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Outcomes From Television Sets Toppling Onto Toddlers
Carla DiScala, PhD;
Martha Barthel, RN, MSN;
Robert Sege, MD, PhD
Arch Pediatr Adolesc Med. 2001;155:145-148.
ABSTRACT
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Objective To assess outcomes of trauma caused by television sets falling onto
children.
Methods Retrospective review of medical charts of 183 children aged 7 years
and younger hospitalized for injuries caused by falling television sets. Descriptive
statistics were applied.
Data Sources Phase 2 (1988-1995) and phase 3 (1995-1999) of the National Pediatric
Trauma Registry.
Outcome Measures Demographics, injured body region, injury severity measured by the Injury
Severity Score, length of hospital stay, admission to the intensive care unit,
surgical intervention, in-hospital death rate, disability resulting from the
injury, and disposition at discharge from the hospital.
Results The sample population represented 0.5% of all National Pediatric Trauma
Registry admissions in this age group. More than half (57.4%) of the children
were boys, and more than three quarters (76.0%) were 1 to 4 years of age.
In most cases (95.1%), the injury occurred at home. Most children (68.3%)
sustained head injury, and 43.7% sustained injuries to multiple body regions.
More than a quarter (28.4%) of the children had injuries of moderate to critical
severity (Injury Severity Score, 10-75), about a third (31.1%) required admission
to the intensive care unit, and 20.2% needed 1 or more surgical interventions.
The average length of hospitalization was 3.3 days. Five children (2.7%) died,
and 48 (26.2%) developed functional limitations, which required discharge
to a rehabilitation facility in 5 cases. Most (94.0%) of the children returned
to their home. The proportion of television set–related injuries increased
more than 100% during the study period.
Conclusions The injuries reported are not trivial. Not only did they require hospitalization,
but they also resulted in an in-hospital death rate comparable to the 2.5%
rate observed in children of the same age group injured by unintentional blunt
trauma, inclusive of motor vehicle traffic–related injuries. Since virtually
all American children are at risk for such injury, we suggest that television
set designs be modified to reduce the incidence and severity of the problem.
INTRODUCTION
TELEVISION (TV) sets are ubiquitous in American households. The Consumer
Electronics Manufacturers Association reported in 1997 that 98% of the households
in the United States own 1 or more TV sets.1
Recently, decreasing costs have led to the widespread popularity of large-screen
TV sets, with screen dimensions of more than 25 inches. Contemporary TV sets
are different from earlier models: they are heavier and, although the screen
is larger (often up to 36 inches), the encasement is smaller.2
These changes bring most of the weight to the front part of the set, making
it difficult to find a stable and balanced placement. The physical characteristics
of TV sets and the large amount of time young children spend watching TV (average,
4 h/d)3 can easily give occasion to injuries
from falling TV sets.
Several physical properties increase the risk of injury from toppling
TV sets. The heaviest portion of a standard cathode-ray tube TV set is the
screen itself. Thus, weight increases dramatically with larger screen sizes,
and the center of gravity of the sets moves forward toward the screen. According
to manufacturers' specifications, TV sets range from an average of 36 kg (80
lb) for a 27-in set to 80 kg (176 lb) for a 36-in set. Furthermore, the cabinets
are not padded and usually feature sharp corners that may concentrate the
force of impact onto a small surface area, increasing the risk of injury.
Television stands and entertainment centers originally designed for smaller,
lighter sets may be used for new larger sets and may not be adequate to prevent
the set from falling when jostled.
There is scant recent literature reporting on this problem. The US Consumer
Product Safety Commission (CPSC) estimated that, from 1982 to 1986, 6 deaths
each year and 8000 to 10 000 emergency department visits were associated
with injuries caused by the tip-over of furniture.4
Most of these injuries and deaths occurred to children when furniture, including
TV stands or TV sets sitting on top of shelves or a chest, overturned. During
that period, overturned TV sets were associated with an estimated 2300 hospital
emergency department–treated pediatric injuries. Four children younger
than 5 years died when the TV sets fell on them. Injuries and deaths resulting
from toppling TV sets among children were documented in a previous study5 by using data compiled by the CPSC and by a single
trauma center. We chose to corroborate the findings of that study and to extend
them to the current era of larger TV sets, by analyzing a much larger cohort
of children injured by falling TV sets and reported to the National Pediatric
Trauma Registry (NPTR) between October 1988 and December 1999. This study
is particularly important as the industry prepares to introduce high-definition
TV models, virtually all of which will be large-screen.
METHODS
The NPTR is a database that contains information about many aspects
of pediatric trauma, its causes, and its consequences. Data are voluntarily
contributed to the NPTR by pediatric trauma centers or by children's hospitals
with pediatric trauma units.
The NPTR collects data on children and adolescents 19 years old and
younger who are admitted to the hospital for an acute injury, including patients
who are dead on arrival or who die in the emergency department. All injuries
are included, except burns, poisoning, and near drowning. The operation, data
management, and quality assurance of the NPTR have been described in detail
elsewhere.6
The injuries recorded in the NPTR represent a subset of all the injuries
occurring to children because the NPTR includes only those injuries that led
to hospitalization. Also, because the NPTR's participating institutions are
hospitals specialized in the treatment of pediatric trauma, the proportion
of severe cases reported to the NPTR is higher than that observed in all hospitals.
The NPTR is a voluntary database, not a population sample, and precise population-wide
incidence estimates cannot be made from NPTR data.
SUBJECTS
We extracted from the NPTR phase 2 (October 1988 to October 1995, N
= 53 113) and phase 3 (October 1995 to December 1999, N = 35 385)
all cases with an assigned "E" code7 for external
cause of injury of E916 (struck accidentally by a falling object) or E917.9
(struck accidentally by objects) that identified in the injury description
the TV set as the object striking the patient. The injury description is a
50-character string in the NPTR that contains pertinent information about
the injury event and can be searched for keywords, such as TV or television in this case. After excluding
5 cases of children aged 8, 8, 9, 12, and 13 years, we identified a set of
183 cases (73 from phase 2 and 110 from phase 3) for analysis. The data were
contributed by 68 hospitals, inclusive of 32 children's hospitals.
MEASURES
Variables analyzed included age, sex, place of occurrence, severity
of injury, injured body region, and use of resources during hospitalization,
including admission to the intensive care unit, surgical intervention (operating
room), length of hospital stay, and clinical outcome.
Severity of injury was measured by the Injury Severity Score.8 In conformance with the computation of the Injury
Severity Score, body regions considered in the analysis were head and neck,
face, thorax, abdomen, extremities, and skin. Outcome was measured by in-hospital
death rate, the number of functional limitations, and disposition at discharge
from acute care.
Functional status was assessed at the time of discharge by rating the
child's ability in 9 or 10 functional domains: vision, hearing, speech, self-feeding,
bathing, dressing, walking, bowel/bladder control (from 1995 onward), cognition,
and behavior. Using performance and neurologic tests, a clinician rated the
performance of the child in each functional area as either age appropriate, impaired, or unable. In our analyses, the categories of impaired and unable were combined to reflect any degree
of functional limitation. In addition, for each functional limitation, the
clinician indicated whether it existed before the current trauma event and,
if so, whether it was worsened by the current injury.
DATA MANAGEMENT AND ANALYSIS
Data analyses were performed using BMDP9
statistical software. Descriptive statistics were applied.
RESULTS
More than half (57.4%) of the children were boys, and more than three
quarters (76.0%) were 1 to 4 years of age (Table 1). Most injuries occurred at the child's or another private
home (95.1%); only 2 (1.1%) took place at day care centers or schools. Most
children (68.3%) sustained injuries to the head, and 43.7% sustained injuries
to multiple body regions (Table 2).
Only 2 children sustained injuries to the thoracic cavity. Most (69.4%) of
the children had injuries of mild severity (Injury Severity Score, 1-9), but
28.4% sustained injuries of moderate to critical severity (Injury Severity
Score, 10-75) (Table 2). The average
length of hospitalization was 3.3 days (median, 2.0 days), approximately one
third (31.1%) of the children were admitted to the intensive care unit, and
one fifth (20.2%) required 1 or more surgical interventions. Five children
(2.7%) died, all from massive intracranial hemorrhage. Forty-eight children
(26.2%) developed 1 or more functional limitations from the current injury.
Activities of daily living were the most frequently impaired, followed by
neurologic functions and sensorial functions (Table 3). Five children developed problems with their bladder or
bowel control or both, but this is probably an underestimated number because
this information was not collected during phase 2 of the NPTR. Most children
(94.0%) returned to their home after leaving the trauma center, but among
the children with the newly acquired disability, 5 were discharged to a rehabilitation
facility.
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Table 1. Patient Characteristics of 183 Children*
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Table 2. Injury Characteristics of 183 Children*
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Table 3. Functional Limitations of 183 Children*
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The proportion of TV set–related injuries changed during the study.
While between 1988 and 1993 it accounted for 0.30% of all unintentional blunt
traumas in this age group, it more than doubled to 0.63% between 1994 and
1999. Moreover, while no child died from this type of injury between 1988
and 1993, 5 fatalities were reported between 1994 and 1999.
COMMENT
Injury is a major cause of death and disability during childhood. Pediatricians
and injury professionals have led successful campaigns to reduce the frequency
and severity of motor vehicle and bicycle injuries through the promotion of
car seats and bicycle helmets. Most states now have statutory requirements
for the use of safety devices by children.
Being accidentally struck by an object is also a relatively frequent
cause of pediatric trauma requiring hospitalization. In the NPTR, among the
36 705 children younger than 8 years who sustained unintentional blunt
injuries and were reported to the NPTR between October 1985 and December 1999,
2242 children (6.1%) required hospitalization for injuries resulting from
being struck by an object. Among these, 183 children were injured by a TV
set that fell while the child was trying to reach it, was climbing on the
TV stand, or was engaged in similar activities likely to cause the fall of
the equipment from its place of support. In several instances, the TV set
was reported to be as large as 36 inches.
Being injured by a falling TV set is not a new problem. The National
Safety Council reported that in 1988 overturned TV sets caused 31 754
injuries to people of all ages, requiring treatment in the emergency department.10 The CPSC estimates that 2300 children require treatment
annually in the emergency department for injuries associated with toppling
of TV sets.4 In addition to recalling TV cabinets,
carts, and guards,11, 12, 13
the CPSC issued a consumer product safety alert in 1988 that includes the
following warning: "Young children can be killed when furniture tips over.
Place TVs on lower furniture, as far back as possible. Use angle-braces or
anchors to secure furniture to the wall."4
Although small TV screens have been replaced by much larger screens,
no alterations in design appear to have been made that would result in making
the device less prone to toppling. Our search for standards of design in the
documents library of the American Association for Testing and Materials, US
Department of Commerce, did not reveal any specific recommendations that dealt
with non–power-related safety.
Yet, the weight of the big TV sets, combined with the instability caused
by the overloaded front, should surely cause concern. Our study confirms earlier
work that falling TV sets can be lethal or cause lifelong disability to young
children. The in-hospital death rate of 2.7% reported in this study is comparable
to the 2.5% in-hospital death rate for the same age group from all causes
of unintentional blunt trauma, inclusive of motor vehicle traffic–related
injuries. In addition, 1 in 4 children had functional limitations at the time
of discharge, which required admission to a rehabilitation facility in 5 cases.
We do not know about less obvious and subtler limitations that may have developed
or become evident later.
The NPTR data suggest that this problem is worsening, as reflected in
the increased proportion of children hospitalized and dying from being struck
by a TV. Even if this proportion is relatively small (0.5% of all NPTR admissions
in the age group of our study), the severity of the outcomes, the increased
frequency of occurrence, and the lengthy exposure of children to TV viewing
are reasons for alarm.
Approaches to prevention of this problem should take into consideration
the need to reach beyond the consumers with access to adequate safety guidelines,
such as those that may be provided by medical personnel or alerts from the
CPSC. It may be more effective for the CPSC to require manufacturers to affix
labels to TV sets warning about the instability of the equipment and specifying
appropriate placement. It may also be possible that simple changes in the
design of TV sets and stands could reduce the risk of this type of injury.
CONCLUSIONS
Clearly, being struck by a toppling TV set can cause serious injuries
and death to young children. As reported by the NPTR,14
more than 40% of children younger than 8 years are injured at home. Many safety
guidelines and educational programs, including TIPP,15 address the issue of home-related injuries, but none
emphasize this hidden hazard. Because we can assume that almost all American
children are exposed to TV sets in their home environment, warnings about
toppling TV set–related trauma should be added to other injury prevention
guidelines in the form of brochures available in hospitals and community clinics.
In addition, since it appears from our data that the CPSC alert has done little
to reduce the number of injuries or deaths resulting from toppling TV sets,
we recommend, as a more effective approach to prevention, the introduction
of regulatory action. Schools, day care centers, and health care facilities
should also inspect their TV sets to ensure that they are properly secured.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
This research was supported in part by grant H133B950006 from the National
Institute on Disability and Rehabilitation Research, Washington, DC, and by
funding from the Maternal and Child Health Bureau of the Health Resources
and Services Administration, Rockville, Md.
From the New England Medical Center, Department of Pediatrics, Tufts
University School of Medicine, Boston, Mass (Drs DiScala and Sege); and Department
of Pediatrics, Children's Memorial Hospital, Chicago, Ill (Ms Barthel).
Corresponding author and reprints: Carla DiScala, PhD, New England
Medical Center, Department of Pediatrics, Tufts University School of Medicine,
750 Washington St, Campus Box 75K/R, Boston, MA 02111 (e-mail: cdiscala_tra{at}opal.tufts.edu).
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