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¿estan los niños seguros en los castillos hinchables?

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Abstract and Figures

Las lesiones producidas en los castillos hinchables han aumentado considerablemente. En los últimos años hemos visto un incremento considerable de traumatismos que acuden al Servicio de Urgencias, tras haberse caído o golpeado en una estructura hinchable. Este aumento exponencial del número de lesiones es llamativo, y fue lo que nos llevó a plantearnos que probablemente estas estructuras aparentemente seguras, no lo son tanto. El objetivo de este estudio es investigar el riesgo que presentan estas atracciones y determinar las medidas necesarias para minimizar el riesgo de accidente, así como concienciar a la población del riesgo encubierto de estos juegos infantiles/recreativos.
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Systematic Review
Are inflatable play structures really safe for our
children?
L. Corominas1
A. Fernandez-Ansorena1
P. Martinez-Cepas2
J. Sanpera3
A. Obieta2
Abstract
Purpose The frequency of injuries sustained while playing on
inflatable toys such as bouncy castles have rapidly increased.
These supposedly safe structures are likely unsafe. The objec-
tive of this review was to investigate the risk that these attrac-
tions represent and the necessary measures to minimize risk
of accidents.
Methods We conducted a prospective study of 114 patients
over a period of one year (2015 to 2016). Demographic data
collected included: age, gender, anatomical location and side
of involvement as well as supervision of the child whilst on
the bouncy castle. The extracted data include mechanism of
injury and risk factors, i.e. lack of supervision of the child,
amounts of users jumping at the same time.
Results The injuries were slightly more frequent in male than
female children; 2:1 up to six years of age. From the age of
ten to 14 years the ration evened to 1:1, the higher incidence
in female children was between the ages of six to eight years.
The most common injuries were to the humerus, followed
by the distal radius. Only 28% of the parents said they were
supervising while the child was jumping.
Conclusion Injuries associated with inflatable bouncers have
increased over time. The main risk factors: were lack of ef-
fective adult supervision and the shared use by an excessive
number of participants of different ages and weights.
These considerations lead to the conclusion that there is a
necessity to enhance child health surveillance and to consider
1 Paediatric Orthopaedic Department, Hospital Universitari Son
Espases, Palma de Majorca, Spain
2 Paediatric Orthopaedic Department, Hospital Universitari Son
Espases, Palma de Majorca, Spain
3 Southmead Hospital, North Bristol Hospital Trust, Bristol,
United Kingdom
Correspondence should be sent to L. Corominas, Department of
Paediatric Orthopaedics, Hospital Universitari Son Espases, Carretera
de Valldemosa 79, 07120, Palma de Majorca, Balearic Islands, Spain.
E-mail: lauracorominas1979@gmail.com
limiting bouncer usage to children over the age of six years,
to prevent and control injuries and to minimize their conse-
quences.
Level of Evidence II - prospective study
Cite this article: Corominas L, Fernandez-Ansorena A, Mar-
tinez-Cepas P, Sanpera J, Obieta A. Are inflatable play struc-
tures really safe for our children?. JChild Orthop 2018;12. DOI
10.1302/1863-2548.12.170191
Keywords: Bouncy castle; children’s fracture; public health
Introduction
Inflatable bouncers or moon bouncers have grown in pop-
ularity over the recent years as they are relatively cheap to
acquire,1 provide a source of entertainment for children
and are generally regarded as a safe environment by par-
ents. There are multiple descriptors for inflatable bounc-
ers, including inflatable play structure, bounce house,
bouncer and bouncy castle. They are encountered at fairs,
festivals and amusement parks as well as at private par-
ties. Restaurants, inns and even hotels, try to attract fami-
lies with the installation of leisure games for minors, such
as playgrounds with various attractions so that the little
ones can have fun while adults enjoy a relaxed after-dinner
or family celebration. In this respect, the bouncers are an
ideal complement for parties and ensure hours of fun at
low cost.
However, as their demand has soared, so have acci-
dent rates.2,3 In recent years, there has been a significant
increase in the number of children treated in the emer-
gency department (ED) for injuries resulting from the
use of these devices (in the United States an injury rate of
5.3/100 000 children has been described).1
The mechanisms of injuries were: first, a fall, both
inside and outside of the bouncy castle; second, a colli-
sion between children due to the differences in sizes and
ages.4-6 Also, less frequently yet more severe, were injuries
resulting from faults in the anchoring system and wind
gusts.7
The main risk factor was the lack of effective adult
supervision, either by the parent or staff responsible for
overseeing the attraction. Furthermore, overcrowding by
children of different weights and sizes increased exponen-
tially the chances of suffering an accident.8
ARE INFLATABLE PLAY STRUCTURES SAFE?
J Child Orthop 2018;12.
We carried out a prospective study of injuries second-
ary to inflatable play structure accidents that attended the
Paediatric Emergency Department at our Hospital Uni-
versitario Son Espases. This is the first prospective Euro-
pean study of its kind, which has been conducted in a
single referral centre for Paediatric Orthopaedics during
a 12-month period (between February 2015 and Febru-
ary 2016). Our hospital is a paediatric referral site for the
entire province; patients not only come from the city but
from all the municipalities of the province. The population
of the province is 1 169 591 inhabitants, with a popula-
tion proportion corresponding to the age range of 0 to 14
years of 15% (Fig. 1).
The increase of inflatable play-related injuries may be
explained by the growth of the inflatables industry,8 as
well as by the lack of prevention measures and initiatives
for reducing injury risks.
The aim of this study is to describe the epidemiology,
type and chronology of the lesions and ultimately, we
would like to outline some safety guidelines for inflatable
attractions and alert civil society to the dangers of such
facilities, still considered safe by the general public.
Material and methods
Only paediatric patients aged 0 to 14 years, who had
experienced trauma in an inflatable play structure, were
chosen for the study.
The patients’ parents were informed at arrival to the
ED about the study, and they consented to and signed the
protocol for data collection.
Demographic data gathered included: age; gender;
mechanism of injury (fall inside the inflatable play structure,
fall outside the bounce house, collision with another partic-
ipant, castle displacement); risk factors (lack of responsible
supervision, users of different ages); type of injury; medical
attention required; and complementary tests.
Adult supervision is defined as the need for vigilance at
all times. There must be at least two people supervising
the attraction.
The shifts should be respected, either by age, or by
height, so that children of different constitution do not
use attraction at the same time. The simultaneous use
by a large number of people at the same time should
be avoided, because it increases the danger of falls and
Fig. 1 Density of inhabitants between 2015 and 2016 in our province (male, left-hand side and female, right-hand side).
ARE INFLATABLE PLAY STRUCTURES SAFE?
J Child Orthop 2018;12.
injuries, especially if children of different age ranges and
weight are mixed.
Results
Between February 2015 and February 2016, 114 chil-
dren were treated for inflatable play structure-related
injuries.
The distribution of injuries showed a higher frequency
in male compared with female children, with a ratio of 2:1
up to six years of age. From the age of ten to 14 years, the
ratio evened to 1:1. The age range where the gender ratio
is inconsistent is between the ages of six and eight where
the incidence is higher in females 1:1.3.
The age peak, independent of gender, was between
the ages of six and eight years (Fig. 2).
The most commonly injured anatomical region in
the upper limb was the humerus, followed by the distal
radius. The most common fracture was the supracondylar
fracture. In the lower limb, the most common lesion was
a sprain, followed by the tibial fracture. Moreover, two
patients presented non-displaced lumbar vertebral frac-
tures, in T12 and T10, respectively.
The trauma in the upper limb was more frequent in
male compared with female children (ratio 1.3:1), and in
the lower limb the ratio was 1.25:1. Both cases of spinal
injuries happened to male children. Injuries sustained to
the face and head were only observed in girls. There were
two cases of traumatic head injuries due to direct collision
with another child, and two cases of lesions to the eye-
brow (Fig. 3).
Bounce houses injuries present seasonal variability
according to literature. The most frequent seasons are
the warmer periods of the year: spring and summer.
We observed a rise in the number of lesions during the
months of May to December, with a drop from December
to March.
Out of our series, as many as 100 patients who attended
ED had an unwitnessed fall, with the parents alerted by
the child crying.
Of the 114 children in our study, only 28% of parents
said they were supervising while the child was jumping,
25% said they were close to the bouncer but did not
observe the fall and 47% said they were not supervising
the child, nor in the vicinity of the bouncer, and were sub-
sequently notified of the fall of the child. Of the 53% of
the parents who claimed to have been in the vicinity of the
castle (both those who observed the fall and those who
did not see it), only 40% said that there was a person con-
trolling access to the inflatable play structure.
At the moment of injury, the number of children jump-
ing simultaneously ranged from two to ten. The men-
tioned mechanisms of injury were either: being hit by
other children, or slipping off or falling out of the inflata-
ble structure, or the trapping and twisting of a limb.
In all, 62 patients out of the total were treated non-op-
eratively. These included: contusions, non-displaced frac-
tures and sprains.
However, of the 114 patients, 52 children required
admission to hospital for treatment and 50 of them
required surgery; including those in the upper extremity.
There were 20 supracondylar fractures, 12 of them were
supracondylar fractures Garland II, eight supracondylar
Fig. 2 Graph describing the incidence of lesions by age and gender, registered during a 12-month period at our hospital.
ARE INFLATABLE PLAY STRUCTURES SAFE?
J Child Orthop 2018;12.
fractures Garland III and two of them with vascular involve-
ment that required an anterior approach and vascular
repair. All of the ten distal radius fractures were reduced
under sedation with Ketamine (Ketolar, Madrid, Spain)
and Midazolam (Laboratorios Normon, Madrid, Spain) and
control of fluoroscope in the operating room. Of ten fore-
arm fractures (including fracture of both bones, or of only
one of them), six of them required fixation with flexible
intramedullary nailing or Kirschner wires and two radial
head fractures needed reduction under anesthesia and
control of fluoroscope without internal fixation. Children
with humerus fractures required hospitalization more fre-
quently, accounting for 47.7% of the total hospitalizations.
In the lower limb, the six displaced tibia fractures and
two femur fractures required surgery, under general anes-
thesia and fixation with a flexible intramedullary fixation
system.
The average hospital stay for fractures that required
surgery with internal fixation was two to three days. Those
who underwent closed reduction had a stay for 24 hours,
to control distal trophism.
The two vertebral fractures were treated orthopaed-
ically with a corset, but required hospital admission for
pain control. The average stay was five days.
Discussion
The medical and public health community has made
recommendations about the safe use of bouncy castles.
Nevertheless, it is also important to involve the political
class in order to toughen security controls and enact more
comprehensive regularizations.9
Inflatable play structures appear very attractive to chil-
dren but this study suggests that they are unsafe. The
lack of adult supervision, the use of the facility by par-
ticipants of different ages and sizes at the same time, as
well as overcrowding, are the main risk factors for injuries.
As observed in the graphs, there is variability in user age,
from two years to ten years old, and as a result, there is
often a variety of weights of children playing. It is imper-
ative to insist upon the implementation of guidelines to
regulate their use, especially with regards to age, where a
minimum age should be set at six years.
With the goal of reducing the number of accidents related
to inflatables structures, the European Safety standards
UNE-EN 14.960:20149 should be complied with at all times.
The standard, which is compulsory in many European
countries, describes the installation of the castles, safety
standards to be taken during the process and the instruc-
tions of management and handling. However, in the cur-
rent Spanish market, not all instalments hold this certificate.
Furthermore, the fact that the facility has passed the quality
and maintenance control does not guarantee it is safe.1,10
In Spain, the UNE-EN 14960 standard specifies the
safety requirements for inflatable play equipment in which
the main activities are bouncing and sliding.
This law regulates both the type and dimensions of the
structure, as well as the permitted materials and threads,
as well as the inflatable volumes, among other details.
On the other side, it also requires the specification of the
capacity and the recommended age of use and requires
an annual review to certify the safety of the facilities, but
in many cases as we have been able to verify in this article,
the basic safety measures are not applied.
Fig. 3 Graph describing distribution by gender and anatomical location (upper E, upper extremity; lower E, lower extremity; head
injury; spine).
ARE INFLATABLE PLAY STRUCTURES SAFE?
J Child Orthop 2018;12.
This has made the law more and more punitive, attrib-
uting responsibility of negligence to the peddler, for the
damages suffered by a minor in an inflatable play struc-
ture.
We recommend that the following measures2,11,12
should be met to ensure the inflatables are safe for use and
that there is a lower amount of injuries associated with
these attractions.
1. There should be responsible adult supervision,
paying close attention to the children at play at all
times during its use.
2. The equipment should be set up, operated and
supervised by the hire company’s own staff.2
3. A rotation system for different age or size groups
should be used, together with the observance of
an age limit for users. There are special inflatables
available for adolescents and adults.
4. A safety distance of 1 m to 2 m should be kept around
the facility, leaving the entrance and exit points free
at all times. At the access to the bouncer, there must
be a ramp that covers the entire width of the entrance
arch. Likewise, there must be some type of material
that cushions possible falls, such as mats or foam. A
simple carpet is not enough; also, curbs, benches,
trees or other accessories should not be present in
that area.
5. The number of children using the bouncy castle must
be limited to avoid overcrowding. This will allow each
child to have safe space to play in.13,14
6. It is forbidden to climb and/or hang from the walls of
the inflatable.
7. Children should not be allowed to use the bouncy
castle in adverse weather conditions such as high wind
or in wet weather (inflatables can flip over and slippery
surfaces may cause injury). It is recommended to
deflate the installation when winds exceed 45 km/h.
8. All children must be made to remove footwear (always
wear socks).
9. Removal of hard or sharp objects such as jewelry,
buckles, pens and other similar pocket contents.
10. The castle must be adequately secured to the ground
and sited away from obstacles such as fences or
overhead power. They should be regularly inspected
while in use.
Writing in Pediatrics, the researchers report that an
estimated 64 657 children were treated in EDs around
the United States for inflatable bouncer-related injuries
between 1990 and 2010, with a mean rate per year of 5.28
injuries per 100 000 children.15
Over the 15-year period between 1995 and 2010
the rate went up 15-fold, although the increase was
more rapid over recent years, with the annual injury
number and rate more than doubling between 2008
and 2010.2,15
In European literature there is an Italian retrospective
article8 for which data of 521 children were collected from
2002 to 2013. In our study, we observe a greater number
of children affected in a one-year period compared with
the mean annual affected population mentioned in the
American and Italian studies.
With this study, we wanted to show the high volume
of injuries than can occur with the temporary inflatable
attractions/structures which are getting increasingly pop-
ular. Currently, bouncy houses and other inflatable struc-
tures are not only present at town fairs or local festivities,
but are also often rented for private parties and family
gatherings. For this reason, it is very important to under-
stand the restrictions of their use and inappropriate and/
or faulty facilities. Nevertheless, the good and responsi-
ble use of the attractions always requires supervision, as
mentioned on several occasions in this study, especially in
private events.
This study has certain limitations. Regarding the num-
ber of children jumping in unison in a bounce house,
we do not know the number of children participating in
games on bouncy castles in order to establish a statistic
that informs us of the chances of suffering an accident. Nor
do we know to what extent the standards of use described
by the European Safety standards UNE-EN 14.960:2014 are
not met, nor whether they are sufficient. What is certain is
that the number of children and the severity of the inju-
ries resulting from these activities that reach the paediatric
emergency services are increasing.
Among the measures to be carried out, it seems sen-
sible to restrict use only to children over six years of age,
since we found that pre-school children are frequently
injured and the ones most often suffering reported frac-
tures of the upper extremity. According to our study, the
number of injuries would be reduced by up to 34%.
Another limitation of this study is that the population
of our province triples during the summer, exponentially
increasing the number of patients who come to the paedi-
atric emergency room
The problem has been exposed. Security technicians
need to study improvements of the current procedures
and the public administrations need to comply with the
standards. Parents should know the risk and possible con-
sequences of these activities.
Conclusions
Bouncy castles are a preventable cause of injury in chil-
dren. Ensuring that parents are aware of the potential
risks, improving surveillance of the injuries, developing
national safety guidelines, especially with regards to age,
where an age limit should be set to over six years old, and
ARE INFLATABLE PLAY STRUCTURES SAFE?
J Child Orthop 2018;12.
separating children according to size and age, as well as
improving bouncer designs, are the first steps to prevent
accidents from happening.
Further investigation is needed to define additional pre-
ventive and safety guidelines and to characterize the full
scope of injuries related to inflatable bounce use, includ-
ing soft-tissue injuries.
Received 24 November 2017; accepted after revision 27 April 2018.
COMPLIANCE WITH ETHICAL STANDARDS
FUNDING STATEMENT
No benets in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
OA LICENCE TEXT
This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.
org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and
distribution of the work without further permission provided the original work is
attributed.
ETHICAL STATEMENT
Ethical approval: This article does not contain any studies with human participants
or animals performed by any of the authors.
ICMJE CONFLICT OF INTEREST STATEMENT
None declared.
ACKNOWLEDGEMENTS
Thank you to Dr. Francisca Yagüe MD and Dr. Victoria Corominas MD, for encouraging
us to write this article. Both are doctors in the paediatric emergency department of
our hospital.
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Article
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Conclusion: Injuries associated with IBs increased over time. Preschooler children were most injured, and this means there is insufficient adherence to existing recommendations concerning an age limit. What is Known: • Along with the skyrocketing popularity of IBs among children, the number of children presenting to ED with injuries from these plays has also been increasing at an alarming rate; • The European literature about this phenomenon is scarce and no specific legislations exist for safety of these devises in European Union (EU). What is New: • This is the first study in EU that examines trends for pediatric inflatable bouncer-related injuries at ED over an 11-year period. • Although American Academy of Pediatrics recommends restrictions of attendance to IBs under 6 years old, injuries and fractures continue to occur more frequently under this age.
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Objective: To investigate inflatable bouncer-related injuries to children in the United States. Methods: Records were analyzed from the National Electronic Injury Surveillance System for patients ≤17 years old treated in US emergency departments (EDs) for inflatable bouncer-related injuries from 1990 to 2010. Results: An estimated 64 657 (95% confidence interval [CI]: 32 420-96 893) children ≤17 years of age with inflatable bouncer-related injuries were treated in US EDs from 1990 to 2010. From 1995 to 2010, there was a statistically significant 15-fold increase in the number and rate of these injuries, with an average annual rate of 5.28 injuries per 100 000 US children (95% CI: 2.62-7.95). The increase was more rapid during recent years, with the annual injury number and rate more than doubling between 2008 and 2010. In 2010, a total of 31 children per day were treated in US EDs for an inflatable bouncer-related injury, which equals a child every 46 minutes nationally. A majority of patients were male (54.6%), and the mean patient age was 7.50 years (95% CI: 7.17-7.83). Most injuries were fractures (27.5%) and strains or sprains (27.3%), and most injuries occurred to the lower (32.9%) or upper (29.7%) extremities. Most injuries occurred at a place of sports or recreation (43.7%) or at home (37.5%), and 3.4% of injured children were hospitalized or kept for <24 hours for observation. Conclusions: The number and rate of pediatric inflatable bouncer-related injuries have increased rapidly in recent years. This increase, along with similarities to trampoline-related injuries, underscores the need for guidelines for safer bouncer usage and improvements in bouncer design to prevent these injuries among children.
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Inflatable bouncers or moonbouncers are very popular in private and public settings and are usually perceived as very safe attractions, but are associated with frequent fractures in children. To date, there are no publications in the medical literature about these types of injuries. The purpose of this study was to show skeletal injuries related to inflatable bouncer use, describe their characteristics, and determine possible risk factors and preventive measures. Demographic data and injury characteristics were analyzed for all patients who were treated for inflatable bouncer-associated injuries in the pediatric fracture clinic of a level I trauma center from October 2002 to March 2007. Forty-nine patients were treated for inflatable bouncer-related fractures. Children ranged in age from 1.5 to 15 years old (mean age, 7.8 years) with a male-female ratio of approximately 3:1. The most commonly injured region was the upper extremity (65.5%, n = 32). The most commonly injured area was the elbow (31%, n = 15), and the most common single diagnosis was supracondylar humerus fracture (22%, n = 11). Diaphyseal long bone fractures were found in 18% (n = 9) of the patients and nondiaphyseal in 71% (n = 35). One patient (2%) had an open fracture. Mechanisms of injury included collision of 1 person with another (67%), falling out of a bouncer onto a hard object outside the device (19%), and twisting motion to the leg (14%). There was no adult supervision in many of the incidents (43%), and the presence of different-aged children inside the jumper took place in 52% cases. Inflatable bouncers can cause serious orthopaedic injuries. Children playing in the bouncer should be placed in small groups according to their size and should be closely supervised at all times. Case series. Level IV evidence.
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A search of the medical literature failed to reveal any articles that discuss pediatric injuries acquired on privately owned recreational trampolines. This study was undertaken to quantify and qualify pediatric injuries from recreational trampoline use. A group of 114 patients who presented to the Emergency Department at Primary Children's Medical Center in Salt Lake City, Utah, with injuries directly related to use of a trampoline are discussed. There was a 1.2:1 male-female ratio. The average age was 8.0 years. Forty-eight percent of the patients were injured on their family's trampoline, with the remainder injured on a friend's, neighbor's, relative's, or gymnasium's equipment. The majority of injuries involved group use of the trampoline and the youngest person in a group was most often the injured participant. Extremity injuries were seen in 55% of the patient and head or neck injuries in 37%. Seventy-five percent of the patients required radiographs, 23% hospitalization, and 17% operative intervention. The history of the trampoline and medical literature discussions concerning injuries and safety are reviewed.
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To describe the epidemiology of emergency department (ED) visits for trampoline-related injuries among U.S. children from January 1, 2000, to December 31, 2005, using the National Electronic Injury Surveillance System (NEISS) and to compare recent trampoline injury demographics and injury characteristics with those previously published for 1990-1995 using the same data source. A stratified probability sample of U.S. hospitals providing emergency services in NEISS was utilized for 2000-2005. Nonfatal trampoline-related injury visits to the ED were analyzed for patients from 0 to 18 years of age. In 2000-2005, there was a mean of 88,563 ED visits per year for trampoline-related injuries among 0-18-year-olds, 95% of which occurred at home. This represents a significantly increased number of visits compared with 1990-1995, when there was an average of 41,600 visits per year. Primary diagnosis and principal body part affected remained similar between the two study periods. ED visits for trampoline-related injuries in 2000-2005 increased in frequency by 113% over the number of visits for 1990-1995. Trampoline use at home continues to be a significant source of childhood injury morbidity.
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