Cold Injuries

Preventing Cold Injuries: Winter Safety Tips

Sharmila Nanda, MD

Dr Nanda is a neonatal fellow in the section of neonatology in the department of pediatrics at West Virginia University School of Medicine in Morgantown.

cold injuriesThe American Academy of Pediatrics (AAP) provides useful tips for avoiding cold injury that are summarized here.1 These tips along with an adequate dose of common sense can go a long way in preventing the potential catastrophic effects of overexposure to the cold and serious injury as a result of irresponsible participation in winter sports.

The CDC’s prevention guide to extreme cold offers the following measures that can help prevent cold injury2:
Plan ahead—prepare your home and car for the winter.
• Dress warmly and stay dry.
• Avoid exertion.
• Eat and drink wisely—avoid alcohol and caffeine.
• Understand the wind chill index.
• Avoid icy paths.
• Be safe during recreation—carry a mobile phone, inform friends, pack dry clothing.
• Pay attention to travel advisories.
• Recognize early signs of hypothermia and frostbite.
• Lock doors with high locks to prevent toddlers from wandering outdoors.
• Take an American Red Cross first aid course.


Hypothermia (body temperature below 35ºC [95ºF]) can develop more rapidly in a child than in an adult. Young children and children with preexisting medical conditions are at greater risk for hypothermia. It often occurs when a youngster is playing outdoors in extremely cold weather in wet clothes or in clothing that is insufficient for low temperatures.

Symptoms may include shivering, lethargy, clumsiness, and slurred speech. However, in moderate hypothermia, the child will not be shivering (the body loses the ability to warm itself).3 Declining mental status may cause the freezing patient to remove clothing (a phenomenon known as paradoxical undressing).3 The most serious consequences of hypothermia are listed in Table 1.3


Hypothermia is not limited to Northern states and causes about 500 deaths each year, half of the victims are older than 65 years. Fortunately, very few children die of overexposure to the cold; however, the vast majority of these deaths are preventable.4

Treatment. Parents should be instructed to call 911 if they think their child has hypothermia and keep the child indoors, remove any wet clothing, and dress him or her warmly and/or use blankets. While mild hypothermia can be managed with passive rewarming techniques done by companions of the victim, the severely hypothermic child requires active rewarming and more aggressive treatment in an emergency or tertiary care facility. The patient must be handled as gently as possible to prevent arrhythmia.3


Frostbite is the most clinically significant type of localized cold injury in the pediatric population.3 It tends to occur on the fingers, toes, ears, and nose, which may become pale, gray, and blistered. At the same time, the child may complain that his/her skin burns or has become numb. Frostbite may occur alone or concurrently with hypothermia.

Localized cold injuries can result from nonfreezing as well as freezing conditions. Trench foot or immersion foot (injury secondary to cold-water immersion), pernio or chilblains (injury secondary to repetitive damp exposure) (Figure 1), and frost nip (reversible superficial cold injury or “pre-frostbite”) are nonfreezing localized injuries.


Figure 1 – Chilblains (pernio) refers to a “benign” inflammatory process that produces painful, burning violaceous papules on the toes. This condition occurs in thesetting of “cold” toes, which may or may not be erythrocyanotic. The trigger is cold, wet, nonfreezing weather that adolescents don’t acknowledge and for which they don’t change their footwear for protection.
(Photos courtesy of Kirk Barber, MD.)




In freezing localized injury or frostbite, tissue freezes to various degrees with various characteristics. First-degree frostbite is the mildest and most superficial type. Second-degree frostbite is shown in Figure 2. Patients with third-degree frostbite have deeper tissue damage and hemorrhagic blisters. Fourth-degree frostbite involves the freezing of subcutaneous tissue, muscle, and bone.

Treatment. Immediate treatment involves putting the frostbitten parts of the body in warm water, 104°F (about the temperature of most hot tubs) is recommended. Warm washcloths may be applied to frostbitten nose, ears, and lips.

The frozen areas should not be rubbed. Thawing must not be attempted if there is danger of refreezing, since a freeze-thaw-freeze cycle adds to the existing damage.5 After thawing, the frostbitten part is kept dry, warm, and loosely covered. Splinting and elevating the affected extremity helps decrease any edema. Children should be kept warm with clothing or blankets and can be given something warm to drink. If the numbness continues for more than a few minutes, parents should call their pediatric practitioner.

Inform parents that topical emollients do not prevent frostbite and that water-based emollients in particular may produce a surface cooling effect secondary to evaporation. Non-water-based emollients may increase the risk of frostbite either by giving the user a false sense of security or by increasing the water content of the stratum corneum and thus raising the freezing temperature of the skin.6 


Winter sports and associated key injuries are listed in Table 2.7 Between 20 and 30 deaths from downhill skiing accidents occur each year in this country. The cause of death is massive head or neck injury, and/or major thoracoabdominal injury. Excessive speed and loss of control are the main contributing factors.

winter sports

Incredibly, children younger than 17 years sustain 12% of all snowmobile injuries. Pyper and Black8 reported 70 snowmobile-related injuries in persons aged 2 to 17 years. These injuries had been caused by losing control of the sled, rollover, striking a fixed object, or striking a motor vehicle or another sled. Fifteen accidents involved more than 1 person, and 5 of the injured children were pedestrians. Three deaths in this series were related to head trauma.

The AAP’s tips for preventing injuries from winter sports are listed below. Key preventive measures are available from other online sources: Advise parents to set reasonable time limits on outdoor play to prevent hypothermia and frostbite, and have children come inside periodically to warm up. Using alcohol or drugs before any winter activity, such as snowmobiling or skiing, is dangerous and should not be permitted in any situation.

Ice skating. Children should skate on approved surfaces only. Check for signs posted by local police or recreation departments, or call your local police department to find out which areas have been approved.

Children can be advised to:
• Skate in the same direction as the crowd.
• Avoid darting across the ice.
• Never skate alone.
• Not chew gum or eat candy while skating.
• Wear a helmet.

Sledding. It is most important to keep children away from motor vehicles while sledding and to have a supervising parent present at all times. Parents can also do the following:

• Keep young children separated from older children.
• Have child sled feet first or sitting up, instead of lying down head-first, or wear a helmet and goggles.
• Use steerable sleds (with well-lubricated steering mechanisms), not snow disks or inner tubes, and structurally sound sleds that are free of sharp edges and splinters.
• Ensure that sled slopes are free of obstructions and are covered in snow not ice, are not too steep (slope of less than 30º), and end with a flat runoff.

Snow skiing and snowboarding. Children should be taught to ski or snowboard by a qualified instructor in a program designed for their age group. They should never ski or snowboard alone. Young children should always be supervised by an adult. Older children’s need for adult supervision depends on their maturity and skill. If older children are not with an adult, they should always at least be accompanied by a friend.

All skiers and snowboarders should wear helmets. Ski facilities should require helmet use, but if they do not, parents should enforce the requirement for their children.

Equipment should fit the child. Skiers should wear safety bindings that are adjusted at least every year. Snowboarders should wear gloves with built-in wrist guards. Eye protection or goggles should also be used.

Slopes should fit the ability and experience of the skier or snowboarder. Children and adolescents should avoid crowded slopes and avoid skiing in areas with trees and other obstacles.

Snowmobiling. The AAP recommends that children younger than 16 years not operate snowmobiles and children younger than 6 years never ride on snowmobiles.

Protective measures include the following:
• Do not use a snowmobile to pull a sled or skiers.
• Wear goggles and a helmet approved for use on vehicles, such as motorcycles.
• Travel at safe speeds.
• Never snowmobile alone or at night.
• Stay on marked trails, away from roads, water, railroads, and areas with pedestrians.

winter home preparation


1. American Academy of Pediatrics. Winter Safety Tips. January 2012. Accessed November 21, 2012.

2. Centers for Disease Control and Prevention. Extreme Cold: A Prevention Guide to Promote Your Personal Health and Safety. Accessed November 21, 2012.

3. Nield LS, Nanda S. Cold injuries: a guide to preventing—and treating—hypothermia and frostbite. Consultant For Pediatricians. 2005;4(9):427-430.

4. Centers for Disease Control and Prevention. Hypothermia-related deaths—United States, 1999–2002 and 2005. MMWR. 2006;55(10):282-284.

5. Fulcher W, White W, MacMillan RW. Emergency medicine: thermal and environmental injuries. In: Rakel RE, ed. Textbook of Family Practice. 6th ed. Philadelphia: WB Saunders Co; 2002:815-819.

6. Lehmuskallio E. Emollients in the prevention of frostbite. Int J Circumpolar Health. 2000;59:122-130.

7. Suresh S. Winter sports injuries: patterns of injury—preventive measures. Consultant For Pediatricians. 2006;5(3):168-175.

8. Pyper JA, Black GB. Orthopaedic injuries in children associated with the use of off-road vehicles. J Bone Joint Surg. 1988;70(2):275-284.