In Spain, falls are the leading cause of unintentional injury in children aged less than 14 years, and based on a study on accidents carried out by the Asociación Española de Pediatría de Atención Primaria (Spanish Association of Primary Care Paediatrics) in 2014, they are much more frequent than poisonings or burns.1

Although most instances do not result in serious injuries,2 they constitute the third leading cause of death by unintentional injury in children aged 0–9 years in countries of the European Union, according to the European Child Safety Alliance.3

Infants aged less than 1 year are particularly at risk of suffering fall-related injuries due to their increasing independent mobility and interest in exploring their surroundings,4 resulting in more than one million visits a year to emergency departments in the United States, according to data from the Centres for Disease Control and Prevention (CDC) for the 2000–2006 period.5

Previous studies have emphasised the need to analyse patterns of unintentional injury in the paediatric population within narrower age ranges.6

In Spain, no studies have been conducted to analyse fall-related injuries in infants aged less than 1 year that would help develop preventive strategies targeting this age group.

Numerous preventive strategies have been developed by different governmental agencies,7,8 in spite of which there is evidence that parents are unaware of the mechanisms that lead to fall-related injuries, which hinders effective prevention.

The aim of our study was to describe the epidemiologic characteristics of falls in children aged less than 1 year and to analyse the risk factors or circumstances associated with serious injuries.

We conducted a cross-sectional, observational descriptive and inferential multicentric study that included children aged less than 1 year that sought care following a fall in the emergency departments of eight Spanish hospitals members of the Working Group on Unintentional Injuries of the Sociedad Española de Urgencias de Pediatría (Spanish Society of Paediatric Emergency Medicine). The study was approved by the Clinical Research and Ethics Committee of each participating hospital.

We defined fall as the event or effect of falling until hitting ground or a firm surface that stops it. We defined serious injuries as those resulting in fractures or requiring a computerised tomography (CT) scan, interventions such as haemodynamic stabilisation, immobilisation/motion restriction or major surgery, or hospital admission.

Patients were recruited over a period of 12 months between March 1, 2014 and February 28, 2015.

We collected data for epidemiologic variables (age, sex, personal history and motor milestones achieved); the circumstances of the injury (day of the week, setting and mechanism of the fall, witnesses of the fall, type of surface that broke fall and height of fall) and the severity factors defined above (presence and type of fracture, performance of CT scan, need for haemodynamic stabilisation, major surgery or immobilisation/motion restriction or hospital admission). We also documented the incidence of death in the first 24h following the fall. We classified patients into four groups by age (<3 months, 3–6 months, 6–9 months and 9–12 months) based on differences in independent mobility and psychomotor development.

The epidemiologic data were obtained by interviewing parents during the time spent in the emergency department, and collected on a form. Data on severity factors was obtained by reviewing medical records.

The data were reported through an electronic database (Google Drive), the access to which was restricted to the principal investigator of the study.

We analysed the data with the software SPSS 18.0. We performed a descriptive analysis calculating the mean, median and standard deviation for quantitative variables and percentages for qualitative variables. We also performed an inferential analysis using logistic regression. We defined statistical significance as a p-value of less than 0.05 in the tests.

Falls are the most frequent cause of mild unintentional injuries in children and adolescents both in the United States and in Spain,1 and they are a major reason for seeking emergency care,3,5 especially in children aged less than 2 years.1,9 In the United States, falls were the main cause of trauma in infants aged less than 1 year between 2001 and 2006, with an incidence of 3049 per 100,000 inhabitants.5 Identifying the risk factors and circumstances that promote falls is essential for the purpose of establishing effective preventive measures.2,10 Some studies have highlighted the ignorance of parents as to the mechanisms of these falls, which hinders their prevention.

Our study found a prevalence of falls in children aged less than 1 year of 0.35%.

In Spain, the prevalence of falls treated in paediatric emergency departments is higher than that of poisonings,11,12 drownings,13 bicycle falls14 or being hit by motor vehicles.15

It should be taken into account that so far no studies have analysed fall-related injuries in children aged less than 1 year in Spain.

As happened in other case series,2,5,16–18 we found a slight predominance of males, although it was not statistically significant.

In our sample, falls occurred mostly between ages 9 and 12 months and from baby equipment, followed by falls from furniture. Pickett et al. also observed a higher risk of falling between ages 9 and 11 months, although the most frequent mechanism identified in their study was falling from furniture.17 Pitone et al. also highlighted falls from objects as the most common type, with a higher incidence than falls from stairs or from the child's own height.19 However, most studies have not analysed falls from baby equipment as a possible mechanism, which is important given the greater risk of falling when children are left or changed in surfaces at a certain height.16,20

The analysis by age group of Pickett et al. found that infants aged less than 3 months mostly fell from their parents’ arms, while in our sample the main mechanism was falling from baby equipment, followed by falling from the caregiver's arms.17

Few patients in our series had a past history of trauma (3.9%), a percentage that was much lower than those reported in other studies, in which up to 39.7% had a past history of falls.2 This may be explained by the younger age of the sample in our study.

A salient finding was that 19.9% of falls occurred in infants that had not even developed the skill of rolling over, with 8.9% of falls involving infants aged less than 3 months. Other authors have also emphasised that a considerable percentage of falls occur in the early stages of development, a fact that caregivers may not be aware of.2

As was the case in the study conducted by the Asociación Española de Pediatría de Atención Primaria (Spanish Association of Primary Care Paediatrics) on unintentional injuries in the paediatric population of Spain,1 one-third of the falls took place on a Saturday, Sunday or holiday, which may be surprising considering that parents presumably spend more time with their children on these days.

Consistent with the findings of other studies, most of the falls (83.5%) in infants aged less than 1 year took place in the primary residence.5,17 This suggests that most of the injuries in this age group could be prevented by the use of appropriate child restraint and surveillance systems.

We found that 52.2% of the children in our study fell from heights of more than 50cm and identified falls from heights of more of 50cm as a risk factor for serious injury. However, other studies found a height threshold for serious injury of 137cm2 and, in less recent studies, of 150cm.21,22

One-third of the falls were not witnessed by the caregiver (32%), but we ought to note that in nearly half of witnessed falls, the child was not within reach of the caregiver (47.3%), which precluded preventing the fall in a very high percentage of cases (79.3%). However, we did not find an association between unwitnessed falls and increased injury severity. We did not find previous studies in the medical literature that analysed the caregiver's proximity at the time of the fall.

Although most of the injuries observed were mild, 12% of injuries were serious, and 9.1% resulted in fractures, and the risk factors for serious injuries identified in our study were the height of the fall, especially for heights of more than 100cm, and age less than 3 months.

In our study, falls in the street and from the caregiver's arms were also associated with serious injury. However, no previous studies have shown an association between these factors and serious injury.

We also found that falls from stairs were associated with serious injuries, as already noted by Elkington20 and then Pomerantz et al. in 2012,23 who described an increased risk of fracture and head injuries in association with these falls compared to falls from home furnishings.23

The main limitations of our study are that it may have missed patients that never sought care in emergency departments because the outcome of the falls seemed mild or because care was sought in primary care settings, and the lack of a subsequent followup to assess patient outcomes and detect potentially delayed effects of the falls.

In our study, we did not take into account the input of families as to the reason for the fall or whether protective–preventive measures were being used in or outside the home. We also did not use validated measures such as the Abbreviated Injury Scale (AIS) or the Injury Severity Score (ISS) to define serious injuries.

In conclusion, there seems to be a false sense of security among caregivers of children with little independent mobility, as the incidence of falls was highest in infants aged 9–12 months, especially in the home and from nursery furniture.

Based on our data, the most serious injuries occur in children aged less than 3 months for falls from heights of more than 50cm, but we did not find an association with unwitnessed falls. We also found that falls from the arms of a caregiver, stairs or that take place in the street are risk factors for serious injuries.

In light of these findings, we ought to refine or reinforce supervision measures, especially when it comes to the use of baby equipment, and emphasise preventive measures in the street, where other potential distractions can influence inattention to children.

The authors have no conflict of interests to declare.