Preventing fall-related playground injuries in children by modifying the environment of the playground (product)

Conclusion: Strong indications for effectiveness

Injuries to children with playground equipment is a complex subject. There are many factors that influence them, including the environment of the playground, the behaviour of the child, and frequency of use (Norton et al., 2004).The majority of playgound injuries are the result of falls from equipment and preventive efforts should be directed at reducing the risk of falls and their impact (CPS, 2002). Preventive interventions include: (1) Reducing the height of equipment so that fall height is decreased, (2) Improving the protective surfacing under and near to playground equipment, (3) Reducing the liklihood of falling from equipment through improved supervision.

Equipment height
Several studies on playground injuries indicated that these injuries are associated with the height of playground equipment. The risk of fall injury is increased 2-3 fold for equipment >2 m high (Khambalia et al., 2006). Nixon et al. (2004) found that 73% of injuries following a fall from a horizontal ladder or track ride were from falls greater than 1.80 metre (median height 1.93 metre). Specifically related to arm fractures, a case-control study (Sherker et al., 2005) suggests that fall height above 1.0 metre and equipment height above 1.5 metre are significant risk factors.

Protective surfacing
A review of risk factors for playground fall injuries found that the risk of fall injury is increased 1-2 fold for non-impact absorbing surfaces beneath the equipment (Khambalia et al., 2006). Recent studies provide evidence that granitic sand playground surfaces are better than engineered wood fibre playground surfaces at preventing upper extremity (arm) fractures from equipment falls (Sherker et al., 2005, Sherker et al., 2004, Howard et al., 2009).

Combining both playground equipment height and protective surfacing, Howard et al (2005) in a controlled study, examined whether the application of a Canadian Standards Association standard for equipment in playgrounds resulted in a reduction in rates of playground injuries. The standard included elements relating to equipment heights ( > 1.5 metres) and unsuitable surfacing. In playgrounds where equipment was removed and replaced, rates of playground injuries declined.

Improved supervision
The risk of playground injuries increases with incorrect usage of playground equipment. Lower levels of supervision increase risk of incorrect playground use (Chelvakumar et al., 2010).

Recommendations (for research & practice)

Suggestions for future research:
Research is needed to evaluate the impact of regulations and policies to develop and maintain safe playgrounds across the range of settings where children engage with such play equipment (Mc Donald EM and Gielen AC, 2010).

Suggestions for practice and policy:
The equipment height needs to be greater than 1.50 metre to allow effective use and less than 2.00 metre to reduce injury.

Playground surfacing standards need to reflect the finding that granitic sand playground surfaces reduced the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Also the maintenance over time of impact absorbing surfaces needs to be guaranteed.

It is important that playground equipment should not only be installed correctly but that it is also maintained over time.

Improving the environment of the playground is important but it needs to be complimented by supervision. The risk of playground injuries increases with incorrect usage of playground equipment. Lower levels of supervision increase risk of incorrect playground use.

Review Date: 30/05/2011
Version: 1.1
Status: Publish

Procedure
Articles (reviews) and reports were included that were published between 1980 and 2010, in English and Dutch. The outcomes of the study were reviewed by the Dutch Consumer Safety Institute.

Strategy: An online literature search was performed by a researcher of the Consumer Safety Institute and after this a more thorough search was performed by the documentation centre of CSI (Catalog CenV, Pubmed, Injury lit, Google, Websites, 'Grey' literature). Results of each search were compared on differences and potential missed studies were added. First the titles and then abstracts were scanned in order to include relevant studies. In the case of insufficient information obtained from abstracts the full text articles were obtained. Relevant articles were scrutinized and background documents were created. In addition, relevant references of included articles were checked on new and relevant articles (i.e., snowball search).

The outcomes of the study were reviewed by an expert in the field of child safety in the summer of 2011.

Background documents

The effect of safer play equipment on playground injury rates among school children (version 1.0)
Andrew W. Howard, Colin MacArthur, Andrew Willan, ... [et al.] (2005)

Preventing injuries on horizontal ladders and track rides (version 1.0)
James W. Nixon, Caroline H.C. Acton, Belinda A. Wallis (2004)

Out on a limb: risk factors for arm fracture in playground equipment falls (version 1.0)
S. Sherker, J. Ozanne-Smith, G. Rechnitzer ... [et al.] (2005)

Playground injuries to children (version 1.0)
C. Norton, J. Nixon, J.R. Sibert (2004)

Risk factors for unintentional injuries due to falls in children aged 0-6 years: a systematic review (version 1.0)
A. Khambalia, P. Joshi, M. Brussoni, ... [et al.] (2006)

Are current playground safety standards adequate for preventing arm fractures? (version 1.0)
Shauna Sherker, Joan Ozanne-Smith (2004)

School playground surfacing and arm fractures in children : a cluster randomized trial comparing sand to wood chip surfaces (version 1.0)
Andrew W. Howard, Colin Macarthur, Linda Rothman ...[et al.] (2009)

The Stamp-in-Safety programme, an intervention to promote better supervision of children on childcare centre playgrounds : an evaluation in an urban setting (version 1.0)
Gayathri Chelvakumar, Karen Sheehan, Amy L Hill ...[et al.] (2010)