Patient Presentation
A 6-year-old male and a 9-year-old male came to clinic with their mother for their health supervision visits. The boys both had attention deficit disorder (with hyperactivity and inattention) and were using stimulant medication without side effects. Their mother reported they were doing well in school. The 9-year-old reported that the medicine “helped my brain stay calmer.” The social history showed that the parents were a firefighter and a nurse who also ran a farm with animal stock and crops.
The pertinent physical exam showed healthy boys with growth parameters in the 10-50% for the 6-year-old and 25-50% for the 9-year-old. Their examinations were normal.
The diagnosis of healthy boys with attention deficit disorder was made.
When discussing anticipatory guidance the pediatrician asked about safety rules they had for the farm. The mother asked the 6 year old, “When you’re outside, where can you play?” He said, “I have to stay on the grass, I can’t go in the road.” “And what if you are by the barns with Dad or Grandpa?” she went on. “I can’t go in the barns without them. If I am by the barns and something is moving then I have to put my hand on the barn, the fence or a tree,” he replied. The mother said that the grass was by the house and most of it was fenced off. The driveway separated the house from the barns and they had taught the children if they were in the barn area with adults and a car, tractor, or large animals were moving, then they had to go next to something big and sturdy like the barn itself or a tree. The 9-year-old said, “We can’t be in the barn by ourselves. I’m still too little to be by the steers, but this summer Dad says I can help him with the goats,” the 9-year-old said proudly. “I get to help with the baby goats, though” the 6-year old protested. “Yes but I get to do that AND be with the big goats,” he again said proudly. “We’re pretty strict about the rules. Grandpa wanted to let them drive the golf cart with him. I even vetoed that one. With their ADHD I’m not sure when I am going to let them drive anything with wheels,” the mother said.
Discussion
“The agriculture industry is consistently ranked as one of the most hazardous industries in the United States with some of the highest rates of work related injuries and deaths. Agriculture is a unique profession in that children who live on farms are exposed to, and in participate in, the family business of farming. Moreover, children who work on their family farm fall outside the regulation of governmental safety and labor practices….There is often little separation between work areas and play or living areas, thus children living on or visiting a farm may be in close proximity to safety hazards.
The rates of agriculture-related injuries are decreasing. Children have overall fewer injuries but their injuries are more severe. A study of 0-19 year olds with agricultural-related injuries from 2001-2006 found an annual incidence of ~26,600 injuries. Of these 29% were work-related, 0.32% were fatal (n=84), with falls (35.2%), machinery (3.7%), transportation (14.4%), assaults and self-harm (11.7%), and fire and explosions (0.63%) being the most common causes of injuries. Of the fatalities, machinery (21.4%), fire and explosions (14.2%), transportation (10.7%) and drowning (9.5%) were the most common causes. Boys report more exposure to potential hazards and are injured more than girls.
Farming is a heterogeneous industry and the activities vary widely. It is important to ask the family the type of farming they engage in when assessing the safety risk factors.
Potential exposures on a farm include:
- Tractors, machinery, cars/trucks, small vehicles (e.g. Gator® utility vehicles, all-terrain vehicles, motorcycles, golf carts, snowmobiles etc.).
- Water hazards – ponds, drainage ditches, water tanks, etc.
- Falls – buildings, machinery and equipment (e.g. hayloft, silos)
- Chemicals, petroleum and pesticide product exposures
- Animal exposures – large animals, domestic animals, wild animals, rodent/insect, etc.
- Farm product exposure – grain dust, raw milk, product holding areas such as grain bins
- Recreational activities – horse-back riding, hunting, shooting, archery, snowmobiling, rodeo, fishing, boating, camping
- Temperature and weather related exposures
Tractors injuries are the leading cause of trauma on the farm for all age groups. This includes operating or being a passenger on a tractor. Tractors and other farm machinery including lawn mowers are designed for adults. The throttles, gears, pedals, and steering wheels are designed for adults and may be beyond the reach of children and youth (anyone < 19 years old), and they often take more strength to operate properly than a child has. As children are not as tall, they can have a reduced field of view. Children and youth also have poorer executive function and lack experience. Impulse control may not occur until adulthood.
Learning Point
Methods to decrease all workplace injuries are the 3 E’s of industrial safety, which are engineering, education and enforcement.
- Engineering design eliminates or reduces the potential hazard. For example, separation from the hazard such as fencing around the home to make a safe area for children to play in.
Understanding ergonomic loads on children to determine if, and how, a child or youth can safely perform a specific farm task. - Education for both parents and children to understand risks and ways to mitigate them. Various methods can be used including school, organizations, community events and educational materials such as farm safety camps, safety certification programs, etc.
- Enforcement by both parents and children again can help to mitigate problems. Parental and older sibling modeling of appropriate safety has been shown to decrease injuries.
- Appropriate supervision is always necessary for children of any age. Supervision includes the adult’s attention (i.e. listening and watching), proximity (within reach or beyond) and supervision continuity over time (intermittent or continuous).
Risks are increased, as would be expected, when parents are farming, or the child is exposed to equipment or animals. Tractor injuries as noted before carry the highest risk. This includes being the driver or a passenger on a tractor or piece of equipment.
While many of the usual safety suggestions may seem logical, like any environment, they may be difficult to implement on a consistent basis. A permanent fence around a pond may be easier to implement than locking up every small tool in a workshop every time. Injuries will occur in any workplace or home and children must also be taught basic first aid and how to obtain help if needed. Basics such as good sleep hygiene and appropriate rest periods can have big effects on the decisions adults and children make for their own and others safety.
Guidance for farm safety includes:
- Engineering
- Make sure children know what areas of the farm are unsafe
- Keep children away from dangerous equipment and water hazards by fencing in play areas
- Layout workspaces to encourage safety – chemicals and petroleum products locked up in a separate area, workshop with tools can be locked, etc.
- Safety equipment should be readily available to encourage their use such as fire extinguishers, first aid kits, respirators, etc.
- Education
- Check equipment regularly to ensure safety features are working properly
- Children should not play on equipment, even with adult supervision
- Monitor changing weather conditions
- Children < 16 years of age should not operate farm vehicles. Allow youths ages 16 to 18 years to operate farm vehicles on public roads only if they have a motor vehicle license and are graduates of a state-approved tractor and farm vehicle safety training program.
- Never allow extra riders on tractors, mowers or ATVs, etc.
- Seat belts should always be used on tractors or any other vehicle
- Limit young children’s access to large animals
- Teach children not to run or speak loudly around animals
- Participate in farm safety events and certificate training programs (e.g. farm vehicle safety, hunter safety, boating safety, etc.)
- Teach and practice a safety plan for common problems that do occur. For example, what to do when they are near a barn when a tractor drives into the area, or animal is startled, or they find a potentially dangerous tool, or need to get emergency help, etc.
- Enforcement
- Children should be adequately supervised at all times
- Make sure children know how and use all safety equipment properly
- Use basic safety equipment – seat belts, eye and ear protection, respirators, clothing, etc.
- Specialized safety equipment should be used appropriately and with additional supervision
- Children should be properly attired for the work
- Appropriate clothing that provides comfort while working yet is protective such as closed toed shoes, long sleeve-shirts, pants, hats
- Hair should be kept short or tied back
- No loose clothing or hair
- Encourage children to ask for help when they encounter problems
Questions for Further Discussion
1. What professional organizations offer farm safety education and training?
2. What is the extension? Program information can be found here and a specific example in the State of Iowa can be found here
3. What diseases are related to livestock exposure?
4. When can a child mow a lawn? A review can be found here
Related Cases
- Disease: Farm Health and Safety
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Farm Health and Safety
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Rasch H. Down on the farm: Don’t let children fall victim to injuries. AAP News. 2012;33(8):25-25. doi:10.1542/aapnews.2012338-25d
Zaloshnja E, Miller TR, Lawrence B. Incidence and Cost of Injury Among Youth in Agricultural Settings, United States, 2001-2006. Pediatrics. 2012;129(4):728-734. doi:10.1542/peds.2011-2512
Schwebel DC, Pickett W. The role of child and adolescent development in the occurrence of agricultural injuries: an illustration using tractor-related injuries. J Agromedicine. 2012;17(2):214-24. doi: 10.1080/1059924X.2012.655120.
Morrongiello BA, Zdzieborski D, Stewart J. Supervision of children in agricultural settings: implications for injury risk and prevention. J Agromedicine. 2012;17(2):149-62. doi: 10.1080/1059924X.2012.655127.
Gallagher SS. Characteristics of evaluated childhood agricultural safety interventions. J Agromedicine. 2012;17(2):109-26. doi: 10.1080/1059924X.2012.664033.
McCallum DM, Murphy S, Reed DB, Claunch DT, Reynolds SJ. What we know about the effectiveness of farm safety day programs and what we need to know. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc. 2013;29(1):20-29. doi:10.1111/j.1748-0361.2012.00426.x
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 