Injury patterns among obese children involved in motor vehicle collisions

Obese adolescents have higher risk for femur fracture after motor vehicle collision

Background

Previous reports identified an association between obese adolescents (OAs) and lower extremity (LE) fractures after blunt trauma. However, the type of LE fracture remains unclear. We hypothesized that OAs presenting after motor vehicle collision (MVC) have a higher risk of severe LE fracture and will require a longer length of stay (LOS) and more support services upon discharge, compared to non-OAs.

Methods

The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-17-years-old) presenting after MVC. The primary outcome was LE fracture. A severe fracture was defined by abbreviated injury scale ≥3. OAs were defined by a body mass index (BMI) ≥30.

Results

From 22,610 MVCs, 3325 (14.7 %) included OAs. The rate of any LE fracture was higher for OAs (21.6 % vs. 18.8 %, p < 0.001). On subset analysis the only LE fracture at higher risk in OAs was a femur fracture (13 % vs. 9.1 %, p < 0.001). After adjusting for sex and age, the risk for severe LE fracture (OR 1.34, CI 1.18-1.53, p < 0.001) was higher for OAs. OAs with a femur fracture had a longer median LOS (5 vs. 4 days, p = 0.003) and were more likely discharged with additional support services including home-health or inpatient rehabilitation (30.6 % vs. 21.4 %, p < 0.001).

Conclusion

OAs sustaining MVCs have increased associated risk of femur fractures. OAs are more likely to have a higher-grade LE injury, experience a longer LOS, and require additional support services upon discharge. Future research is needed to determine if early disposition planning with social work assistance can help shorten LOS.

Obesity as a Risk Factor for Adverse Outcomes After Pedestrian Trauma Accidents in the Pediatric Population

OBJECTIVE

The aim of the study is to determine whether overweight or obese children are at an increased risk for injury and adverse outcomes following pedestrian motor vehicle accidents.

METHODS

We performed a retrospective study of patients between the ages of 2 and 17 who were pedestrians injured in a collision with a motorized vehicle, presenting to a level 1 trauma center, between January 1, 2010, to December 31, 2021. Patients with admission weights falling above the 90th percentile of the Centers for Disease Control and Prevention's sex-specific growth charts were identified as overweight/obese, those below the cutoff were categorized as nonobese. Groups were compared regarding demographics, mechanism of injury, Injury Severity Score, and Abbreviated Injury Scale by body region of injury. Outcome measures included hospital admission, length of hospital stay, intensive care unit (ICU) admission, ICU length of stay, and mortality.

RESULTS

Of the 306 patients included, 72 (23.5%) were overweight/obese and 234 (76.5%) were nonobese. The mean Injury Severity Score scores were higher among overweight/obese patients (5.37 vs 8.74, P = 0.008). Overweight/obese children were more likely to sustain severe abdominal injuries (Abbreviated Injury Scale ≥ 3) (12.2% vs 5.1%; odds ratio [OR], 2.64; 95% CI, 1.07-6.56; P = 0.030), be admitted to the hospital (94.5% vs 74.3%; OR, 12.07; 95% CI, 2.87-50.72; P < 0.001), require ICU admission (31.0% vs 20.0%, OR, 1.87; 95% CI, 1.03-3.36; P = 0.036), and require a longer ICU stay (0.9 vs 0.4 days, P = 0.014) compared with nonobese patients.

CONCLUSIONS

Obese and overweight children are at increased risk for higher injury severity scores, severe abdominal injuries, and ICU admission after pedestrian motor vehicle accidents.

The Role of Obesity in Motor Vehicle Injuries and Fatalities in the Pediatric Population: A Systematic Review

PURPOSE

A systematic review done to evaluate obesity as a risk factor for injuries and mortality in motor vehicle accidents (MVAs) in the pediatric population, as there has not been a systematic review done in over 10 years. This study aims to update the literature regarding obesity as a risk factor for injuries in MVAs in the pediatric population.

MATERIALS AND METHODS

A systematic review was conducted according to the PRISMA guidelines with strict inclusion and exclusion criteria, resulting in the use of 3 total articles to analyze obesity as a risk factor for overall injury and mortality in the pediatric population.

RESULTS

Zaveri et al demonstrated a statistically significant, but weak, decrease in the odds of extremity injury in overweight patients ages 2 to 17 years old (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4-1.0, P ≤ 0.05). On the other hand, Pollack et al and Haricharan et al found an increase in extremity injury in the obese population, in ages 9 to 15 years (OR = 2.54, 95% CI = 1.15-5.59, P ≤ 0.05), and 10 to 17 years (Age 10-13: OR = 6.06, 95% CI = 2.23-16.44, P ≤ 0.05, Age 14-17 OR = 1.44, 95% CI = 1.04-2.00, P ≤ 0.05), respectively. Haricharan et al also found an increase in thoracic injuries in obese children, ages 2 to 13 and increased risk of head/face/neck injury in obese children ages 2 to 5 (OR = 3.67, 95% CI = 1.03-13.08, P ≤ 0.05), but a decreased risk of head injury in obese children ages 14 to 17 (OR = 0.33, 95% CI = 0.18-0.60, P ≤ 0.05).

CONCLUSIONS

There are sparse data that are conflicting, regarding the effect of obesity on extremity injuries in the pediatric population. Obesity is not protective against thoracic, head, or abdominal injuries. However, it was found to be a risk factor for trunk injuries in ages 2 to 13, as well as head/face/neck injuries for ages 2 to 5. Since the literature is so sparse, further research is warranted in these areas.

Obesity is associated with a reduced odds for blunt intra-abdominal injuries in children

OBJECTIVES

Children with obesity may possess unique injury characteristics that may affect their emergency care. To better understand this relationship, we investigated the association of obesity in pediatric trauma patients and intra-abdominal injuries (IAIs) and routinely utilized emergency department (ED) diagnostic procedures (computed tomography (CT) scans and ultrasound (US) examinations).

METHODS

This secondary data analysis utilized Pediatric Emergency Care Applied Research Network (PECARN) data from 2007 to 2010. Since height data were not available, children (2-17 years) with obesity were defined using weight-for-age percentiles. Non-parametric testing determined potential confounders. Adjusted odds ratios (aOR) were calculated using binary logistic regression for weight status and IAIs and diagnostic procedures.

RESULTS

There were 3846 patients with actual weight recorded: 3301 (85.8%) children without obesity and 545 (14.2%) with obesity. Children with obesity had decreased odds for IAI after adjusting for race, mechanical force injury (MFI) type, vomiting, and abdominal wall trauma (adjusted odds ratio (aOR)=0.58 (95% CI 0.35-0.97); p-value=0.04). Patients with obesity had reduced odds for a CT examination. No association was found between obesity status and US utilization. African-American patients had decreased odds for IAIs, CT scans and US examinations after adjustment which could be related to MFI type.

CONCLUSIONS

Obesity appears to reduce the odds for pediatric IAIs and CT scans, but not for US examinations. Selection bias is possible due to injury severity and missing or excluded weight data. Further research is needed in other pediatric populations with obesity and blunt injuries.

The relationship between weight indices and injuries and mortalities caused by the motor vehicle accidents: a systematic review and meta-analysis

BACKGROUND

The relationship between weight indices and injuries and mortality in motor vehicle accidents is unknown. Systematic review studies addressing the collection and analysis of the relationship in investigations are very limited. The purpose of this systematic review is to determine the relationship between BMI, obesity and overweight with mortality and injuries and their severity and vulnerable organs after the motor vehicle accident.

METHODS

The databases (MEDLINE/PUBMED, EMBASE, Web of Science, etc) were searched for relevant abstracts using certain keywords. Of all the articles, similar ones were removed considering different filters. The collected data were entered into the STATA SE v 13.1. The heterogeneity of the data was analyzed using i2 statistics. In addition, the estimates of the study were done based on the age group (children and adults) and the impact of obesity on different regions of the body.

RESULTS

A direct relationship was observed between the overall BMI and the degrees of injuries (CI=0.503-1.139), and mortality due to motor vehicle accident (CI=1.267-1.471). A positive relationship was found between obesity and AIS+2 (CI=0.653-1.426), and AIS+3 (CI=1.184-1.741), and ISS (CI=1.086-1.589). Also, a negative relationship between overweight and injuries rates, and a direct relationship between overweight and mortality (CI=0.979-1.167), and injuries with index of AIS+2 (CI=1.178-0.768) and AIS+3 (CI=0.48-2.186) were found.

CONCLUSIONS

The prediction of injury, mortality and severity of injuries in the motor vehicle accident by the variable of obesity and overweight determines the need to design prevention programs for this vulnerable group at all levels.

Obesity in pediatric trauma

BACKGROUND/PURPOSE

The implications of childhood obesity on pediatric trauma outcomes are not clearly established. Anthropomorphic data were recently added to the National Trauma Data Bank (NTDB) Research Datasets, enabling a large, multicenter evaluation of the effect of obesity on pediatric trauma patients.

METHODS

Children ages 2 to 19years who required hospitalization for traumatic injury were identified in the 2013-2014 NTDB Research Datasets. Age and gender-specific body mass indices (BMI) were calculated. Outcomes included injury patterns, operative procedures, complications, and hospital utilization parameters.

RESULTS

Data from 149,817 pediatric patients were analyzed; higher BMI percentiles were associated with significantly more extremity injuries, and fewer injuries to the head, abdomen, thorax and spine (p values <0.001). On multivariable analysis, higher BMI percentiles were associated with significantly increased likelihood of death, deep venous thrombosis, pulmonary embolus and pneumonia; although there was no difference in risk of overall complications. Obese children also had significantly longer lengths of stay and more frequent ventilator requirement.

CONCLUSIONS

Among children admitted after trauma, increased BMI percentile is associated with increased risk of death and potentially preventable complications. These findings suggest that obese children may require different management than nonobese counterparts to prevent complications.

LEVEL OF EVIDENCE

Level III; prognosis study.

Obese children experience more extremity fractures than nonobese children and are significantly more likely to die from traumatic injuries

Two of the most prevalent problems children facing worldwide are injuries and obesity. We conducted a systematic review of published studies that evaluated the effects of obesity on children with traumatic injuries. Six studies published between 2006 and 2014 were identified, comprising a total of 4594 children: 867 were obese and 3727 were not. Obese children were 25% more likely to have extremity fractures than nonobese children (p = 0.003), and their mortality rate was significantly higher at 4.7% versus 2.8% (p = 0.026).

CONCLUSION

Our review showed that obese children were more likely to have extremity fractures and die of traumatic injuries than nonobese children.

The role of Body Mass Index in child pedestrian injury risk

The goal of the current investigation was to examine obesity as a potential risk factor for childhood pedestrian injury. A racially diverse sample of 7- and 8-year-old children completed a road-crossing task in a semi-immersive virtual environment and two pedestrian route selection tasks. Multiple linear regression analyses revealed that children with a higher Body Mass Index (BMI) waited less before crossing, had a smaller temporal buffer between themselves and oncoming traffic while crossing, and had more collisions with traffic. Girls were more cautious than boys when crossing the virtual roadway. Unlike the results from the virtual road-crossing task, BMI was not associated with risky route selection. Instead, race emerged as the strongest predictor, with African-American children selecting riskier routes for crossing. Together, these findings suggest overweight and obese children may be at increased risk for pedestrian injury. The discussion considers explanations for why obese children may exhibit riskier road-crossing behavior.

Evaluation of developmental metrics for utilization in a pediatric advanced automatic crash notification algorithm

OBJECTIVE

Appropriate treatment at designated trauma centers (TCs) improves outcomes among injured children after motor vehicle crashes (MVCs). Advanced Automatic Crash Notification (AACN) has shown promise in improving triage to appropriate TCs. Pediatric-specific AACN algorithms have not yet been created. To create such an algorithm, it will be necessary to include some metric of development (age, height, or weight) as a covariate in the injury risk algorithm. This study sought to determine which marker of development should serve as a covariate in such an algorithm and to quantify injury risk at different levels of this metric.

METHODS

A retrospective review of occupants age < 19 years within the MVC data set NASS-CDS 2000-2011 was performed. R(2) values of logistic regression models using age, height, or weight to predict 18 key injury types were compared to determine which metric should be used as a covariate in a pediatric AACN algorithm. Clinical judgment, literature review, and chi-square analysis were used to create groupings of the chosen metric that would discriminate injury patterns. Adjusted odds of particular injury types at the different levels of this metric were calculated from logistic regression while controlling for gender, vehicle velocity change (delta V), belted status (optimal, suboptimal, or unrestrained), and crash mode (rollover, rear, frontal, near-side, or far-side).

RESULTS

NASS-CDS analysis produced 11,541 occupants age < 19 years with nonmissing data. Age, height, and weight were correlated with one another and with injury patterns. Age demonstrated the best predictive power in injury patterns and was categorized into bins of 0-4 years, 5-9 years, 10-14 years, and 15-18 years. Age was a significant predictor of all 18 injury types evaluated even when controlling for all other confounders and when controlling for age- and gender-specific body mass index (BMI) classifications. Adjusted odds of key injury types with respect to these age categorizations revealed that younger children were at increased odds of sustaining Abbreviated Injury Scale (AIS) 2+ and 3+ head injuries and AIS 3+ spinal injuries, whereas older children were at increased odds of sustaining thoracic fractures, AIS 3+ abdominal injuries, and AIS 2+ upper and lower extremity injuries.

CONCLUSIONS

The injury patterns observed across developmental metrics in this study mirror those previously described among children with blunt trauma. This study identifies age as the metric best suited for use in a pediatric AACN algorithm and utilizes 12 years of data to provide quantifiable risks of particular injuries at different levels of this metric. This risk quantification will have important predictive purposes in a pediatric-specific AACN algorithm.

Do obese children experience more severe fractures than nonobese children? A cross-sectional study from a paediatric emergency department

OBJECTIVES

To determine whether there is an association between childhood obesity and severe extremity fractures. Associations between obesity and complications related to the fracture and/or fracture management were also examined.

METHODS

The present study was a retrospective, cross-sectional study conducted at a tertiary care children's emergency department. Eligible cases for review were children (two to 17 years of age) with an extremity fracture. Severe extremity fractures were defined as those requiring manipulation under anesthesia, open operative repair and/or admission to hospital. The primary outcome was the proportion of severe extremity fractures and the secondary outcome was the proportion of complications.

RESULTS

A total of 1340 charts of children who presented with extremity fracture from January 2008 to December 2010 were reviewed. The mean (± SD) age of the study population was 9.1±4.0 years and 62.1% were male. Overall, 19.9% (95% CI 17.8% to 22.0%) were obese and 39.6% (95% CI 36.7% to 39.1%) sustained a severe extremity fracture. The OR of severe extremity fractures among obese versus nonobese children was 1.00 (95% CI 0.76 to 1.32), adjusted for age, sex and mechanism of injury. In addition, the OR of experiencing complications among obese relative to nonobese children was 1.12 (95% CI 0.68 to 1.85).

CONCLUSIONS

The results of the present study demonstrated that in children with extremity fractures, obese children were not at increased risk for sustaining more severe extremity fractures or subsequent complications compared with nonobese children.

Variation in U.S. traffic safety policy environments and motor vehicle fatalities 1980-2010

OBJECTIVE

To examine the impact of variation in state laws governing traffic safety on motor vehicle fatalities.

STUDY DESIGN

Repeated cross sectional time series design.

METHODS

Fixed effects regression models estimate the relationship between state motor vehicle fatality rates and the strength of the state law environment for 50 states, 1980-2010. The strength of the state policy environment is measured by calculating the proportion of a set of 27 evidence-based laws in place each year. The effect of alcohol consumption on motor vehicle fatalities is estimated using a subset of alcohol laws as instrumental variables.

RESULTS

Once other risk factors are controlled in statistical models, states with stronger regulation of safer driving and driver/passenger protections had significantly lower motor vehicle fatality rates for all ages. Alcohol consumption was strongly associated with higher MVC death rates, as were state unemployment rates.

CONCLUSIONS

Encouraging laggard states to adopt the full range of available laws could significantly reduce preventable traffic-related deaths in the U.S. - especially those among younger individuals. Estimating the relationship between different policy environments and health outcomes can quantify the result of policy gaps.

Effectiveness of booster seats compared with no restraint or seat belt alone for crash injury prevention

OBJECTIVES

The objective was to evaluate the effectiveness of belt-positioning booster seats, compared with no restraint use and with seat belt use only, during motor vehicle crashes among U.S. children.

METHODS

This was a retrospective matched cohort study with data from the 1998 through 2009 National Automotive Sampling System (NASS) Crashworthiness Data System (CDS). The study sample consisted of children aged 0 to 10 years who were not seated in the front seat of the vehicle. We used Cox proportional hazards models to estimate the risk of overall, fatal, and regional body injury.

RESULTS

Children using seat belts in belt-positioning booster seats experienced less overall injury (Injury Severity Score [ISS] > 0, adjusted risk ratio [RR] = 0.73, 95% confidence interval [CI] = 0.55 to 0.96; Abbreviated Injury Scale [AIS] score of 2 or higher, adjusted RR = 0.30, 95% CI = 0.16 to 0.58; ISS > 8, adjusted RR = 0.19, 95% CI = 0.06 to 0.56), and less injury in most body regions except the neck (adjusted RR = 4.79, 95% CI = 1.43 to 16.00) than did children with no restraint use. Children using seat belts in belt-positioning booster seats had an equal risk of injury but higher risks of neck (adjusted RR = 1.86, 95% CI = 1.02 to 3.40) and thorax (adjusted RR = 2.86, 95% CI = 1.33 to 6.15) injury than did children restrained by seat belts only.

CONCLUSIONS

Children using belt-positioning booster seats appear to experience a higher risk of AIS > 0 injury to the neck and thorax than do children using seat belts only. Future research should examine whether the observed increase in neck and thorax injuries can be attributed to improper use of booster seats.

Acute care costs in overweight children: a pediatric urban cohort study

BACKGROUND

Evidence indicates obese children have increased health care utilization. It is unknown if this is true within the emergency department (ED) setting. Our purpose is to determine if overweight children presenting for emergency care have increased resource utilization over normal weight peers.

METHODS

We conducted a retrospective cohort study of children 2 to <18 years old presenting to a pediatric ED in 2007. Overweight was defined as >95th percentile sex-specific weight-for-age, and normal weight was defined as ≤95(th) percentile. We used a subsample validation to compare these study definitions to BMI-based definitions. We compared total billed charges and secondary outcomes of ED length of stay and admission rate using multivariate and logistic regression models. Outcomes were reported for admitted and discharged patients. Four diagnoses were examined for primary and secondary outcomes.

RESULTS

Of 32,996 included visits, 6333 (19.2%) were for overweight children. Study definitions correctly classified 98.3% of normal weight children but only 51.3% of overweight children. Overweight children were more likely to be older, black, and publicly insured. Median charges for overweight and normal weight children, whether discharged or admitted, were not different in the adjusted model. Admitted overweight children with asthma and fractures or dislocations had higher median charges than normal weight $4617 (2065-375,669) versus $4177 (1980-37,432, p=0.01) and $9855 (6681-58,546) versus $8137 (1461-52,557, p=0.01), respectively.

CONCLUSIONS

Overall acute care costs for overweight children are not different from normal weight children. However, admitted overweight children have disease-specific increased use of resources.

Childhood obesity is associated with increased risk of most lower extremity fractures

BACKGROUND

A number of studies have found an increased risk of lower extremity injuries in obese patients. Most studies, however, are unable to provide stable population-based estimates based on the degree of obesity and few assess the risk pertaining to more detailed fracture location in the lower extremities.

QUESTIONS/PURPOSES

We therefore investigated the relationship between obesity and lower extremity fractures in different age and fracture locations in a stable population.

METHODS

This is a population-based, cross-sectional study from the electronic medical records of 913,178 patients aged 2 to 19 years. The body mass index (BMI) for each patient in the cohort was used to stratify patients into five weight classes (underweight, normal weight, overweight, moderate obesity, and extreme obesity) based on BMI for age. Records were assessed for the occurrence of lower extremity fractures for each cohort member. The associations among the five weight classes and specific lower extremity fractures were estimated using multiple logistic regression models and expressed with odds ratios (ORs) and 95% confidence intervals (CIs) using multivariate analysis to adjust for patient demographic variables.

RESULTS

Overweight, moderately obese, and extremely obese patients all had an increased OR of fractures of the foot (OR, 1.14, 1.23, and 1.42, respectively, with 95% CI, 1.04-1.24, 1.12-1.35, and 1.26-1.61, respectively) along with the ankle, knee, and leg (OR, 1.27, 1.28, and 1.51, respectively, with 95% CI, 1.16-1.39, 1.15-1.42, and 1.33-1.72, respectively). The association was strongest in the 6- to 11-year-old age group. We found no association between increasing BMI and increased risk of fractures of the femur and hip.

CONCLUSIONS

Increasing BMI is associated with increased odds of foot, ankle, leg, and knee fractures in children.

LEVEL OF EVIDENCE

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Pediatric obesity and traumatic lower-extremity long-bone fracture outcomes

BACKGROUND

Pediatric obesity is associated with lower-extremity injuries and poor outcomes after blunt trauma. Our aim was to determine if obese pediatric patients with femur and tibia fractures have more severe injury patterns and worse outcomes compared with those of nonobese patients.

METHODS

We performed a retrospective cohort study of obese and nonobese pediatric patients with femur or tibia fractures treated at two Level I trauma centers from 2004 to 2010. Patients weighing 95th percentile or greater for age and sex were classified as obese. Patients were compared regarding demographics, Injury Severity Score (ISS), as well as intra-abdominal and orthopedic injuries. Outcomes included fracture treatment, orthopedic complications, intensive care unit and hospital length of stay, ventilator days, and mortality.

RESULTS

Of the 356 patients included in the study, 78 (21.9%) were obese and 278 (78.1%) were nonobese. Obese patients were older (mean [SD], 9.9 [3.7] years vs. 8.8 [3.9] years; p = 0.0162), had a higher ISS (20.8 [13.4] vs. 14.5 [10.8]; p = 0.0002), and sustained more intra-abdominal solid organ (24.4% vs.13.5%; p = 0.0200) and hollow viscus (3.9% vs. 0.0%; p = 0.0105) injuries. They had more pelvic fractures (15.4% vs. 6.9%; p = 0.0196), bilateral tibia fractures (8.0% vs. 0.0%; p = 0.0332), and operatively treated femur fractures (89.9% vs. 79.1%; p = 0.0484). Adjusting for age, obese patients were more likely to be admitted to the intensive care unit (relative risk, 1.68; 95% confidence interval, 1.10-2.55) and die in the hospital (relative risk, 3.45; 95% confidence interval, 1.14-10.41). Adjusting for ISS, these associations were nonsignificant.

CONCLUSION

Obese patients with femur and tibia fractures have more severe injuries, which may predispose them to greater inpatient morbidity and mortality than do nonobese patients.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Association between weight and risk of crash-related injuries for children in child restraints

OBJECTIVE

To determine the association between weight and the risk of injury in motor vehicle crashes (MVCs) for children 1 through 8 years of age who were using child restraints.

METHODS

This was a cross-sectional study of children 1 to 8 years of age in MVCs, in which cases from the National Automotive Sampling System Crashworthiness Data System were used. Abbreviated Injury Scale scores of ≥2 indicated clinically significant injuries.

RESULTS

The National Automotive Sampling System Crashworthiness Data System study sample included 650 children 1 to 5 years of age in forward-facing child restraints who weighed 20 to 65 lb and 344 children 3 to 8 years of age in belt-positioning booster seats who weighed 30 to 100 lb. With adjustment for seating position, type of vehicle, direction of impact, crash severity, and vehicle model year, there was no association between absolute weight and clinically significant injuries in either age group (odds ratio: 1.17 [95% confidence interval: 0.96-1.42] for children 1-5 years of age in forward-facing child restraints and 1.22 [95% confidence interval: 0.96-1.55] for children 3-8 years of age in belt-positioning booster seats).

CONCLUSIONS

The risk of clinically significant injuries was not associated with weight across a broad weight range in this sample of children in MVCs who were using child restraint systems. Parents should continue to restrain their children according to current recommendations from the American Academy of Pediatrics and the National Highway Traffic Safety Administration.

Child passenger safety

Despite significant reductions in the number of children killed in motor vehicle crashes over the past decade, crashes continue to be the leading cause of death for children 4 years and older. Therefore, the American Academy of Pediatrics continues to recommend inclusion of child passenger safety anticipatory guidance at every health-supervision visit. This technical report provides a summary of the evidence in support of 5 recommendations for best practices to optimize safety in passenger vehicles for children from birth through adolescence that all pediatricians should know and promote in their routine practice. These recommendations are presented in the revised policy statement on child passenger safety in the form of an algorithm that is intended to facilitate their implementation by pediatricians with their patients and families. The algorithm is designed to cover the majority of situations that pediatricians will encounter in practice. In addition, a summary of evidence on a number of additional issues that affect the safety of children in motor vehicles, including the proper use and installation of child restraints, exposure to air bags, travel in pickup trucks, children left in or around vehicles, and the importance of restraint laws, is provided. Finally, this technical report provides pediatricians with a number of resources for additional information to use when providing anticipatory guidance to families.