Pediatric Annals

Healthy Baby/Healthy Child 

Staying Safe This Summer

Leah Khan, MD

Abstract

The arrival of summer brings more sunshine, more time outside, and more opportunities for recreation and play. Although these activities may look a little different this summer as a result of the coronavirus disease 2019 (COVID-19) pandemic, they also allow us to get outside, interact safely with others, and remain connected to our friends and communities. Along with fun activities and exercise, there also comes a need for heightened awareness of summertime safety. Because so many childhood activities occur during the summer, precautions must be taken to ensure the safety and health of our children. From appropriate sun protection and water safety to insect exposure and recreational precautions, it is important to review key safety points to ensure a happy and healthy season. As the COVID-19 pandemic is still very active, there will also be an added layer of complexity to staying safe this summer, including adapting activities to meet the guidelines of social distancing. This article addresses some of the most common dangers encountered during the summer months and offers protective measures to decrease risk and promote safety. [Pediatr Ann. 2020;49(7):e285–e289.]

Abstract

The arrival of summer brings more sunshine, more time outside, and more opportunities for recreation and play. Although these activities may look a little different this summer as a result of the coronavirus disease 2019 (COVID-19) pandemic, they also allow us to get outside, interact safely with others, and remain connected to our friends and communities. Along with fun activities and exercise, there also comes a need for heightened awareness of summertime safety. Because so many childhood activities occur during the summer, precautions must be taken to ensure the safety and health of our children. From appropriate sun protection and water safety to insect exposure and recreational precautions, it is important to review key safety points to ensure a happy and healthy season. As the COVID-19 pandemic is still very active, there will also be an added layer of complexity to staying safe this summer, including adapting activities to meet the guidelines of social distancing. This article addresses some of the most common dangers encountered during the summer months and offers protective measures to decrease risk and promote safety. [Pediatr Ann. 2020;49(7):e285–e289.]

After months of quarantine, social isolation, and distance learning due to the coronavirus disease 2019 (COVID-19) pandemic, summertime offers a welcome respite, allowing more flexibility with our time and our activities. Although added precautions are necessary this summer (ie, wearing masks, practicing social distancing), outdoor activities will provide opportunities for exercise, recreation, and social interaction. Along with precautions related to the pandemic, many other safety measures should be considered to ensure a healthy, safe, and fun summer.

Sun and Heat Exposure

The years of childhood and adolescence account for a significant percentage of sun exposure that one gets in their lifetime, largely due to the amount of outdoor recreation as well as athletics in which this age group participates.1,2 Because of this high exposure, education about sun safety for this age group is extremely important. Children need to be taught about protection from sunburn, and from heat illness as well. Children and adolescents typically are not well informed about sun safety and have negative attitudes toward many sun safety measures.2 Their source of knowledge about sun safety typically comes from parents (55%), school (21%), and public campaigns (12.5%).1

Risk of sunburn is higher in the summer as we spend more time outside and have more hours of sunlight. Occurrence of sunburn during the childhood and adolescent years, along with frequent sunburns, increases the risk of developing skin cancer in the future.1,2 Rates of melanoma in the pediatric population have increased over the last 40 years, and those with light skin color, light hair or eye color, family history of skin cancer, chronic sun exposure, and freckles are at higher risk.2,3 Certain medications can also increase risk of sunburn, including tetracycline antibiotics, sulfonamides, nonsteroidal anti-inflammatory drugs, and even some cosmetics.3

Important steps to prevent sun damage include limiting exposure, wearing protective clothing (including hats and sunglasses), using sunscreen appropriately (applying 30 minutes before going outside and reapplying every 2 hours), and using water-resistant sunscreen with a sun protection factor (SPF) of least 15.2,3 Parental practices have shown to largely influence children's sun protective behaviors, so it is important that adults set a good example.2 Several other factors also seem to influence sun protection behaviors. Girls tend to be better about sunscreen use, staying in the shade, and wearing sunglasses, whereas boys tend to be better about wearing shirts that cover their shoulders and wearing hats.2 Those with lighter skin and hair colors also tend to be more diligent about sun protection than those with darker skin and hair colors.2 As children get older and become more independent, their use of these protective factors decreases.2 Geographic location also plays a role, with one study showing that in areas that tend to be sunny year round (eg, Hawaii), the use of sun protective measures is lower.2

Heat illness is another concern during summertime. With heat illness, the body's cooling system shuts down and a person is no longer able to regulate their body temperature.3 The ability to sweat decreases and a person becomes thirsty, tired, dizzy, and can have headaches, cramping, nausea, vomiting, decreased alertness, and elevated temperature.3 Alcohol as well as medications such as antihistamines, tricyclic antidepressants, and diuretics can increase risk of heat illness.3 Athletic practices in significant heat pose a particular risk for heat illness. If a person begins to show symptoms, they should lie down in a cool place, elevate their legs, and use water or wet towels along with fanning to help cool down until emergency help arrives.3

Pools/Open Bodies of Water

Many summer activities occur in or around water. Whether it is swimming in a pool, playing on the beach, or participating in boating activities, it is important to be aware of safety guidelines at all times. Drowning is the most common injury-related cause of death in children age 1 to 4 years, with nearly 4,000 drowning deaths occurring each year in this age group in the United States.4,5 There is a second peak for drowning during the adolescent years (age 15–19 years).6 Younger children are more likely to drown in a pool whereas older children are more likely to drown in open bodies of water.4,6 The World Health Organization defines drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.4 Terms describing types of drowning, including near, wet, dry, passive, active, and secondary, are confusing and outdated and should not be used.4

Risk factors for drowning include being male, inadequate supervision, alcohol use, and having a comorbid condition such as seizure disorder, developmental delay, or autism.4,5,7 Protective factors include providing safe play spaces separate from the pool area for younger children, installing barriers to pool access, and teaching children to swim and practice water safety.4,7 Water safety includes learning survival flotation, energy-conservation swimming, and safe poolside behavior.7 Studies show that swimming and water safety lessons for children age 4 years and older are protective, but lessons for children younger than age 4 have not shown a change in drowning rates.7 Swimming in the presence of a lifeguard is also protective, as it has been found that rates of bystander cardiopulmonary resuscitation (CPR) are much higher when a lifeguard is present.5

Private and public swimming pools should have a fence that is at least 4 feet high surrounding all four sides of the swimming pool.4,5,8 If the pool is at a home, the house should not be the fourth side of the fence if at all possible.8 If the house must have direct access to the pool, the exit door and any windows that access the yard/pool should have an alarm.8 Also, the homeowner should ensure that there are no pet doors or other entrances into the pool space.8 Pool gates should open away from the pool, be self-closing and self-latching, and the latch should be at least 58 inches high so that it cannot be reached by children.4,8 Rescue equipment and a working portable phone should also be kept poolside.8 Be aware that inflatable swimming aids, such as rings, floaties, and toys are not the same as life jackets and should not allow for less stringent monitoring around pools.8 These rules apply to inground pools as well as large, inflatable above-ground pools.8 Children should never be left alone near a pool or spa, and children of any age should never swim alone.8 Whenever a child younger than age 5 years is in or around water, an adult should be within arm's length at all times, providing “touch supervision.”3,5

When near open bodies of water, children should wear a life jacket at all times.8 This includes when on boats, docks, and beaches.8 Parents should set a good example and also wear life jackets when in or around water.8 It is best to swim in areas where a lifeguard is present, and children should remain within designated swimming areas at all times.8 Children should not be permitted to swim in canals or other areas with fast moving water and should learn about rip currents and how to swim out of them.8 They should also never dive unless permitted by an adult who has checked the depth of water and ensured that there are no dangerous obstacles under the water.8

If someone has experienced a drowning incident, prompt resuscitation is extremely important. Rather than the focus on cardiac then airway and breathing as in typical CPR, the focus should be on airway and breathing first.4 Most cardiac arrhythmias in drowning victims are caused by hypoxia, so securing the airway and providing breaths should be done first.4 Quick removal from the water is also key, as submersion longer than 6 minutes is associated with poor outcomes.4 This can be a challenge, as one study showed 62% of victims were unwitnessed at the time of drowning and were found unresponsive after an unknown length of time.5 If the patient is conscious, a lung evaluation should be done, and if there are rales or a need for supplemental oxygen an evaluation in the emergency department is required.4 Some drowning victims who have no medical complications and demonstrate clear lung fields at the site do not automatically require evaluation and may be able to go home.4 This is the case in about 94% of lifeguard rescues.4 Of note, vomiting occurs in anywhere from 30% to 85% of drowning victims, largely due to the amount of water that is swallowed and positive pressure ventilation during resuscitation putting pressure on the stomach.4 Fresh water versus salt water or cold water versus warm water does not make a difference in outcomes.4

Insect Bites and Stings

Insect bites and stings are another common occurrence during the summer months. Aside from the discomfort that comes with a bite or sting, there are also significant diseases that can be passed to humans through insect vectors.9 Ticks can transmit Lyme disease, and mosquitos can transmit West Nile, Chikungunya, Zika, and others.9 There are many things that can lower the risk of bites and stings as well as the transfer of diseases. Prevention is key in avoiding these uncomfortable insect attacks. When going outside, do not use scented soaps, perfumes, lotions, or hairsprays that will attract insects like a flower does.9 Wear lightweight clothing that covers the arms and legs, avoid bright colors and flower patterns, and wear a hat.9 Eliminate standing water in bird baths, fish ponds, baby pools, and buckets of water as these can become breeding grounds for insects.9 Finally, for those older than age 2 months, the use of insect repellant is the most effective way to deter insects from biting or stinging.9 Insect repellant should contain DEET (N,N-diethyl-mtoluamide) at high enough concentrations to be effective without having to reapply too frequently.3,10 DEET-containing repellent has been around for a long time and was registered for public use in 1957.10 Animal testing and observational studies have found no adverse events associated with DEET when used as directed.10 One study that looked at the effectiveness of DEET-containing repellent in malaria prevention in pregnant women showed no adverse effects in the mothers or their children once they were born.10,11 The effectiveness of different concentrations of DEET is similar, but the length of action increases as the concentration increases.9,11 For example, 10% DEET will supply less than 2 hours of protection whereas 30% DEET will supply closer to 3 to 5 hours of protection.9,10 Sunscreen that contains DEET should be avoided as sunscreen requires much more frequent application and would result in too much DEET exposure in the course of 1 day.9 Children should rinse off at the end of the day to avoid prolonged exposure.9

If a bite or sting does occur, early management can help reduce symptoms and spread of infection. Tickborne illnesses (particularly Lyme disease) tend to be transferred after the tick has been attached for longer than 24 to 36 hours.3 For this reason, it is important to check skin and hair for ticks daily if there is possible exposure (playing in the yard, hiking in the woods, etc.). If a bee sting occurs, remove the stinger by scraping it out of the skin with a fingernail or rigid plastic card (eg, driver's license, credit card etc.).3 Do not use tweezers to grab the stinger or try to squeeze the stinger out of the skin as this will push more venom into the body.3

Bicycles, Scooters, and Skateboards

A common pastime when the weather is nice is riding bikes, scooters, and skateboards. The most important safety point related to these activities is helmet use. Helmets decrease the risk of serious injury and should be worn at all times.9,12 When choosing a helmet, make sure to look for one that meets the Consumer Product Safety Commission standards, which will be indicated by a sticker or label on the helmet.9 Helmets must fit well in order to provide the appropriate protection. Helmets should be worn level on the head so that the forehead is covered, the strap should be securely fastened with the ability for 2 fingers to fit between the strap and the chin, and the helmet should fit snugly on the head so that if it is moved, the skin on the forehead and temples moves with it.9,12 Bright or reflective clothing is also helpful, along with limiting riding to daytime hours when visibility is optimal.12 When riding, bicyclists should ride on the right side of the road facing the same direction as traffic and should obey all traffic signs and lights.9 Skateboards and scooters should be used only in skateboard parks and other designated areas and never on roads or in traffic.9 Roller skates, in-line skates, and shoes with wheels (ie, Heelys) should only be used on designated paths, parks, or rinks.9

The most common method of injury from bicycles and other similar recreational gear is falls.9 Proper helmet use has a protective effect against brain injury somewhere between 60% and 88%.12 People who die due to bicycle crashes are 3 times less likely to have been wearing a helmet.12 Children tend to follow their parents' lead with regard to helmet use, so adults should also wear a helmet at all times when riding or skating.12

Playgrounds

Playgrounds are found in many settings including schools, daycares, public parks, apartment building play areas, and private homes. They are important areas where children can get exercise, develop motor skills, and socialize with other children.13 Although public playgrounds are regulated, the testing standards are based on those for car safety and have not been updated recently.14 Results show that playground materials that pass the current testing standards do not sufficiently protect children from brain injury.14 Younger children have a higher risk for brain injury and skull fractures with playground falls, but playground-related brain injury in older children age 5 to 9 years has increased over the past decade as well.14

Playground equipment must be properly maintained whether in a public park or at home. Mats or loose-fill material should cover the surface area of the playground at a depth of 9 inches and should extend out 6 feet in all directions.9 Seats on swings should be made of rubber, plastic, or canvas.9 Ropes, jump ropes, or leashes should never be tied on playground equipment, and helmets or any other potential hazards should be removed before playing on the playground.9 Children should always be supervised on playground equipment.9

Along with falls from playground equipment, slide injuries, in particular, are common, accounting for about 20% of playground injuries.13 More than 350,000 children younger than age 5 years were injured on slides between 2002 and 2015.13 About 60% of playground injuries occur at a public park or playground.13 Younger children (younger than age 3 years) are more likely to sustain lower extremity injuries, whereas older children tend to sustain injuries to the head/neck and upper extremities.13 The most frequent injuries are fractures, followed by lacerations.13 Children who are sitting on the lap of an adult are more likely to have lower extremity injury as their foot can catch on the slide surface and the force of the larger person who they are with can cause a twisting and pulling force that results in a fracture.13 For this reason, it is recommended that children not go down a slide on another person's lap.13 Falls from slides have shown a higher risk of severe injury versus other playground equipment.

Trampolines

Backyard trampolines are a popular but dangerous apparatus. The American Academy of Orthopedic Surgeons discourages the use of recreational trampolines.9 Trampoline injuries are common, and about 10 years ago, rates were 160 per 100,000 for children age 5 to 14 years, with hospitalization rates around 3%.15 It is important to note that many of the safety features available for trampolines do not actually help reduce injuries.9,15 Injury risk from trampoline use includes falls (which account for 27%–39% of injuries), ankle sprains, strains, contusions, and bony injury in younger children.15 Lower extremity injury is most common, followed by upper extremities (with 60% of those being fractures) and then head and neck injuries.15

Although we should counsel against trampoline use, if a family chooses to use one there some safety measures that can help lower risk of injury. First, the family should check with their homeowners insurance agent to see if trampolines are covered, because they are often listed as an exclusion and additional coverage may be needed.9,15 There should only be one person allowed on the trampoline at a time, as most injuries occur when there are multiple jumpers.9,15 Children younger than age 6 years should not use trampolines because they have a higher risk of fractures and injury.15 Somersaults and flips should be forbidden as these account for many of the falls and head/neck injuries that occur on trampolines.15 The trampoline should be placed on an even surface, padding should extend to cover the springs and frame of the trampoline, and there should not be a ladder available to access the trampoline so as to avoid young children jumping unattended.15 Trampoline nets and enclosures have not been shown to improve safety.15

Home trampoline use has declined over the last decade while the number of commercial trampoline parks has increased.15 There are few data on the safety of these parks, so caution should be used when participating.15 There are instances where trampoline use is helpful in developing competitive skills for gymnastics, diving, figure skating, and skiing. These sports often use rectangular trampolines that are significantly bigger, of better quality, and much more expensive than home trampolines.15 Athletes who are using these trampolines to train should be monitored closely and use a bungee or rope system while they are mastering their tumbling skills.15

Lawnmowers

Although not a recreational part of summertime, lawn mowing is something that is done frequently throughout the warmer months. Lawnmower injuries in children and adolescents are estimated to be about 9,400 per year in the United States with about 5.5% to 8% requiring admission for treatment.16 By taking some precautionary steps, we can greatly reduce the risk of lawnmower injuries in children. First, children younger than age 6 years should not be outside or in the yard while someone is mowing the grass.9,16 No one younger than age 12 years should operate a walk-behind lawnmower, and no one younger than age 16 years should operate a ride-on lawnmower.9,16 Children should never be allowed to ride as passengers on a ride-on mower.9 The mower operator should wear sturdy shoes, eye protection, ear protection, and long pants.9 All mowers should have a control that can stop the mower blade, and the operator should turn off the mower blades and wait until they stop before crossing a gravel path or road, removing the grass catcher, or cleaning any part of the mower.9 Before mowing, someone should walk through the lawn and remove any objects that could cause injury.9

When injury does occur, the lower extremity is the most common location, with 69% involving the foot.16 There are two peak ages of injury from lawnmowers, with the first being preschool age and the second being the mid-teens.16 Ride-on mowers carry a higher risk for more severe injury.16 Boys are at higher risk for injury, accounting for about 80% of lawnmower-associated injuries.16

Fireworks, Campfires, and Grills

Along with the summer weather comes more outdoor living and celebrating. One of the bigger celebrations of the summer is Independence Day, when many Americans choose to celebrate with fireworks. It is recommended that people choose professional fireworks displays to enjoy rather than attempt their own at home.2,9 About 8,500 people are treated in emergency departments each year as a result of a fireworks injury.17 About 75% of those injuries occur within a 30-day window surrounding July 4th.17 Even sparklers can be dangerous as they can reach temperatures >1,000°F.9 Most fireworks injuries affect the hands, face, and eyes and can result in severe burns, blindness, scars, and death.9,17

Along with fireworks, outdoor heat sources can be a danger to children as well. Whenever food is being cooked outdoors, whether on a grill or over a campfire, children should be monitored closely so they do not get too near the heat source.3 If a burn does occur and is minor, it can often be treated at home by running water over it and covering with a clean dry cloth.3 Do not place ice, petroleum jelly, or butter on the burn as this can trap in the heat and cause more damage.3 For more severe burns (those larger than a person's hand) or burns on the hands, feet, face, genitals, or over a joint, treatment is required, and these patients should be seen in the emergency department.3

Conclusion

Summertime has many benefits, allowing children to get outside and be active, spend less time watching screens, and enjoy many activities that can only be done outside. Although options for activities this summer are limited due to the COVID-19 pandemic (with added measures like wearing masks and practicing good social distancing), we can still safely take advantage of many of our favorite summer activities. Using common sense and being aware of safety risks discussed in this article can lead to a happy, healthy, and fun summer outside.

References

  1. Andreola GM, Carvalho VO, Huczok J, Cat MNL, Abagge KT. Photoprotection in adolescents: what they know and how they behave. An Bras Dermatol. 2018;93(1):39–44. doi:10.1590/abd1806-4841.20185489 [CrossRef] PMID:29641695
  2. Patel AR, Zaslow TL, Wren TAL, et al. A characterization of sun protection attitudes and behaviors among children and adolescents in the United States. Prev Med Rep. 2019;16:100988. doi:10.1016/j.pmedr.2019.100988 [CrossRef] PMID:31660287
  3. Meadows M. A primer on summer safety. FDA Consum. 2004;38(3):18–25. PMID:15218841
  4. Mott TF, Latimer KM. Prevention and treatment of drowning. Am Fam Physician. 2016;93(7):576–582. PMID:27035042
  5. Chan JS, Ng MX, Ng YY. Drowning in swimming pools: clinical features and safety recommendations based on a study of descriptive records by emergency medical services attending to 995 calls. Singapore Med J. 2018;59(1):44–49. doi:10.11622/smedj.2017021 [CrossRef] PMID:28367581
  6. American Academy of Pediatrics. Water safety for teens. Accessed June 22, 2020. http://www.healthychildren.org/English/safetyprevention/at-play/Pages/Water-Safety-for-Older-Children.aspx
  7. Davey M, Callinan S, Nertney L. Identifying risk factors associated with fatal drowning accidents in the paediatric population: a review of international evidence. Cureus. 2019;11(11):e6201. doi:10.7759/cureus.6201 [CrossRef] PMID:31890403
  8. American Academy of Pediatrics. Swim safety tips. Accessed June 22, 2020. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Summer-Safety-Tips-Sunand-Water-Safety.aspx
  9. American Academy of Pediatrics. Summer safety tips: staying safe outdoors. Accessed June 22, 2020. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Summer-Safety-Tips-Staying-Safe-Outdoors.aspx
  10. Chen-Hussey V, Behrens R, Logan JG. Assessment of methods used to determine the safety of the topical insect repellent N,N-diethyl-m-toluamide (DEET). Parasit Vectors. 2014;7(1):173. doi:10.1186/1756-3305-7-173 [CrossRef] PMID:24892824
  11. Koren G, Matsui D, Bailey B. DEET-based insect repellents: safety implications for children and pregnant and lactating women. CMAJ. 2003;169(3):209–212. PMID:12900480
  12. Okun A. Bicycle safety. Pediatr Rev. 2015;36(3):138–139. doi:10.1542/pir.36-3-138 [CrossRef] PMID:25733768
  13. Jennissen CA, Koos M, Denning G. Playground slide-related injuries in preschool children: increased risk of lower extremity injuries when riding on laps. Inj Epidemiol. 2018;5(suppl 1):13. doi:10.1186/s40621-018-0139-x [CrossRef] PMID:29637487
  14. Li X, Kleiven S. Improved safety standards are needed to better protect younger children at playgrounds. Sci Rep. 2018;8(1):15061. doi:10.1038/s41598-018-33393-z [CrossRef] PMID:30305685
  15. Briskin S, LaBotz MCouncil on Sports Medicine and FitnessAmerican Academy of Pediatrics. Trampoline safety in childhood and adolescence. Pediatrics. 2012;130(4):774–779. doi:10.1542/peds.2012-2082 [CrossRef] PMID:23008455
  16. Garay M, Hennrikus WL, Hess J, Lehman EB, Armstrong DG. Lawnmowers versus children: the devastation continues. Clin Orthop Relat Res. 2017;475(4):950–956. doi:10.1007/s11999-016-5132-5 [CrossRef] PMID:27785676
  17. Centers for Disease Control and Prevention. Notice to readers: injuries from fireworks in the United States. MMWR Wkly Rep.2000;49(24):545–546.
Authors
Leah Khan, MD

Leah Khan, MD, is a Pediatrician, Park Nicollet Clinics.

Address correspondence to Leah Khan, MD, 300 Lake Drive East, Chanhassen, MN 55317; email: leahdkhan@outlook.com.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20200622-01

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