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Preventing playground injuries

Active outdoor play contributes immeasurably to children’s health, well-being and overall development. Local playgrounds offer opportunities to climb, slide, jump, run and socialize with other children, and to play creatively. Playgrounds are also places where injuries can happen, but risks to children can be minimized by improving equipment design, safer placement and better surfacing and still provide ample scope for physical activity. Preventive measures that minimize risk include ensuring that equipment heights are age-appropriate, upgrading impact-absorbing surfaces around and beneath play structures, inspecting/maintaining equipment and play areas regularly, and providing adequate and active supervision.

Playground data

At least 29,000 children younger than 15 years of age receive treatment for playground injuries in hospital emergency departments each year in Canada [1]. Children five to nine years of age have the highest risk of injury, with males injured slightly more often than females (53% versus 47%). Playground injuries occur most often in summer (43%), followed by fall (27%), spring (24%), and winter (6%).

Mechanisms and types of injury

Up to 75% of injuries seen in emergency departments are incurred by falling [2]-[4]. Most other injuries are the result of impact with an obstacle (11%), a body part being cut, pinched or crushed (8%), or entrapment (1%) [5]. Fractures, usually of an upper limb, are the most common form of injury [2][5][6], with falls from a climbing structure – compared with from a swing or slide – being the most common cause [7].

Head injuries account for about 15% of the playground injuries seen in emergency rooms [5], with falls from a swing – compared with from a slide or climbing structure – being the most common cause [7].

Hospitalizations

From 1994 to 2003, an estimated 2500 children ≤14 of age were hospitalized every year in Canada for serious injuries from playground falls. Approximately 81% of these children had a fracture, while 14% were hospitalized for a head injury; the remaining 5% had injuries such as joint dislocations and open wounds. Over the period studied, hospitalization rates declined by 27%, likely in response to improvements to playground equipment and compliance with playground safety standards [8].

Home playground injuries

Backyard play equipment accounts for about 20% of all play area injuries. Children aged one to four years are more likely to get hurt at home than older children. Climbing structures, swings and slides are involved in most home playground injuries [8].

Deaths

Playground deaths are rare and almost always caused by strangulation. Strangulation can happen when clothing drawstrings, a scarf or a skipping rope get caught on play equipment, usually at the top of a slide. A child’s head can also be entrapped in an opening in playground equipment (eg, in the space between ladder rungs); this has happened when children were wearing a bicycle helmet [8].

Strategies to reduce playground injuries

Improvements to playground design, especially to equipment height and surfacing, would further reduce playground injuries [4][12].

Research shows that fall height and impact (ie, the surface a child falls on) influence the nature and extent of injuries [4][9]-[11]. One study found that falling from higher than 1.5 metres (4 ft 11 in) quadrupled the risk of injury [9]. Falls from higher heights cause even more serious injuries [10]. Impact-absorbing materials, such as sand or pea gravel, provide better protection [4] than a grassy surface, with one study finding that risk of injury is reduced by 1.7 times when playgrounds are surfaced with sand rather than grass [11].

The Canadian Standards Association (CSA, www.csa.ca) developed the only nationally recognized standard for playground safety. Their guide, entitled Children’s Playspaces and Equipment, was first published in 1990. It was revised and accepted as a voluntary national standard by the Standards Council of Canada in 1998, with updated editions published in 2003 and 2007. The CSA standard provides detailed specifications for playground layout, access (ie, for getting on and off equipment), and surfacing materials, equipment strength, performance requirements and installation, inspection and maintenance, and design specifications for each piece of play equipment. The standard recommends:

• Reducing the maximum fall height of equipment. Strategies include:
  • innovative designs for new equipment at lower heights
  • using age-appropriate equipment.

• Reducing the risk of falling from equipment. Examples include:
  • protective barriers and guardrails
  • using vertical rather than horizontal bars (to discourage climbing)
  • using peaked or curved surfaces for guardrails (to discourage their use as play surfaces).

• Improving protective surfacing under and around play equipment. Appropriate surfaces include:
  • loose fill, such as coarse sand or pea gravel (smooth, round, pea-sized stones), wood chips and synthetic surfaces, to depths of at least 15 cm (6 in) for preschool equipment and 30 cm (12 in) for full-sized equipment.

Changes and enhancements to the current standard included a lower optimum fall height measurement, a surfacing materials comparison chart and additional guidelines for making play spaces more accessible to children with special needs [18]. One study has shown that playgrounds modified to meet the current CSA standard can reduce associated injuries by as much as 49% [13].

Active supervision is important. Research has shown that children younger than five years of age were much less likely to take harmful risks when a parent was near by [14][15]. One program has been successful at increasing teacher supervision of young children in playgrounds, with an associated outcome of fewer risk-taking behaviours by the children [16][17].

In addition to structured playgrounds, communities may consider more nontraditional outdoor play environments. These areas can be less expensive to develop and are designed to challenge children’s natural faculties and their urge to play without the risk of falling from equipment. Examples ‘alternative’ playgrounds can be found at www.evergreen.ca.

Recommendations

To protect children from the most common playground injuries, the Canadian Paediatric Society recommends that:

Health care providers:

• Offer anticipatory guidance about playground injuries and what parents can do to reduce children’s risk. SafeKids Canada <www.safekidscanada.ca> and the Canadian Paediatric Society <www.caringforkids.cps.ca> have evidence-based information and resources on making playgrounds safer, for families, child care providers and communities.
• Report playground injuries to local playground operators and authorities.
• Educate playground operators about injury prevention by being involved with municipal planning and public health initiatives. A participating physician or health care professional can bring credibility to safety issues and provide specific details about the nature and risk of playground injuries.
• Advocate that new and existing playgrounds in the community be designed or upgraded to meet current CSA guidelines. To obtain a copy of Children’s Playspaces and Equipment, visit www.csa.ca.

Policy makers:

• Ensure that municipal policies on playground development and maintenance focus on compliance with CSA standards and reflect evidence-informed strategies to reduce playground-related injuries in children. To obtain a copy of Children’s Playspaces and Equipment, visit www.csa.ca.

Parents and caregivers:

• Provide active supervision.
• Teach and model playground safety rules, and remind children how to use equipment safely.

• Check local playground equipment and surfacing regularly, reporting problems to operators.
  • Dress children in a neck warmer instead of a scarf in cold weather, and avoid clothing with drawstrings or cords. These items can catch on playground equipment and cause strangulation.
  • Remove a child’s helmet before permitting access to play equipment.
  • Build home playgrounds to meet the CSA standards. To obtain a copy of Children’s Playspaces and Equipment, visit www.csa.ca.

Note: For parent information, visit www.caringforkids.cps.ca

Acknowledgements

This position statement has been reviewed by the Canadian Paediatric Society’s Healthy Active Living and Sports Medicine Committee.

INJURY PREVENTION COMMITTEE

Members: Claude Cyr MD; Brent E Hagel PhD; I Barry Pless MD; Jeffrey W Scott MD; Lynne J Warda MD (Past Chair); Natalie L Yanchar MD (Chair); Mitchell Zelman MD (Board Representative)
Liaisons: Dominic Allain MD, CPS Paediatric Emergency Medicine Section; Pamela Fuselli, Safe Kids Canada; Gail Salminen, Health Canada, Consumer Product Safety Bureau; Robin Skinner, Public Health Agency of Canada
Consultants: Matthew J Bowes MD; Amy Ornstein MD
Principal authors: Pamela Fuselli; Natalie L Yanchar MD 

References

1. Injury Section Public Health Agency of Canada analysis of data from the Canadian Institute for Health Information (CIHI) and the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP). In; 2000.
2. Chalmers DJ, Langley JD. Epidemiology of playground equipment injuries resulting in hospitalization. Journal of Paediatrics & Child Health 1990;26(6):329-34.
3. Mowat DL, Wang F, Pickett W, Brison RJ. A case-control study of risk factors for playground injuries among children in Kingston and area. Inj Prev 1998;4(1):39-43.
4. Norton C, Nixon J, Sibert JR. Playground injuries to children. Arch Dis Child 2004;89(2):103-8.
5. Vollman D, Witsaman R, Comstock RD, Smith GA. Epidemiology of playground equipment-related injuries to children in the United States, 1996-2005. Clin Pediatr (Phila) 2009;48(1):66-71.
6. Roberts I, Norton R, Jackson R, Hassall I. Effect of environmental factors on risk of injury of child pedestrians by motor vehicles: a case-control study. British Medical Journal 1995;310:91-4.
7. Loder RT. The demographics of playground equipment injuries in children. J Pediatr Surg 2008;43(4):691-9.
8. Safe Kids Canada. Child and Youth Unintentional Injury: 1994-2003 10 Years in Review 2006.
9. Chalmers DJ, Marshall SW, Langley JD, Evans MJ, Brunton CR, Kelly AM, et al. Height and surfacing as risk factors for injury in falls from playground equipment: a case control study. Inj Prev 1996;2:98-104.
10. Macarthur C, Hu X, Wesson DE, Parkin PC. Risk factors for severe injuries associated with falls from playground equipment. Accid Anal Prev 2000;32:377-82.
11. Laforest S, Robitaille Y, Dorval D. Surface characteristics, equipment height, and the occurance and severity of playground injuries. Inj Prev 2001;7:35-40.
12. Roseveare CA, Brown JM, Barclay McIntosh JM, Chalmers DJ. An intervention to reduce playground equipment hazards. Inj Prev 1999;5(2):124-8.
13. Howard AW, Macarthur C, Willan A, Rothman L, Moses-McKeag A, Macpherson AK. The effect of safer play equipment on playground injury rates among school children. Canadian Medical Association Journal 2005;172(11):1443-6.
14. Morrongiello BA, Rennie H. Why do boys engage in more risk taking than girls? The role of attributions, beliefs, and risk appraisals. Journal of Pediatric Psychology 1998;23(1):33-43.
15. Morrongiello BA, Dawber T. Mothers' responses to sons and daughters engaging in injury-risk behaviors on a playground: implications for sex differences in injury rates. Journal of Experimental Child Psychology 2000;76(2):89-103.
16. Chelvakumar G, Sheehan K, Hill AL, Lowe D, Mandich N, Schwebel DC. The Stamp-in-Safety programme, an intervention to promote better supervision of children on childcare centre playgrounds: an evaluation in an urban setting. Inj Prev 2010;16(5):352-4.
17. Schwebel DC, Summerlin AL, Bounds ML, Morrongiello BA. The Stamp-in-Safety program: a behavioral intervention to reduce behaviors that can lead to unintentional playground injury in a preschool setting. Journal of Pediatric Psychology 2006;31(2):152-62.
18. Canadian Standards Association. Children's playspaces and equipment Z614-07. 2007

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.