Methods

This study is one section of a three part survey designed to assess various aspects of infant and child safety. Subjects, primary caretakers of children seen in a continuity practice for pediatric residents during a five week period in the summer of 1996, were invited to participate.

The questionnaire was administered as a structured interview by three students trained in interview techniques by an experienced social worker. Ten questions specifically addressed infant walkers, including the decision to acquire a walker; other questions gathered demographic data.

Analysis by χ² was initially used to compare demographic factors between walker users and non-users. Logistic regression then determined whether birth order (first born or not) or maternal education (high school graduate or not) influenced the timing of the decision to purchase a walker (before or after birth).

Results

One hundred and fifty four primary caretakers participated and only six refused. The majority of caretakers were mothers (90%); others represented included fathers (3%), grandmothers (3%), and other relatives (4%). Racial distribution of the sample included African American (79%), white (18%), Hispanic (2%), and other (1%). Birth order of the study subjects' children was 45% first born, 27% second born, 19% third born, and 7% fourth born or greater. Maternal education included from no high school (21%), some high school (29%), high school graduate (27%), some college (13%), and college graduate (10%).

Forty two per cent of participants said that they consider the pediatrician as a source of safety information. Maternal grandmothers (16%), television (21%), magazines (13%), books (14%), and “no-one” (18%) were the other major sources of safety information used by caretakers. When specifically asked if their pediatrician ever spoke to them about child safety issues, 81% responded positively. A review of a sample of medical records demonstrated documentation (checklist) of physician provided anticipatory guidance about infant walkers at both the four month and six month visits.

In the sample, 77% of the caretakers used infant walkers. For children who weren't first born, 85% of caretakers had used walkers for their other children. As expected, there were no differences between the walker users and non-users with respect to the sex or birth order of the child, race, maternal education, or type of caretaker. There was also no difference between these groups with respect to having received safety information from the pediatrician.

To help assess the decision making process, two questions were asked. The first question focused on when the caretaker first heard about walkers, and the second targeted the time frame when the decision to obtain a walker was made. Ninety seven per cent of caretakers heard about infant walkers before the baby was born. However, the decision to use walkers was made by only 35% of them before the baby's birth. The remaining 65% made the decisions when the baby was a few weeks old (4%), when the baby was a few months of age (53%), or at another time (8%). Logistic regression showed that timing of the decision to buy a walker, either before or after birth of the child , was not influenced by maternal education or by the child's birth order.

A third question was asked to determine who was the greatest influence on the caretaker's decision to acquire a walker. Interestingly, 61% of the subjects responded that no-one influenced them; they simply obtained a walker because they wanted one. In addition, of the 81% of caretakers whose pediatrician spoke about infant safety issues, 75% used walkers anyway.

Caretakers obtained walkers from several sources. The majority (75%) purchased them for their child, while 16% received them as a gift, and 7% received them as hand-me-downs or had one from a previous child. Thus, it appeared that the decision to acquire a walker was not influenced by individuals or other sources.

When asked if walker use was beneficial to their child, 78% of caretakers responded affirmatively and 72% believed that children who use walkers learned to walk earlier. Adverse consequences mentioned by those who did not think that walkers were beneficial included delayed walking, falling out of walker, and falling down stairs.

Discussion

In this study, we confirmed a prevalence of infant walker use (77%) comparable with previous studies.^{1–6, 11} Mothers still believe a walker is beneficial. Some believe it promotes the development of independent walking skills, despite the fact that there is no justifying support for this view.^{5, 9, 11–14} Only 22% of those questioned believed that walkers were of no benefit to their children, and many parents were unsure why walkers were not good for them.

Pamphlets are available that discourage walker use.¹⁵ Although parents say that their pediatrician speaks to them about safety issues, and we can document that anticipatory guidance is provided about the danger of walkers, parents remain uninformed or misinformed about their use.

Our data suggest a “window of opportunity” for education from the time the mother hears about infant walkers before the birth of her baby until the time she decides to acquire a walker when her infant is several months old. This window of opportunity, up to several months in length, may be the best time for appropriate anticipatory guidance. New parents are motivated to make changes in their own lifestyles “for the good of the baby”.¹⁶ We can capitalize on this specific behavior with strong media campaigns and antiwalker promotions to reinforce the pediatricians' message. Media campaigns have been effective in advocating use of bicycle helmets^17–20 and in the “Back to Sleep” program.^21–23 Like these campaigns, efforts designed to prevent walker use should be widespread and not only involve the media, but extend into physicians' offices, the women, infants, and children office, and public health clinics. At present, physicians may be providing this guidance too late, or with too much other anticipatory guidance. Perhaps providing information on this single subject, in a repetitive manner, from the time of birth, would be more effective.

Pediatricians have repeatedly stated that infant walkers have no value and increase injuries. The American Academy of Pediatrics supports this view and recommends a ban on the manufacture and sale of infant walkers.⁹ There are mandatory and voluntary standards regarding infant walkers.⁹ Some of these have been successful in decreasing specific injuries. Several proposals have been advanced to further alter walker design, but these changes have not been implemented. Until changes are mandated, pediatricians need to work with their state legislatures to develop effective legislation banning the sale of infant walkers.

Children are being injured in a device parents look upon as beneficial for their children. It is crucial to intervene before the decision to acquire a walker is made. We suggest that there is a critical period where an intervention may make a difference. Until effective legislation is passed, it is necessary to utilize this window of opportunity to prevent walker use.