Arriving home from my job as a night nurse at a local skilled nursing facility, I rejoiced at the quiet and prepared to catch a moment of rest. Crash! Bang! Scream! I ran to my 2-year-old child’s room to find her under the dresser with her two front teeth bleeding. Instead of sleeping, I spent the next few hours at the ED. Now, in my role as a visiting public health nurse, I often think back to that incident as I enter the homes of families with young children. Could that accident have been prevented? What are the dangers to the children in these different homes?

Children are vulnerable to hazards in their environment. In 2003, approximately 1,520 children age 4 and younger died, and nearly 2 million visited the emergency room for injuries occurring in the home. Accidental home injury deaths to children are caused primarily by airway obstruction, fire and burns, drowning, firearms, falls, choking and poisoning.¹ Asthma, lead poisoning, and allergies are also serious problems. However, these do not happen by chance. Patterns of injury and illness reflect children’s ages, developmental level, environments, and activities.

Prevention is key to decreasing unintentional injuries to children. During well-child or home visits, nurses can assist families to assess their homes for health and safety hazards. Parents should evaluate their homes, daycare settings, vacation rentals, and any other place where children spend a significant amount of time, including the houses of grandparents and other family members. By combining home assessment with the knowledge of children’s developmental levels, nurses can devise precautionary safety strategies with families. Nurses need to present this information in a manner free from lecturing or criticizing parenting styles. By understanding children’s developmental progression from birth to 5 years of age, families can learn to anticipate problems and protect their children. Nurses can take advantage of their close, trusted relationship with caretakers to provide guidance.

Infants

Preparation for preventing injury begins before the baby comes home after birth. The law requires children under the age of 4 or who weigh less than 40 pounds to ride in a car seat. Advise expectant parents to buy the car seat before their baby is born so they can learn to install and use it properly. Motor vehicle traffic crashes are the most common type of fatal injury among children. Use of child restraint systems can greatly reduce the number and severity to child occupants of motor vehicles. In 2002, 40% of children ages 1 through 4 years old who died in crashes were unrestrained.² Car seats, when properly used, can reduce the chance of death by 90% and injury by 70%. Be sure to follow the manufacturer’s instructions carefully. To ensure you’ve installed your child safety or booster seat correctly have it checked at a child safety seat inspection station or by a certified child passenger safety technician. For current safety requirements and how to locate a child safety seat inspection station by zip code, go to www.nhtsa.gov/cps/cpsfitting/ or call (888) 327-4236.

Infants from birth to 12 months are completely dependent, trusting in caregivers to keep them safe. At this age, vigilance is imperative because babies’ capabilities, especially their mobility, change quickly and dramatically in the first year. For example, newborns move quickly from learning to roll over, crawl, sit, and eventually stand. Well-baby checkups provide a good opportunity for nurses to talk to caregivers about the implications of these developmental changes.

Caregivers need to “childproof” the home before a baby begins to crawl or move across the floor. Advise parents to get down on the floor and view the room from the baby’s perspective. Teach them never to leave babies alone where they are at risk of falling, especially from beds, tables, or countertops, and be careful around furniture or stairs.³ Babies are safest in places like approved playpens. Everything else in which a baby is placed should have a seat belt type of restraint to prevent falls and when choosing a changing table, select one with two-inch guard rails. Because data indicates a considerable risk for injury and even death from the use of infant walkers, the American Academy of Pediatrics recommends a ban on the manufacture and sale of mobile infant walkers. There is no benefit from their use. Nurses can recommend stationary activity centers as a safer alternative to mobile infant walkers.⁴

When a baby can sit up, the crib mattress may be lowered so the child will not fall out. Once a child can stand, the mattress needs to be lowered again, and bumpers and anything else that could be used as a step need to be removed. Hanging strings from shades and blinds that could strangle a baby should be eliminated. Have caregivers install safety gates on stairways, keep doors closed, and use guards and/or locks on windows. Playpens can protect children from falling or entering unsafe areas, but some gates are dangerous. Accordion-style gates with large V-shape openings are entrapment and strangulation hazards. Although accordion-style gates have not been sold since 1985, gates and other hazardous equipment may still be sold at thrift stores and garage sales. Advise parents to check with the manufacturer’s website or information line for recall information.⁵

Babies learn quickly in their first year. They gain knowledge of their world by tasting, touching, and feeling the objects around them. Mechanical suffocation and suffocation by ingested items cause the most fatalities of children less than 4 years of age.⁶ Infants can also suffocate from lying face down on a soft surface. Babies need to be away from waterbeds, soft bedding, lamb’s wool pads, beanbag chairs, and pillows. Babies are best positioned for sleep on their backs on a firm mattress. Have parents make sure crib rails are no more than two and three-eighths inches apart (about the diameter of a soda pop can), so that the infant’s head cannot become lodged. More infants die every year in accidents involving cribs than in accidents involving any other nursery product. Only new cribs that meet federal safety regulations should be used.⁶ When a child is 5 months old or has begun to push up on hands and knees — whichever comes first — all toys strung across crib or playpen areas should be removed to prevent strangulation.

When choosing products intended for a child, safety should be the primary consideration. Parents need only use products as directed, keep them in good repair, and properly dispose of them if they become a hazard. Choking can occur when children cannot swallow an object that obstructs the trachea. Lack of oxygen during this time can lead to brain injury or death. If an object is less than one and one-quarter inches wide (the size of a silver dollar), babies may choke on it. Small objects, such as balloons, strings, or ribbon, should be kept away from them. Rattles should be large enough to prevent them from getting lodged in a baby’s throat and sturdy enough to prevent them from separating into small pieces that can be swallowed or inhaled. Never tie pacifiers or other items around a child’s neck.⁷ Children also need supervision when eating. As babies grow, parents should not feed them grapes, peanuts, popcorn, hard candy, hot dogs, or carrots, all of which can easily block the airway. All solid foods need to be cut into very small pieces.

In 2003, 320 children ages 14 years old and younger died as a result of unintentional drowning, and 256 were less than 4 years old.¹ Parents can prevent drowning. Teach them to never leave a child in a bathtub alone or under only sibling supervision. A toddler can drown in as little as two to three inches of water. Never leave water in the tub when it’s not in use.⁶ Children need to be kept away from buckets, toilets, pools, and any things that contain water. At the pool, beach, or in the tub, if a parent must leave, advise them to take the child with them. Checking the water temperature on the wrist or elbow before bathing can prevent burns and scalds. Set the household hot water thermostat for 120 F; however, a baby’s bathwater should be 100 F. Antiscald devices can keep water temperature below 120 F. They range in price from $15 to $75 and require installation. Don’t allow children in a whirlpool, Jacuzzi, or hot tub; their bodies are more sensitive to hot water.⁷ Advise parents never to hold a child while they are cooking, smoking, or drinking hot liquids.

Nurses can educate mothers during check-up visits before and after birth of the baby. Informational booklets and videos can be made available to them. For example, videos on the growth and development of infants and product safety can be played in the waiting room so that the nurse can answer questions during the visit.

Toddlers

Children from 12 to 24 months of age become toddlers who start to walk, climb, and explore. As they investigate their environment, toddlers tend to put everything in their mouth. This period can be particularly hectic. Education about toddler issues should begin at the 9 month check-up when some babies are already beginning to stand.

The 2002 Annual Report of the American Association of Poison Control Centers (AAPCC) indicated that almost 550,000 children under age 6 were treated for exposure to pharmacological substances (medications) and more than 700,000 were treated for nonpharmacological exposures (household cleaners, pesticides, and food extracts).⁸ Child-resistant caps are not childproof. In fact, when manufacturers test child-resistant caps, federal regulations consider 85% a passing grade, meaning that 15% of children are able to open these containers.⁹ Nurses should advise parents to never call medicine, even vitamins, “candy” and avoid taking medicine in front of children, who may imitate the behavior. All medicines, mouthwashes, liquors, cleaning products, insecticides, paints, and other poisonous or potentially toxic substances should be stored in original containers in a locked cabinet where children cannot reach them. Many poisonings occur while these items are in use, so they should always be used with extreme caution. Parents can play it safe by not using them at all if a child is in the room. Advise families to inventory all hazardous substances in the home and use drawer latches and knob covers wherever items are stored. Remind parents to clean up after adult nighttime activities so their toddler does not discover cigarettes and not-completely empty containers of alcohol first thing in the morning. Chewing on cigarette butts has the potential for nicotine poisoning for the toddler and only a small amount of ingested alcohol can be toxic.⁹

Families need to have the number for poison control taped to the telephone or affixed to the refrigerator by a magnet. The national toll free number (800) 222-1222 will connect parents with the poison control center in their area. Syrup of ipecac should be readily available, but it should not be administered unless instructed by a poison control or health care professional. The purpose of syrup of ipecac is to induce vomiting. If ipecac is given to a child who took an acidic poison that caused tissue damage when ingested, it can cause further harm by exposing the same tissue to the toxic substance when it is brought back up. If a poisoning does occur, parents should call for help immediately and be prepared for questions by having the child and the poison nearby during the call.

Toddlers are at great risk of falling from a window.³ Advise families to keep chairs, tables, sofas, and cribs away from windows in the home. Opening windows from the top is a simple way of blocking access to children. Encourage families to use window guards and locks as effective safeguards. For instance, a mass media-supported campaign in New York that provided free window guards to families living in apartments resulted in a 50% reduction in falls and a 35% decrease in mortality.¹⁰

Preschool

From 2 to 3 years of age, children learn quickly. They run, jump, climb, and ride tricycles and other riding toys. They also get into closets, drawers, and cabinets. Although they can follow simple commands, they want to do things on their own. Unfortunately, preschoolers are not adept at judging what can cause harm. No running and jumping in the house and no playing in the kitchen and bathroom are some good rules to set at home.

Parents should make sure that the same dangerous objects that were hidden away from toddlers remain inaccessible to preschoolers. For example, children under age 5 who play with cigarette lighters account for 150 deaths each year.¹¹ Matches and lighters must be out of children’s reach. Advise caregivers to teach children not to touch these items, as well as guns, knives, or needles. Children need to learn to tell a grown-up right away if they come across these things. They should also know what to do if they find a gun — that is, not touch it, leave the area, and tell an adult. Again, caregivers who learn to “think” like children can anticipate problems before they occur. For instance, the microwave is a common source of burns in children. This appliance is dangerous for children not only because they don’t understand how to operate it, but have difficulty taking things in and out of it. Children need to be monitored and taught that such appliances are simply out of bounds to them.

Eighty percent of fall-related injuries among children less than 4 years of age occur in the home.¹² They fall from play gyms, trees, swings, windows, and anything else they can climb or ride on. Families should keep children away from stairs, porches, pools, or streets while on riding toys. Toy chest accidents have occurred when children were reaching over and into the chest when the lid dropped, either falling on their heads or trapping them at the neck between the lid and the edge of the chest. Some children have suffocated when they climbed into chests to hide. Instruct caregivers to look for a toy chest with a lid support that will hold the lid open in any position. A spring-loaded lid support device can keep a lid from falling on a child’s neck or from closing and trapping a child playing inside the chest. This device costs about $7.50 and should be used on all chests that store toys.⁷

Doors must be removed from old freezers and refrigerators, which need to be picked up for disposal as soon as possible to keep a child from getting trapped inside.

From 4 to 5 years of age, children try new activities, such as jumping from high places. These older children are at greatest risk of falling from playground equipment, which results in injuries that drive about 211,000 U.S. children to EDs each year. Monkey bars, jungle gyms, swings, and slides account for 88% of the injuries.¹² In 2001, there were almost 75,000 injuries that resulted from trampolines,¹² and it’s the recommendation of the American Academy of Pediatrics that trampolines not be used in the home or at outdoor playgrounds. Nurses can caution caregivers to assess their yards and public spaces for safety. A safe playground requires adequate space, impact-absorbing surfaces (such as wood chips), and well-maintained and age-appropriate play equipment, as well as supervision. Mechanisms need to be in place to prevent children from wandering off. Playgrounds should be set back from the street where active play will not accidentally flow into traffic. If this is not possible, vegetation or fencing can be used as a barrier. Children need to learn to stop, look, and listen before running after a ball or crossing a street. Nurses can advise parents to instruct children in bicycle safety that includes helmets to protect against head injuries and other accidents.¹¹

In this age group, safety education can be directed toward the child as well as the parent. Preschool children can learn songs and rhymes about safety. Instruction should be simple, with one concept introduced at a time. Short stories, puppet shows, songs, coloring activities, and role-playing games are all suitable for teaching preschoolers safety behaviors.¹³

Fire safety

Because of poor danger perception and a limited ability to react appropriately, children under age five are at greatest risk of death from home fires. These fires most often result from cooking and heating equipment and smoking materials. Smoke alarms can reduce fire deaths by 50%.³ All homes should have a working detector on each level of the house and near the sleeping area. Alarms need monthly testing and annual battery changes, which can be linked to an event like a child’s birthday or changing clocks for daylight-savings time.

Families can practice fire drills that include several escape routes from the house, as well as an outdoor meeting place. Children should know to stop, drop, and roll if they are on fire. Their clothing and bedding should be flame-resistant. Parents should avoid overuse of extension cords and electrical outlets. Cooking materials, space heaters, and/or candles should not be left unattended whenever in use. Children should not be allowed to touch the fireplace or wood stove.

Indoor pollutants

Assessing exposure to indoor pollutants is essential because children spend 80% or more of each day indoors.¹⁴ Children are particularly vulnerable to toxins because their central nervous systems are not yet fully developed and because they drink more water, eat more food, and breathe more air in proportion to their size than adults.¹⁴ Exposures can lead not only to developmental problems, but also to medical problems and even death.

Nurses need to ask the right questions to assess the indoor home environment. For example, are there unusual, noticeable odors or stale or stuffy air in the home? Is there excessive humidity or signs of mold and mildew? Is central air conditioning or heating equipment faulty or dirty? Are flue pipes or chimneys damaged or in need of cleaning? Has there been recent remodeling? Has there been a health reaction after remodeling, weatherizing, using new furniture or household or hobby products, or moving into a new home? Does anyone feel noticeably healthier outside the home? Any positive answer could indicate an indoor environmental problem.

Good home maintenance is the best strategy for preventing childhood exposure to indoor toxicants. For instance, homes built before 1978 may have lead paint.¹⁵ Peeling paint will produce dust that gets on children’s hands and toys and allows lead ingestion. Any home older than 20 years is likely to have asbestos, which should also be replaced. Deteriorated, damaged, or disturbed pipe insulation, fireproofing, flooring, or acoustical materials can launch microscopic asbestos particles that can be inhaled. Remodeling or simply trying to eliminate toxins can disturb and release asbestos, lead, formaldehyde, and other hazardous materials into the home. Advise families to ensure that contractors follow safe practices for containment and disposal of materials during and on completion of the work. Finally, homes with excessive humidity or a water leakage problem may have mold and mildew.

Carbon monoxide can come from unvented fossil-fuel space heaters, gas stoves, and ovens, as well as back drafting from furnaces and water heaters. This odorless, colorless, tasteless, but potentially lethal gas can cause headache, nausea, muscle weakness, and even death.¹⁶ Its ability to bond with blood hemoglobin at the sites in red blood cells where oxygen would normally bind can deprive the body of needed oxygen. Families need to ensure that heaters are in good working order and ventilated properly. Cribs and beds need to be positioned away from heating vents that might concentrate emission in a child’s airspace. Carbon monoxide detectors should at least be placed near sleeping areas and the furnace.¹⁶

Because infants and toddlers spend a lot of time on the floor, families should be aware that pesticides, lawn chemicals, and contaminated soil could be tracked in on shoes and deposited on the floor. Visitors can prevent this by wiping their shoes on a mat at the door or leaving them at the door. Family members who work in manufacturing, in mining, or with chemicals can also bring toxins into the house. Proper care and handling of uniforms and equipment can prevent this. Floor surfaces and the layer of air near them contain toxins — some of which are toxic gases from unvented or poorly maintained wood stoves — that layer close to the floor.¹⁷ Heavy lead dust and paint chips can also fall to the floor and contaminate surfaces. Children who crawl on the floor or put their hands in their mouth are exposed to these hazards. Mopping, handwashing, and the use of a playpen can reduce the risks.

House ventilation that brings in fresh air can dilute the indoor concentration of pollutants. Air conditioning units are the best means of filtering outdoor air and reducing indoor air humidity during warm seasons. However, units set too high can trigger temperature-induced asthma and respiratory problems. The temperature should be set between 78 F and 80 F, just low enough to reduce humidity and make the room comfortable. Filters capture dust and contaminants and, if dirty, can become breeding grounds for mildew and mold. Both air conditioning and heating systems need to have filters cleaned or replaced regularly.¹⁸

Allergies and asthma

It is estimated that 40 million to 45 million Americans have some type of allergy.¹⁸ An allergy occurs when the immune system overreacts to an otherwise harmless substance. Common indoor allergens include house dust mites, cockroaches, molds, and animal dander and saliva. For the nearly 15 million adults and children in the U.S. with asthma,¹⁹ allergies often initiate swelling, mucous production, and constricted airways. Although medications help control allergies and asthma, it is also important to reduce exposure to allergens. Allergen control should start in the sleeping area and move throughout the rest of the house.

House dust mites are most commonly found in dust from mattresses, pillows, bedding, carpets, upholstered furniture, clothes, and toys, such as stuffed animals. Advise families to cover mattresses and pillows with allergen-impermeable covers. Pillows and bedding should be washed weekly in hot water and carpets and draperies removed from sleeping areas. Toys, stuffed animals, books, and knickknacks can be stored in enclosed units. Homeowners should avoid exposed shelving and upholstered furniture. They need to wet-dust and vacuum the house weekly. If cockroaches are present, roach traps and boric acid may help eliminate them; however, depending on the level of infestation, professional extermination may be required. Poisons should be used with extreme caution when children and pets are present. Keeping all food and food waste in closed containers, not leaving dirty dishes in the sink, and cleaning kitchen cabinets regularly will keep bugs and rodents away. Do not collect brown paper bags or cardboard boxes, as cockroaches like to breed in them.

Molds are microscopic fungi that live on plant or animal matter and thrive in high-humidity, damp areas. Maintain low indoor humidity, ideally between 30% to 50% relative humidity. Hygrometers, which are available at local hardware stores, can measure humidity levels. Bathrooms should have ventilation to prevent mold growth. Remove plants from the bedroom, as their soil is often moldy. Repair any floor, ceiling, or wall areas with water damage. A 1:10 diluted bleach and water solution is effective against mold and mildew on hard surfaces.

When children are allergic to cats or dogs, the animals should be removed from the home. If this is not possible, keep pets out of the sleeping area with the bedroom door shut. Fish and turtles are good alternative pets.

Secondhand smoke, also known as Environmental Tobacco Smoke (ETS) includes both exhaled mainstream smoke from smokers and side stream smoke from the end of a cigarette, cigar, or pipe. Secondhand smoke contains more than 4,000 substances, including over 50 compounds that have been identified as carcinogens and many of the compounds in tobacco smoke are released at higher rates in side stream smoke than in mainstream smoke.¹⁹ ETS increases the risk of lower respiratory tract infections, ear infections, and asthma exacerbation in young children whose lungs are still developing. The home should be a smoke-free environment. Advise caretakers of the dangers to children. Encourage smokers to quit. If they are not ready to quit, recommend that all smoking be done outside the home or in the presence of fans and open windows to increase ventilation. Suggest the new methods to assist in quitting, such as oral aids and patches. Gently probe about smoking-cessation attempts and provide encouragement at each encounter. (For more information about smoking cessation, see CE 207, “Smoking Cessation — Developing a Workable Program,” at www.nursingspectrum.com.)

Nursing’s bond with the environment began with Florence Nightingale, who wrote about the importance of ventilation, light, cleanliness, and the health of houses. It is part of our heritage. Nurses understand how important the condition of the home is to the health of patients. During the 21st century, we need to keep the environment firmly in the forefront of our practice.