With regard to the use of commercially available dietary fluids, the message from Wendland and Arbus should be clear: Don't administer unspecified "clear" fluids to babies with diarrhea. The administration of some prepared clear soups can be hazardous because of their high salt content. In theory, many products that are hyperosmolar or have a high sugar content can worsen and prolong diarrhea unless they are diluted to the point where their osmolarity approaches that of plasma. Thus, many soft drinks and fruit juices should be diluted to at least half-strength. None of these dietary fluids can meet the nutritional requirements of the infant, but during the acute phase of severe infectious diarrhea one has no practical option other than to restrict energy and protein intake. However, nutritional reserves are limited in infants,9 and, undoubtedly, nutrients are important for repair after enteric infection.10 Within 24 to 48 hours adequate energy and protein intake should be provided. These objectives are met not by giving hyperosmolar sugar solutions but by instituting a balanced diet. Fortunately, there seems to be a considerable margin for error and most sick babies, even those with acute enteritis, recover, whatever their treatment. Nevertheless, in this "modern" era of nutritional ignorance a careful assessment of what we feed these fragile patients seems appropriate.

References 1. ROHDE JE, NORTHRUP RS: Taking science where the diarrhoea is, in A cute Diarrhoea in Childhood, Ciba Foundation Symposium 42, Elsevier, New York, 1976, p 339 2. GALL DG, HAMILTON JR: Infectious diarrhoea in infants and children. Cliii Gastroenterol 6: 431, 1977 3. CARLSON JAK, MIDDLETON PJ, SZYMANSKI MT, et al:

Fatal rotavirus gastroenteritis - analysis of 21 cases. Am J Dis Child 132: 477, 1978 4. BISHOP RF, DAVIDSON GP, HOLMES IH, et al: Virus particles in epithelial cells of duodenal mucosa from children with acute non-bacterial gastroenteritis. Lancet 2: 1281, 1973 5. MIDDLETON PJ, SZYMANSKI MT. ABBOTT GD, et al:

Orbivirus acute gastroenteritis in infancy. Lancet 1: 1241, 1974 6. DAVIDSON GP, GALL DG, BUTLER DG, et al: Human rotavirus enteritis induced in conventional piglets - intestinal structure and transport. J Clin invest 60: 1402, 1977 7. TELCH J, SHEPHERD RW, BUTLER DG, et al: Jejunal glucose transport in acute invasive viral enteritis (abstr). Cliii Res 26: 852A, 1978 8. TALLETT 5, MACKENZIE C, MIDDLETON P, et al: Clinical,

laboratory and epidemiologic features of a viral gastroenteritis in infants and children. Pediatrics 60: 217, 1977 9. HEIRD WC, DRISCOLL JM JR, SCHULLINGER JN, et al: Intravenous alimentation in pediatric patients. J Pediatr

80: 351, 1972 10. HAMILTON JR, GALL DG, BUTLER DG, et al: Viral gastroenteritis: recent progress, remaining problems, in A cute Diarrhoea in Childhood, op cit, p 209

Skateboard injuries ROBERT G. SMITH,* MD, FRCP[C]

With summer in full swing the fractures and sprains from winter skiing have been replaced in hospital emergency departments by skateboard injuries. In 1977, 184 persons with skateboard injuries were treated at the Hospital for Sick Children in Toronto1 and 53 were seen during a 4-month period at the Children's Centre in Winnipeg (The Medical Post, Feb. 14, 1978, p 63). No cross-Canada figures are available, but it has been estimated that more than 87 000 skateboard injuries were treated in emergency departments in the United States in 1978.2 Because of our colder climate and the availability of other attractive summer activities, the Canadian rate of skateboard injuries is probably less than the customary 10% of the American figure. However, skateboard accidents are still a cause for concern among parents and pediatricians, some of whom are putting pressure on legislators to "ban the boards". Before someone sums up this summer's skateboard injuries toll it would be wise to review the available *Member, child health committee, Manitoba Medical Association Reprint requests to: Dr. Robert G. Smith, Selkirk Medical Centre, 353 Eveline St., Selkirk, Man. RiA lN1 510 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121

information about the dangers of skateboarding, propose tactics to reduce the frequency of injury and consider the wisdom of restricting the use of skateboards. Half of all reported skateboard injuries are fractures of limbs. Fatalities are rare, but in the United States there were 24 deaths in a 3-year period, most due to head injuries or contact with moving vehicles.2 Further analysis of injuries reveals some interesting facts.2 One third of accident victims had been skateboarding for less than 1 week, and most of them were injured the first time they tried skateboarding. Two of five injured persons had borrowed skateboards. One third of accidents occurred when a board struck irregularities in the riding surfaces; in one quarter of accidents the victims lost their balance. Most skateboarders, it is believed, are between 10 and 17 years of age; 14- and 1 5-year-olds are the primary users of skateboards. Of all persons injured 45% are between 10 and 14 years of age. Thus, the inexperienced young skateboarder who tests his or her skill on an irregular riding surface, or on unfamiliar or unrepetitive terrain, is at the greatest risk of injury. Are skateboards safe to use? Some may validly argue that skateboards are inherently unstable and are thus unsafe to use. Be that as it may, product

failure accounts for only 1 % of all injuries.2 Some features, nevertheless, do make some skateboards safer to use than others. Basically, skateboards consist of three parts: the deck, the wheels and the trucks. The deck of the skateboard is usually 60 to 75 cm long and is constructed of wood, plastic, fibreglass or aluminum. The more flexible the deck, the more skill needed to maneuver the skateboard. Fibreglass decks are the most flexible and wooden ones the least. Skateboards with short decks are the best for doing tricks and gaining speed. Those with relatively long inflexible decks and a nonslip covering are the safest for beginners. The aluminum boards are not recommended because the edges of their decks wear to a razor-like sharpness. Wide wheels (stokers) are from 5 to 6 cm wide and make the board more stable; although narrow wheels (slicks), which are from 3 to 4 cm wide, are less stable, they increase maneuverability. The best wheels are made of plastic or polyurethane, not rubber. The wheels should have sealed steel bearings and should be held on the axle by lock nuts that can be tightened without limiting the motion of the wheel and will not loosen with use. The trucking mechanism is the device by which the wheels are attached to the deck. It should be so constructed as to allow side-to-side movement and therefore steering. Trucks should be adjustable according to the weight of the rider and should be attached to the deck with lock nuts. Experience notwithstanding, riders can make skateboarding safer by using a helmet, knee and elbow pads, and heavy gloves. These may be ineffective in reducing the incidence of fractures, but they can reduce the incidence of head injuries, contusions and abrasions. Thus, the incidence of injuries due to skateboarding can be reduced, perhaps by as much as one third,2 if skateboard riders use their equipment in a controlled environment such as an area where they will not come into contact with automobiles, where there are smooth riding surfaces, and where the riding surface is repetitive and familiar, and if riders can be encouraged to wear protective equipment and have periodic safety checks of their equipment. With the use of helmets and the avoidance of collision with automobiles, death can be eliminated. Since experience plays an important part in the prevention of injury, consumer education is obviously important. Should skateboards be banned? No, they should not. Certainly attempts should be made to discourage their use on dangerous surfaces such as roadways. Attempts have been made to ban the use of skateboards on the streets, but the regulations have proved unenforceable. However, the goal should be to encourage riders to enjoy and develop this sport safely. After all, doesn't skateboarding develop the attributes we would like to see our children attain - grace of motion, agility, coordination and a sense of achievement in a sport they enjoy? The means to achieve safety may seem simple the development of parks for skateboarding comparable to ice-skating rinks, where the rigid regulation of safety standards and the compulsory use of safety equipment are enforced. In the United States the popu512 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121

larity of such parks shows that the idea is a good one. It matters not that the parks are soon abandoned by many experienced skaters because the repetitive surfaces no longer challenge their skills. At least for inexperienced and part-time skaters the environment is controlled and reasonably safe. In Canada, however, such parks are scarce. The climate in most parts of Canada makes skateboarding a seasonal sport. Indoor parks are expensive to build and insure, and private entrepreneurs have not rushed to fill the demand. Some cities in Canada are in the process of establishing small outdoor public parks, but there are problems not only in the reluctance of those who control the public purse, but also in the free exchange of ideas on the most functional and safest designs. For example, when individuals in Winnipeg were attempting to design outdoor parks, they could not, after several enquiries, obtain any information from those who had established parks in the United States. The industry is competitive and secretive. What are the answers? At present, parents and concerned groups can only ensure that the sport is made safer. In other words, parents should insist that their children have the most reliable skateboards and that they use safety equipment. Safe skating areas (e.g., temporarily closed residential streets and supermarket parking lots) must be provided until parks can be established. An ongoing program of consumer education should be initiated. Rather than pressuring governments to attain unreachable objectives such as banning the use of skateboards from the streets, we should pressure them to study the phenomenon of skateboarding in Canada and determine the problem areas and the risks, to promote consumer education and, finally, to set safety standards regarding the construction of skateboards sold in Canada. At present, we allow the sale of unsafe equipment, we make no demands that manufacturers package their product with warnings or instructions on its safe use and we raise no objections when the media show persons skateboarding without safety equipment or in an unsafe environment. These are areas in which governments can act and in which we should encourage them to do so. Perhaps skateboards will go the way of the hulahoop. I don't think so and I hope not. For the present, however, let us encourage participants to use them safely. References 1. HAFFEY H: Annual Report - Accident Survey, Hospital for Sick Children, Toronto, 1978 2. Hazards Analysis Reports. Injuries Associated with Skateboards (product code 1333), economic analysis, hazard identification and analysis directorate, US Consumer Product Safety Commission, Washington, 1977

Recommended reading MADDOX D: Skateboarding: the spill-and-skill sport. Physician Sports Med 6: 108, 1978 Idem: Skateboards: zip-and-zap riders. Physician Sports Med 4: 24, 1976 ATIENZA F, SIA C: The hazards of skateboard-riding. Pediatrics 57: 793, 1976 JACOBS RA, KELLER EL: Skateboard accidents. Pediatrics 59: 939, 1977 Skateboards. Which Dec: 643, 1977