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Consumer and competition policy directorate

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  1. Consumer and Competition Policy Directorate Research into the mouthing behaviour of children up to 5 years old.
  2. July 2002 Research commissioned by the Consumer and Competition Policy Directorate, DTI. Department of Trade and Industry 1 Victoria Street London SW1H 0ET Carried out under contract by: Dr Beverley Norris Stuart Smith Institute for Occupational Ergonomics School of Mechanical, Materials, Manufacturing Engineering and Management University of Nottingham University Park, Nottingham, NG7 2RD Tel: 0115 9514039 Fax: 0115 9514000 URN 02/748
  3. Page No Contents SUMMARY 1 CHAPTER 1. Design of the research 2 1.1 Aims of this research 2 1.2 Data Collection 2 1.3 Experimental design 3 CHAPTER 2. Methodology 5 2.1 Development of materials 5 2.1.1 Pre-pilot trials 5 2.1.2 Pilot trials 5 2.2 Observation protocols 6 2.2.1 Timing of mouthing behaviours 6 2.2.2 Classifying what was mouthed 6 2.2.3 Classifying the type of mouthing behaviour 6 CHAPTER 3. Participant Details 7 3.1 Children's mouthing characteristics and child care details 7 CHAPTER 4. Results 10 4.1 Estimated daily mouthing time by item mouthed 10 4.2 Estimates of daily mouthing times according to what was mouthed and how 13 4.2.1 All items 14 4.2.2 Dummy/soother 14 4.2.3 Fingers 16 4.2.4 Toys 18 4.2.5 Other objects 20 4.2.6 Items not recorded 22 4.3 What was mouthed 23 4.3.1 Categories of toys and other objects mouthed 23 4.3.2 Mouthed toys and other objects by material 25 4.3.3 Items intended to be mouthed 26 4.3.4 Number of items mouthed 29 CHAPTER 5. Validation 30 5.1 Analysis of mouthing time 30 5.2 Analysis of what was mouthed 31 5.3 Analysis of how the children mouthed 32
  4. CHAPTER 6. Discussion 33 6.1 Validity and reliability of the study 33 6.2 Mouthing times 33 6.2.1 Mean and maximum mouthing times 33 6.2.2 What is mouthed 34 6.2.3 How items are mouthed 34 CHAPTER 7. Implications 36 7.1 Why children mouth 36 7.2 Overview of legislation and standards 36 7.3 Accident statistics on mechanical hazards 37 7.4 Mouthing times 38 7.5 Items mouthed 38 7.6 Hazards from items mouthed in this study 39 7.7 Reducing accident levels 43 7.7.1 Toys 43 7.7.2 Other objects 44 7.8 Using product features to deter mouthing 44 CHAPTER 8. Conclusions 45 CHAPTER 9. Recommendations 47 9.1 Toys 47 9.2 Other objects 47 CHAPTER 10. References 49 Appendix A: Observation recording form 50 Appendix B: Toy and objects details sheet 51 Appendix C: Child’s daily routine form 52 Appendix D: Questionnaire 53 Appendix E: Pictures illustrating mouthing behaviours 56 Appendix F: Examples of Toy Categories 57 Appendix G: Examples of "other objects" categories 69
  5. Summary This report supplements "Report on research into the mouthing behaviour of children up to 5 years old – Executive Summary" (DTI, 2002). This report presents background information to the study and further data and discussion from the study, specifically: i) Information regarding the methodology and protocols of the study ii) Background data on the sample: Details of children’s mouthing habits, the child’s family, the observers and their care and work circumstances and child care arrangements iii) Estimated data on time spent each day mouthing on dummy/soothers, fingers, toys, and other objects by how the items were mouthed, for each age group iv) Details of the validation study v) Discussion of the findings of the work vi) Details of the items mouthed in the study vii) Literature review of chemical and mechanical hazards from children’s toys and other plastic items viii) The forms used in data collection. Information presented in this report should be used in conjunction with the summary report described above. Page 3
  6. Chapter 1 Design of the Research 1.1 AIMS OF THIS RESEARCH The research described in this report was designed to expand upon the knowledge of the mouthing behaviour of children. The ages of children to be observed in this study ranged from 1 month to 5 years, to investigate the extent of exposure to products at this older age (given the findings of Warren et al. (2000) that over 20% of the children in their study carried a non-nutritive sucking habit past the age of 36 months). The overall aim of the project was to produce a figure for the total time that children within this age range are expected to mouth items per day. This could then be used to assess potential mechanical hazards posed by items on which children were found to mouth. 1.2 DATA COLLECTION The behaviour of young children may be greatly affected by all types of stimuli. In studies such as this where we are attempting to gain information on normal and natural behaviour of children it is imperative that the environment in which the data are gathered is as unaffected by the observation as possible. This means that the child should be surrounded by things that they are used to and know. For this reason, the research by Groot et al (1998) and Juberg et al (2001) both rely on data being recorded by the parent(s) of each child using a diary format. The child is obviously used to the presence of their parent and so natural behaviour may be assumed. The use of a structured formal diary recording system serves to control the type of information that the parent is recording and therefore provides a level of validity and reliability to the research. Greater levels of reliability would possibly be obtained through the use of trained researchers observing the child in their home environment, as the observer is trained to record certain types of behaviour consistently, and so providing good repeatability of observation. The same is true for the use of video recording equipment, where very short behaviours can be reliably recorded. However, it is likely that a child will be very aware of a video camera and being filmed, and this could lead to a change in behaviour. Likewise, the presence of a stranger in the home is likely to alter the behaviour of the child being observed to a greater or lesser extent, so while the reliability of the data may be high, the circumstances are less "realistic" and lower the validity of the data. Another problem with video recording is that young children are often on the move, which would make capturing every behaviour extremely difficult. For these reasons this research used parents/carers as observers, to ensure children’s mouthing behaviour, and behaviour generally, were as natural as possible to ensure high data validity. Observations were carried out at home rather than nurseries or childcare establishments as the home environment has a vast range of items that are accessible to children, not all of which are intended for use by them. This is a worst case scenario but also realistic compared to more sterile environments such as playgroups and nurseries where the contents of rooms are very carefully and rigidly controlled. Because of the factors mentioned above it was felt that an examination of the reliability of parents as observers should be carried out. This has not been investigated by prior studies which have also used parents as observers. A comparison of parent and trained observer data collection was carried out on a sample of 25 children. Information on this validation part of the research may be found in Section 5 of this report. Page 4
  7. 1.3 EXPERIMENTAL DESIGN Observation was carried out by parents in the child’s home for a total of five hours, split into 20 fifteen minute observation sessions. A period of two weeks was allowed for the observations to be completed and the data returned. These observation sessions were to be spread out over different times of the day and the week as follows: i) Weekdays: • 4 fifteen minute sessions between the child waking and 11am • 4 fifteen minute sessions between 11am and 2 pm • 4 fifteen minute sessions between 2pm and 6pm • 4 fifteen minute sessions between 6pm and the child going to bed for the night ii) Weekend: • 1 fifteen minute session between the child waking and 11am • 1 fifteen minute session between 11am and 2 pm • 1 fifteen minute session between 2pm and 6pm • 1 fifteen minute session between 6pm and the child going to bed for the night. This gives in total 5 hours of observation time on each child. Observations could be done at the discretion of the parent at any time within these zones. However, no more than two observation sessions were allowed within the same time zone on any one day, and at least 30 minutes was required to be left between observation sessions. These provisions were included in order to ensure data was gathered spread evenly across the days and week to gather a representative picture of the child’s behaviour, and also to reduce potential errors from fatigue caused by observation. In each 15 minute observation session the following information was recorded: • the duration of each mouthing behaviour • what types of items were mouthed • the type of mouthing behaviour for each item mouthed • what was mouthed • which room of the house the observation was undertaken in • other people present in the room • whether the child was feeling unusually ill or tired during the observation • how long it had been since the child last ate and slept • what the child was doing during the observation. Page 5
  8. Information gathered over the whole study for each participant also included: • details of the child’s physical and psychological development • details of the child’s family (e.g. size, type of house lived in, social class) • details of the time the child spent outside of the family home in a care environment (e.g. a nursery, playgroup) • details of toys mouthed by each child, part of toy mouthed and what each part mouthed was made of • details of what other objects were mouthed and what they were made of • details of the child’s daily routine for the first and last days that they were observed i.e. what time they got up and went to bed, and time spent eating and sleeping during the day. The questionnaires and forms used to gather these data are presented in Appendices A, B, C and D. Page 6
  9. Chapter 2 Methodology 2.1 DEVELOPMENT OF MATERIALS 2.1.1 Pre-pilot trials The use of a diary type observation recording system requires that the forms for recording behaviour are simple and intuitive to complete. For this reason, a pre-pilot stage was undertaken. Several alternative observation recording forms were produced and trialed in a local day nursery by members of the Product Safety and Testing Group (PSTG) trained in observation protocols. For the purposes of this stage, a single child was observed by both members of the PSTG for a 15 minute period, with the type and duration of each mouthing behaviour being recorded. This process was repeated for each of the sample forms in turn. The results were then analysed for the similarity of findings between the two members in terms of duration and type of behaviours. Ease of use of each form was also assessed. One observation recording form was chosen to be used in the pilot trials. 2.1.2 Pilot trials The materials developed for use in the pilot trials were as follows: • Consent form • Set of written instructions • Observation recording form (as trialed in the pre-pilot stage) • Questionnaire • Daily routine form • Toy and object details forms. Also included in the observation pack were a stop-watch, a pen and a freepost labelled envelope for returning the completed observations. The pilot trials followed the same format that was proposed for the main part of the study. Participants were given the folder containing all the required materials (as listed above). They were given only brief instructions about what they were being asked to do, as it was anticipated that the only contact with participants taking part in the main study would be on the telephone, and so the main instructions included in the observation pack would provide all of the necessary information. Participants were given one week to complete the five hours observation time. Seven parents were recruited to undertake the observations of their child for the purposes of pilot testing the protocols and materials developed for the research. Two were unable to complete the study for personal reasons, and results from one participant did not arrive back at the PSTG until after the deadline for analysis, providing data from four participants for analysis. The ages of the children observed were 4 months (female), 10 months (male), 27 months (female) and 55 months (female). Feedback was obtained from each participant on the ease of use of the materials contained within the observation pack which resulted in changes being made to the documents. The final versions that were then used in the main study are presented in Appendices A to D. Page 7
  10. 2.2 OBSERVATION PROTOCOLS 2.2.1 Timing of mouthing behaviours Participants in the research were each provided with a stopwatch for timing the duration of mouthing events. They were not required to start, stop and reset the watch each time an event occurred. Instead, the stopwatch was started at the beginning of the session and not stopped until the 15 minutes was over. When the behaviour began, i.e. when the item first entered the mouth, the time on the stopwatch was recorded on the observation form (to the nearest second), and when that particular behaviour finished the time was again noted. This enabled a quicker and more accurate time map of the child’s behaviour to be produced than by starting and stopping the watch for each behaviour, especially for very short time behaviours. 2.2.2 Classifying what was mouthed Products/items mouthed were classified into four categories: a dummy/soother, fingers, toys, and other objects. The "fingers" category includes any part of the body of the child or of another person, and whether an item was classified as a toy or other object was decided upon by the observer. 2.2.3 Classifying the type of mouthing behaviour Mouthing behaviour was classified into three categories. The instructions given to observers on how to classify behaviour were as follows: • Licking/lip touching. This is where the item is placed to the front of the mouth, without actually entering into the mouth. The child may be actually licking an object, or may be touching the object to their lips. The time recorded should be from when the object first touches the child’s mouth to when the object is no longer in contact with the mouth. If a child is licking an object it may be difficult to record because of the short time period involved. In this case note the time when the object is put close to the mouth to be licked, and then taken away from the mouth • Sucking/trying to bite. The item is put directly into the mouth of the child. The child may be sucking, holding the object in their mouth or trying to bite (gumming) the object • Biting or chewing. The item is directly in the mouth of the child. It is clear that the child is biting or chewing on it. It can be difficult to tell exactly what a young child is doing with an item if it is in or near their mouth. Observers were told that unless they could see that actual biting or chewing was happening they should tick the sucking/trying to bite category. If the child did more than one action then they were asked to tick both, e.g. if they lick and then bite an item to put a tick under both headings. Photographs were included illustrating the licking and sucking behaviours, as shown in Appendix E, but not biting/chewing; this is difficult to illustrate as the item is shown as just being at/inside the mouth without the movement which means chewing or biting is occurring. Page 8
  11. Chapter 3 Participant Details 236 children were observed by their parents. The number of children observed in each age group were as follows: Age group Number of boys Number of girls Total 1-3 months 3 6 9 3-6 months 7 7 14 6-9 months 6 9 15 9-12 months 6 11 17 12-15 months 5 11 16 15-18 months 5 9 14 18-21 months 11 5 16 21-24 months 6 6 12 2 years 18 21 39 3 years 13 18 31 4 years 17 12 29 5 years 14 10 24 Table 1: Number of children observed in each age group The upper age limit for each age group was the day before the final month age is reached, e.g. 1-3 months includes children from one month to two months three weeks and six days. 3.1 CHILDREN'S MOUTHING CHARACTERISTICS AND CHILDCARE DETAILS Background information was gathered on each child and their families, covering the child’s physical development, mouthing habits of the child, and information on the child’s family. The information collected is detailed below. i) The mouthing habits of the child: • 29% of children leave bite marks in toys • 25% of children damage items by biting • 28% of children use a dummy/soother • 69% of children were/are breast-fed ii) Who did the observations, who cares for the child, do they work: • 99% of the observations were done by the child’s mother • 97% of the children were (mainly) cared for by their mother • 47% of main carers did not undertake paid work, 50% worked part-time, 3% worked full-time Page 9
  12. iii) Childcare arrangements: Childcare arrangements for each child observed ranged from none (i.e. always at home with the mother or father) to 5 days a week. Details are presented in Figure 1 of the type of childcare that children taking part in the study attended. For each day of childcare separate values are presented, for example, day one is not necessarily the same day for all children but instead means that this represents a single day (or part of a day) where childcare occurs for that child. Day one none creche playgroup relative / friend childminder nursery Day two none creche playgroup relative / friend childminder nursery Day three none creche playgroup relative / friend childminder nursery Page 10
  13. Day four none creche playgroup relative / friend childminder nursery Day five none creche playgroup relative / friend childminder nursery Figure 1: Childcare arrangements, by day, for children observed in the study. As the number of observation days increases the number of children going to some form of childcare decreases. Nursery is the most popular form of childcare. Information was gathered on how much time during a typical normal day the child would have available to spend mouthing, that is, time not spent sleeping or eating. Table 2 presents the mean, minimum and maximum times available to mouth for each age group Age group Mean Minimum Maximum 1-3 months 8:22 3:51 13:30 3-6 months 9:09 6:20 12:48 6-9 months 9:21 7:10 11:50 9-12 months 9:06 6:45 11:23 12-15 months 9:15 7:20 11:05 15-18 months 9:50 6:57 12:42 18-21 months 10:10 8:30 12:15 21-24 months 10:12 6:50 13:39 2 years 10:45 7:35 13:20 3 years 11:10 9:35 13:50 4 years 11:31 9:40 14:10 5 years 11:22 9:30 14:00 Page 11
  14. Chapter 4 Results The following sections present results for: 4.1 Estimated mouthing time according to what was mouthed 4.2 Estimated mouthing time according to what was mouthed and how it was mouthed 4.3 A breakdown of what was mouthed, including by material (and if it is intended to be mouthed – as far as can be known). The estimated daily mouthing time is extrapolated from the mouthing behaviour recorded over the five hours observation time. This is calculated as follows: Observed mouthing time * time available to mouth per day Total time observed for Where: Observed mouthing time = the amount of mouthing time recorded for each child Total time observed for = the total amount of time that they were observed for (5 hours) Time available to mouth = the time available over the whole day for the child to mouth per day i.e. the time during the day when they were awake but not eating This calculates the average time spent mouthing per hour, multiplied by the total number of hours each day that each child has available to mouth i.e. the number of hours they are awake during the day but not eating. This has been based on the assumption that children are likely to mouth at the same rate throughout the day. A Kruskal-Wallis1 test showed no significant differences in observed mouthing between the different times of the day that children were observed. The presented mean values were calculated by dividing the total estimated mouthing time for each category of item mouthed within each age group by the total number of subjects in that age group. For example, for 3-6 months olds, only 4 subjects may have actually mouthed on a dummy/soother but the total estimate of daily mouthing on a dummy/soother for that age was divided by the total number of subjects in that age group (14) to give the mean value of daily mouthing time that could be expected across that age group generally. Because of the skewed2 nature of the raw data used to produce these estimates care should be taken if using mean estimated daily mouthing values for the purposes of safety. This is because the mean value may not reflect the true average or middle value of the sample for each age group, depending on the degree to which the data are skewed. 4.1 ESTIMATED DAILY MOUTHING TIME BY ITEM MOUTHED Figure 2 presents the mean estimated daily mouthing time for males and females combined for each item mouthed (in hours:minutes:seconds). Each mean behaviour is the average time that a child in each age group could be expected to mouth a given item over a normal day. Mean total daily mouthing time is the time that any child could be expected to mouth, on anything, on average over a normal day, and is the sum of mean mouthing time on all items for each age group. 1 The Kruskal-Wallis test is a non-parametric statistical test used to determine whether values of scores for three or more groups are significantly different, in this case we have four groups, i.e. those observed between waking and 11am, between 11am and 2pm, between 2pm and 6pm, and 6pm until bedtime. 2 Page 12 The observed data have a skewed distribution because in general a high percentage of observed mouthing behaviours for each age group were very short in nature (i.e. only a few seconds), with only a small percentage being observed with duration of between 1 and 15 minutes.
  15. Table 3 presents the mean and maximum estimated daily mouthing data, for males and females combined. Data shown for males and females combined as a Mann-Whitney1 test showed no statistically significant difference in mouthing time between the sexes. The presented maximum values are the highest estimated daily mouthing times of any child in each age category, for each item. It does not necessarily follow that the maximum values in each age group for each item were exhibited by the same child, that is, one child may have mouthed a lot on a dummy/soother while another child in the same age group may have mouthed a lot on fingers. Also presented is the maximum estimated daily mouthing time for mouthing on all and any items, in each age group, by any single child. 2:15:00 2:00:00 1:45:00 Dummy / Soother Mean mouthing time 1:30:00 Fingers 1:15:00 Toys 1:00:00 Other objects 0:45:00 Not recorded Total 0:30:00 0:15:00 0:00:00 2 3 4 5 1-3 3-6 6-9 9-12 12-15 15-18 18-21 21-24 Age category Figure 2: Estimated mean daily mouthing time for each item mouthed and for all items (total mouthing) (hours:minutes:seconds) 1 The Mann-Whitney test is a non-parametric statistical test used to determine if there are significant differences between scores or values of two groups with different subjects in each group, i.e. males and females. Page 13
  16. Item mouthed Age Group 1-3 3-6 6-9 9-12 12-15 15-18 18-21 21-24 2 3 4 5 months months months months months months months months years years years years Mean 0:47:13 0:27:45 0:14:36 0:41:39 1:00:15 0:25:22 1:09:02 0:25:12 0:32:55 0:48:42 0:16:40 0:00:20 Dummy/ Soother Max 2:54:50 2:32:48 1:40:02 5:23:45 3:32:15 3:40:21 5:17:35 1:54:37 3:37:00 5:04:03 5:21:39 0:08:08 Mean 0:18:22 0:49:03 0:16:54 0:14:07 0:08:24 0:10:07 0:18:40 0:35:34 0:29:43 0:34:42 0:19:26 0:44:06 Fingers Max 0:50:31 1:36:02 1:17:13 1:38:42 0:35:53 0:39:21 1:20:29 1:53:10 2:27:48 3:18:33 2:51:01 9:02:45 Mean 0:00:14 0:28:20 0:39:10 0:23:04 0:15:18 0:16:34 0:11:07 0:15:46 0:12:23 0:11:37 0:03:11 0:01:53 Toys Max 0:00:59 2:34:45 3:46:46 1:04:49 0:44:01 0:58:28 0:32:49 1:42:04 2:05:48 1:34:36 0:20:46 0:11:20 Mean 0:05:14 0:12:29 0:24:30 0:16:25 0:12:02 0:23:01 0:19:49 0:12:53 0:21:46 0:15:16 0:10:44 0:10:00 Other Objects Max 0:28:11 0:36:39 1:10:23 1:31:00 1:03:03 1:38:02 1:06:21 0:40:20 2:57:58 1:25:29 1:16:40 0:52:47 Mean 0:00:45 0:00:24 - 0:00:01 0:00:02 0:00:08 0:00:11 0:14:13 0:02:40 0:00:01 0:00:05 0:02:58 Not Recorded Max 0:06:42 0:03:07 - 0:00:09 0:00:26 0:01:55 0:02:05 2:50:37 1:35:15 0:00:37 0:02:24 1:05:08 Table 3: Estimated mean and maximum daily mouthing time for all items mouthed (hours:minutes:seconds). Item mouthed Age Group 1-3 3-6 6-9 9-12 12-15 15-18 18-21 21-24 2 3 4 5 months months months months months months months months years years years years Total Mean 1:11:48 1:57:41 1:35:11 1:35:16 1:36:01 1:15:13 1:58:49 1:43:39 1:39:27 1:50:19 0:50:05 0:59:17 estimated mouthing on all items Max 3:31:50 3:36:24 5:16:59 6:53:01 4:17:09 5:14:42 6:52:18 6:35:01 7:41:31 8:30:12 5:28:44 10:01:07 Table 4: Estimated mean and daily mouthing time on all items mouthed (hours:minutes:seconds). Page 14
  17. No clear age pattern exists for total mouthing time, with the highest estimated daily mean mouthing time being exhibited by children aged 18-21 months. However, a Kruskal – Wallis test for differences in observed mouthing time on all items between the age groups was significant (Chi- square = 30.050, d.f. = 11, p
  18. 4.2.1 All items Estimated daily mean mouthing time is presented in Figure 4, for mouthing on all items, by how items were mouthed at each age group. 2:15:00 2:00:00 1:45:00 lick, suck and bite suck and bite Mean mouthing time 1:30:00 lick and bite 1:15:00 lick and suck 1:00:00 bite 0:45:00 suck 0:30:00 lick 0:15:00 0:00:00 1-3 3-6 6-9 9-12 12-15 15-18 18-21 21-24 2 3 4 5 Age category Figure 4: Estimated mean daily mouthing on all items by how they were mouthed (hours:minutes:seconds). Sucking is shown to be the most common mouthing behaviour at all ages. 4.2.2 Dummy/Soother Figure 5 shows how dummies/soothers were mouthed at each age group, and Table 5 presents the estimated daily mouthing data shown in Figure 5. 1:20:00 1:10:00 Not recorded 1:00:00 Lick, Suck and Bite Mean mouthing time 0:50:00 Suck and Bite Lick and Bite 0:40:00 Lick and Suck 0:30:00 Bite Suck 0:20:00 Lick 0:10:00 0:00:00 1-3 3-6 6-9 2 3 4 5 9-12 12-15 15-18 18-21 21-24 Age category Figure 5: Estimated mean daily mouthing time for dummy/soothers according to how they were mouthed (hours:minutes:seconds). Page 16



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