?Consider Each Case Individually

Choking Hazards: BalloonsMost Common Cause of Toy-Associated Fatalities

▪ Responsible for 121 deaths between 1973 and 1988

▪ Not considered safe for children under eight

▪ Hazardous as an office favor

Henderson JM. American Family Physician 40:171, 1989.

National and Florida StatisticsDeaths and Injuries in Motor Vehicle Accidents

▪ Motor vehicle accidents are the leading cause of unintentional injury deaths in

children ages 5 – 14 years old in the United States and the second leading

cause of injury deaths in children ages 1 – 4, causing a total of 7,882 deaths

in those age groups in 2015

▪ In Florida in 2015 there were 666,091 motor vehicle accidents involving

children less than 18 years old, resulting in 35,992 injuries and 149 deaths

among children in that age group

▪ Injuries to children and teens in Florida due to motor vehicle accidents resulted

in costs of $339 million in 2013, with total injury costs in all age groups totaling

$3.02 billion, the largest total of any state in the Southeast

Centers for Disease Control: https://www.cdc.gov/injury/images/lc-

charts/leading_causes_of_injury_deaths_unintentional_injury_2015_1050w760h.gif

Florida Highway Safety and Motor Vehicles:

https://www.flhsmv.gov/pdf/childsafety/crashes-by-county.pdf

Centers for Disease Control: https://www.cdc.gov/motorvehiclesafety/pdf/statecosts/fl-

2015costofcrashdeaths-a.pdf

Winston FK et al. The Danger of Premature Graduation to Seat

Belts for Young Children. Pediatrics 105:1179, 2000.

Supervision for Injury Prevention

The Safety Gap: Age 4 – 8 Years

Home Safety Checklist: 2 – 6 Years

Automobile Safety

Accident or Neglect?Questions to Ask in All “Accidents”

• How foreseeable and preventable

was the injury?

• How do the caretaker’s actions compare to

the standard in the community?

• What is the overall level of concern about the

child’s welfare?

• What is the potential for the child to be injured

again if no services are provided?

Child DeathsPrior Involvement of DCF

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 39.

Types of Caretaker ImpairmentIt’s Not All Drugs

Florida Child Abuse Death Review Committee. Annual Report,

December 2017, page 42.

Risk Factors for Child DeathsThe Big Three

Age Less Than 5 Years Negligence

Substance Abuse

State of Florida Abuse Death Review Committee. Annual Report,

December 2011.

Home Safety ChecklistsAn Approach to Reducing Deaths and Injuries

▪ Many of those who do home

inspections don’t really know what

to look for or how to explain the

hazard to the family

▪ Digital original copies are of the

Home Safety Checklists are

available on the conference

website

▪ Encourage those in your agencies

to use Home Safety Checklists to

assist in identifying hazardous

conditions and behaviors

▪ We can decrease preventable

deaths and injuries to children

END