LOOK BEFORE YOU LEAPThe Dangers of Trampolines

Seven-year-old Jennifer* lay whimpering on the emergency room bed. The ambulance ride had been frightening and the nurse was just now giving her pain medication. What had been a glorious spring day complete with a team barbecue after a successful soccer season had suddenly turned tragic when Jennifer took a nasty spill on her coach's backyard trampoline. Several children were jumping at once when Jennifer collided with another child. Jennifer's mother heard her daughter's startled screaming and ran to find her lying motionless on the trampoline. In the frantic moments that followed, someone called 911 and an ambulance arrived within 10 minutes. The emergency room was busy, and Jennifer waited more than an hour to see the pediatric emergency physician. She told Jennifer's mother that a specialist was needed and another hour went by before the orthopedic surgeon entered the room and said to the nurse, "I'll call the OR." Jennifer's mother, trying to be strong, was crying. "Are you going to put her in a cast?" she asked. He responded hurriedly but not unkindly, "Jennifer's arm is broken in several places. She needs to have surgery in order to align the fragments, and I will put in some pins to hold them together." Later she would recall that he also said, "With these types of fractures, sometimes the growth plates in the bone are affected, and it is possible that Jennifer's injured arm will have a deformity that will need to be fixed in a subsequent surgery several years from now."

Jennifer is not the only one getting hurt on a trampoline. In 1998, the journal Pediatrics reported a 98 percent rise in trampoline-related injuries, calling it a "national epidemic”. In that same year, an estimated 640,000 trampolines were sold — a 350 percent increase over sales a decade earlier. With approximately 3 million backyard trampolines currently in use, the number of children getting injured is rising. Broken bones, while no small injury, generally heal, but other injuries can be much more devastating. For example, the American Journal of Physical Medicine and Rehabilitation recently published a report of an 11-year old boy who had fallen off a trampoline, injuring the left side of his neck. Twelve hours later, he was admitted to the hospital with a serious injury to the vertebral artery in his neck (which helps to supply blood to the brain). This child's injury will likely not heal without a trace — sadly, he will almost certainly have permanent brain damage. The injuries that both of these children endured highlight the vital information that most doctors already know: trampolines are dangerous and should not be used in backyards as recreational toys. In fact, the American Academy of Pediatrics (AAP) has come out with a formal policy statement on this important topic which states that "the trampoline should not be used at home, inside or outside... should not be part of routine physical education classes in schools... has no place in outdoor playgrounds and should never be regarded as play equipment." Dr. Gary Smith, director of the Center for Injury Research and Policy at Columbus Children's Hospital in Columbus, OH, helped to craft the AAP's policy statement on trampolines. He explains: "Trampolines were not designed to be backyard toys. They were designed to be training equipment for gymnastics and diving sports." Dr. Smith suggests that if parents want their children to learn to use a trampoline, they should send them to a gym where professionals can teach them how to jump and do gymnastics routines while at the same time making sure that there are proper safety devices to protect them. Even at a gym where there is proper supervision and training, injuries can still occur. However, emergency room physician Dr. Frank Jehle reports that most of the children he treats with trampoline injuries have been hurt on backyard trampolines where there was little or no parental supervision. Dr. Jehle agrees that if children are going to use a backyard trampoline, parents should definitely be present to enforce the rules. But he notes that even the most vigilant parents cannot make trampolines safe for their children — they can only make them somewhat less dangerous. Dr. Jehle advises parents: "Backyard trampolines should not be permitted because they are unsafe in any setting, supervised or not."

In an effort to at least minimize the risk of serious injury to children, the Consumer Product Safety Commission (CPSC) has worked with the trampoline industry to develop new standards for the equipment; these went into effect in 1999. Four new requirements were added to decrease the risk of serious injury and to alert consumers to potential dangers: • There must be padding that completely covers the metal frames, hooks and all springs. • A label must be printed on the trampoline box stating that trampolines over 20 inches tall are not recommended for children under 6 years of age. • Ladders cannot be sold with trampolines, in order to prevent access by young children. • A warning label on the trampoline bed must alert consumers not to allow more than one person at a time to jump and to warn them against somersaults (flips) which can result in paralysis and death. One of the unfortunate consequences of these new "safety standards" is that they may give parents the false sense that following these recommendations will make trampolines safe. In fact, they serve only to make the trampolines somewhat less hazardous. There is still significant danger. For example, a parent might assume that a trampoline is safe because it has a net surrounding the mat. While it is true that nets do reduce the risk of a child falling off a trampoline, studies show that less than one-third of trampoline-related injuries occur in this manner. The majority of pediatric trampoline injuries (7 out of every 10 injuries) occur from falls or collisions on the mat itself. Another factor closely associated with trampoline injury is the common practice of several children jumping on the trampoline simultaneously. Injuries are usually most severe when the child lands with great force. Besides the risk of collision between children, having another person jumping on the trampoline can significantly increase the force with which a child lands on the mat itself. For example, if one child jumps up at the same time another child is coming down (and the mat is accelerating upwards), the child who is landing may hit a mat that feels like concrete. Dr. Smith saw this precise scenario one day when a mother brought her son to the emergency room with a shattered leg. She told Dr. Smith that she was standing right by the trampoline and videotaped the entire sequence of events. Indeed, when he reviewed the film, he said it was remarkable how innocent the scene appeared as the boy landed correctly on what should have been a soft mat (but instead was rock hard due to the altered forces from another child jumping at the same time). Dr. Smith calls this type of situation the Myth of Supervision, whereby a parent believes that "if I follow the directions and I watch my child, there will be no injury." Unfortunately, with regard to trampolines, this is often not the case. Which is precisely why no matter what preventive measures one takes, backyard trampolines are simply never safe for children to use. So what should parents do if there is a trampoline already accessible to their children? Dr. Denise Dowd, chief of the section of injury prevention at Children's Mercy Hospital in Kansas City, MO, advises, "If it's your neighbor's trampoline, don't get on it. If it's yours, get rid of it."


Ten things parents can do to protect their children from trampoline injuries

1. Just say, "No!" 2. Prohibit multiple jumpers. 3. Avoid ladders that give access to young children. 4. Ban flips and other stunts. 5. Be sure there is adequate padding on all springs and exposed metal. 6. Use a net around the mat. 7. Keep the trampoline away from all other structures. 8. Position on level ground with padding below. 9. Have an adult present to enforce the rules. 10. Never allow a child who is not your own to take a turn unless you have the permission of his or her parent.

*This is a true story, but the names and identifying details were changed to protect the privacy of the patient and her family.

LINDA COZZENS is a mother and practicing pediatrician at Southboro Medical Group in Southboro, MA, and a member of the American Academy of Pediatrics.

JULIE SILVER is a mother and practicing physiatrist who is also an assistant professor at Harvard Medical School and the medical director of the Spaulding-Framingham Outpatient Center in Massachusetts.