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Evidence-Based Strategies for Common Clinical Questions

October, 2018

Playing it Safe Around the Holidays: Anticipatory Guidance for Clinicians

Primary Author: James Odum, MD | Chief Pediatric Resident 

Column Editor: Rupal Gupta, MD | Medical Director, Operation Breakthrough Clinic | General Academic Pediatrics | Assistant Professor, UMKC School of Medicine

Holidays are like pediatric milestones: they bring excitement and celebration, but in anticipating their arrival, parents should consider how to keep their children safe. And as pediatricians, we should be prepared to provide anticipatory guidance to our patients and families regarding how to stay safe while enjoying the festivities.

Children age 19 and younger suffered a total of 5.7 million holiday-related injuries between 1997 and 2006—just over 500,000 holiday-related injuries per year, as shown by D’Ippolito et al., in a 2010 study published in Pediatrics. In this study, the top four holidays associated with injury included Labor Day, Memorial Day, Fourth of July and Halloween.1 Christmas carried the fewest associated injuries, but incidence still ranged from 48,427 injuries in 1997 to 49,394 injuries in 2006. While only a fraction of the injuries resulted in hospital admission (1.7%) or death (0.3%), this study only included patients who presented to one of 98 emergency departments. It likely underestimates the true incidence of injuries overall, and does not factor in those who did not seek medical treatment. So, with the variety of activities that take place on each holiday, how should pediatricians best counsel parents on the most effective ways to promote safety?

While summer holidays carry the highest risk of injury – often associated with outdoor activities, wheeled activities, recreational activities and sports – winter holiday safety is covered most effectively by guidance around pedestrian safety, food safety and toy safety. According to a Morbidity and Mortality Weekly Report published by the CDC in 1997, children may be four times more likely to be killed as a pedestrian on Halloween than any other day of the year.2 Providers should discuss pedestrian safety with families, with special emphasis on wearing bright clothing at night and establishing safe street-crossing routines with their children. 

During Thanksgiving, providers can teach families about proper food storage to minimize the risks for consuming foodborne pathogens. With the abundance of food that is typical of a Thanksgiving meal, leftovers are common. Families should refrigerate leftovers within two hours of cooking, and avoid eating leftovers that are more than three to four days old.3 Recommend parents discard leftovers by the Tuesday after Thanksgiving.

The literature has several case reports of aspiration events occurring near Christmas, including aspiration of ornaments, small toys and even Christmas tree needles,4, 5, 6 but this type of injury only accounts for 1.5% of ED visits.1 Discussing age-appropriate toys is still important anticipatory guidance to provide, including the avoidance of choking hazards in children under 3 (a quick rule of thumb is any item that can pass through a toilet paper roll tube can pose a choking risk). 

It is wise for parents to discuss birthday or holiday gift requests with children, and to consider appropriate safety measures and equipment prior to making risky purchases. For example, older children may request self-balancing scooters, also called “hoverboards,” which have come under criticism for related injuries. Despite their recent introduction into the consumer market, one study found that 26,854 pediatric injuries were related to hoverboards between 2015 and 2016, with the most common injury being upper extremity fracture. The dangers of hoverboards are related in part to a higher use of these devices indoors, where there is less space to maneuver and possibly a lower likelihood of children wearing protective gear. Hoverboard injuries also peak at 12 years of age, compared to skateboards that have an increasing incidence of injury as age increases. This suggests that younger children are routinely using these devices as compared to skateboards.7 In general, children are 1.5 times more likely than adults to sustain life-threatening injuries from hoverboards.8 Thus, pediatricians can encourage parents to limit use of hoverboards indoors, ensure that riders of all ages wear protective gear, and supervise young children using these devices.

When considering adolescent safety, New Year’s tempts teens like no other holiday; more than 25% of all holiday-related injuries in the 15- to 19-year age group occurred around New Year’s Eve.1 While not being confirmed as a cause for the injuries, alcohol consumption within this age range poses a clear risk to teens. During adolescent visits, providers should recommend abstinence from alcohol and drug use, as well as emphasize the importance of choosing safe transportation that does not involve riding with drivers who are under the influence of any substance. This can be highlighted around important adolescent events such as homecoming and prom as well. 

Overall, holiday-related injuries account for a sizeable portion of acute visits to the ED. While the vast majority of these injuries result in treatment and discharge from the ED (96.8%), providers should engage in preventive discussions on how to minimize the risks of injuries around the holidays. Establishing safe behaviors in their children ahead of time is critical to preventing holiday-related injuries. Methods of safe street-crossing, proper handwashing techniques and use of protective gear while riding bicycles, skateboards and hoverboards are all applicable to safety around the holidays. 

By encouraging teens to model these behaviors around younger siblings, parents can empower their older children to feel responsible and included in parenting strategies. This will subsequently allow parents to broach the important adolescent topics related to alcohol use and car safety in a familiar way that encourages teenagers to anticipate activities that have an increased risk of injury, and to develop contingency plans to ensure that they arrive home safely each night. While the holidays are full of excitement and celebration, planning can help families avoid the emergency department and to have all of their children safely tucked into bed at the end of a long day.


References:

  1. Epidemiology of Pediatric Holiday-Related Injuries Presenting to the US Emergency Departments. D’Ippolito A, Collins CL, Cornstock RD. Pediatrics (2010). Vol 125 (5): 931-937.

  2. Childhood Pedestrian Deaths during Halloween—United States 1975-1996. MMWR 1997;46:987-90. https://www.cdc.gov/mmwr/preview/mmwrhtml/00049687.htm

  3. FoodSafety.gov, Thanksgiving, https://www.foodsafety.gov/keep/events/thanksgiving/index.html, Accessed Sept. 9, 2018.

  4. When Christmas Decoration Goes Hand in Hand with Bronchial Aspiration. Carsin A, Baravalle-Einaudi M, Dubus JC. Respiratory Medicine Case reports 22 (2017): 266-267.

  5. A Christmas Tree in the Larynx. Philip J, Bresnihan M, Chambers N. Pediatric Anesthesia (2004). Vol 14 (12): 1016-1020.

  6. Oh Christmas Tree, Oh Christmas Tree… Yanchar N, Pianosi P, Fraser R. CMAJ (2004). 171 (12): 1435-1436.

  7. Pediatric Hoverboard and Skateboard Injuries. Bandzar S, Funsch DG, Hermansen R, Gupta S, Bandzar A. Pediatrics (2018). Vol 141 (4):e20171253.

  8. Injuries Associated with Hoverboard Use: A Review of the National Electronic Injury Surveillance System. McIlvain C, Hadiza G, Tzavaras TJ, Weingart GS. American Journal of Emergency Medicine (2018). https://doi.org/10.1016/j.ajem.2018.06.022.