Partners for child passenger safety: a unique child-specific crash surveillance system

Family challenges in personal transportation of children with medical complexity

PURPOSE

This study aimed to explore the family experience and associated challenges of transporting children with medical complexity (CMC) in personal vehicles.

METHODS

Parents/guardians of CMC in Maryland were recruited to participate in an audiotaped, semi-structured interview. Conventional content analysis was applied to transcripts.

RESULTS

Data from 29 participants who indicated use of personal vehicles to transport their CMC were included in the analysis. Transportation challenges were common, and analysis revealed the following themes: 1) challenges transitioning in/out of the vehicle: excess planning time, child factors (e.g., weight), equipment factors (e.g., wheelchair), physical and environmental factors, 2) safety and comfort: CMC positioning/restraints, driver distraction, 3) financial challenges: travel costs related to medical care, accessible modification costs, transportation equipment costs, insurance delays in equipment coverage, 4) adverse family repercussions: parental physical health, isolation, and 5) evolving and unpredictable transportation needs.

CONCLUSION

Families with CMC experience multifactorial challenges that impact all phases of travel in personal vehicles and negatively impact child and family safety, access to community and medical care, family finances, and overall well-being. Health care providers can support families by identifying transportation challenges that contribute to health inequities, tailoring solutions to the family's unique needs, and advocating at a policy level to promote change.

Methodological considerations in MVC epidemiological research

Background

The global burden of MVC injuries and deaths among vulnerable road users, has led to the implementation of prevention programmes and policies at the local and national level. MVC epidemiological research is key to quantifying MVC burden, identifying risk factors and evaluating interventions. There are, however, several methodological considerations in MVC epidemiological research.

Methods

This manuscript collates and describes methodological considerations in MVC epidemiological research, using examples drawn from published studies, with a focus on the vulnerable road user population of children and adolescents.

Results

Methodological considerations in MVC epidemiological research include the availability and quality of data to measure counts and calculate event rates and challenges in evaluation related to study design, measurement and statistical analysis. Recommendations include innovative data collection (eg, naturalistic design, stepped-wedge clinical trials), combining data sources for a more comprehensive representation of collision events, and the use of machine learning/artificial intelligence for large data sets.

Conclusions

MVC epidemiological research can be challenging at all levels: data capture and quality, study design, measurement and analysis. Addressing these challenges using innovative data collection and analysis methods is required.

Translational Research in Child and Adolescent Transportation Safety

Motor vehicle crash (MVC)–related injury is the leading cause of death among youths age 1 to 19 years. Advances in MVC and injury prevention depend on interrelated combinations of technology, policy, and education, and research on these topics can inform policy and lead to improvement in safety. This article presents two examples of translational research in transportation injury prevention. In the first example of child passenger protection, the authors describe a program of research designed to reduce the gap between the theoretical and practical effectiveness of safety methods. In the second example of novice teen drivers, the authors examine translational research related to two complementary approaches to reducing the exposure of novice teen drivers to high-risk driving conditions—graduated driver licensing policy and parental management of novice teen drivers. The examples suggest the utility of systematic programs of research designed to improve the translation into practice of MVC and injury prevention technology and policy.

Extending the value of police crash reports for traffic safety research: collecting supplemental data via surveys of drivers

BACKGROUND

Police crash reports have been used to advance motor vehicle safety research, though their value is limited by their focus on the crash event rather than outcomes of the crash.

OBJECTIVE

To develop and evaluate the effect of enhanced recruitment methods, including a monetary incentive, on response rates of drivers identified on police reports in a national MVC surveillance system.

METHODS

The National Automotive Sampling System-General Estimates System (NASS-GES) was used to identify passenger vehicle crashes between 1 July and 30 October 2012 involving drivers ≥16 years old with at least one child occupant ≤17 years old. We collected data from the driver via self-administered hardcopy or interviewer-administered telephone surveys. Within each survey mode, half the drivers were randomly assigned to receive a small monetary incentive. Response rates were calculated overall, and by mode of survey administration and incentive condition.

RESULTS

495 drivers were eligible, and 127 completed the survey, yielding an overall response rate of 25.7% (95% CI 21.8% to 29.5%). The response rate across the two modes was higher for those who received an incentive than for those who did not (35.6% vs 15.7%, p<0.01). The highest response rate (45.9%) was for drivers allocated to the telephone survey who received an incentive.

CONCLUSIONS

The NASS-GES provides a surveillance system from which cases of interest can be identified and supplemental data collected via surveys of drivers identified on police reports. We adapted procedures commonly used in public health surveillance systems, including monetary incentives and branded recruitment materials, to improve driver response rates.

Infant car safety seats and risk of head injury

BACKGROUND/PURPOSE

We observed a high incidence of traumatic brain injuries (TBI) in properly restrained infants involved in higher speed motor vehicle crashes (MVCs). We hypothesized that car safety seats are inadequately protecting infants from TBI.

METHODS

We retrospectively queried scene crash data from our State Department of Transportation (2007-2011) and State Department of Public Health data (2000-2011) regarding infants who presented to a trauma center after MVC.

RESULTS

Department of Transportation data revealed 94% of infants in MVCs were properly restrained (782/833) with average speed of 44.6 miles/h when there was concern for injury. Department of Public Health data showed only 67/119 (56.3%) of infants who presented to a trauma center after MVC were properly restrained. Properly restrained infants were 12.7 times less likely to present to a trauma center after an MVC (OR=12.7, CI 95% 5.6-28.8, p<0.001). TBI was diagnosed in 73/119 (61.3%) infants; 42/73 (57.5%) properly restrained, and 31/73 (42.5%) improperly/unrestrained (p=0.34). Average head abbreviated injury scale was similar for properly restrained (3.2±0.2) and improperly/unrestrained infants (3.5±0.2, p=0.37).

CONCLUSION

Car safety seats prevent injuries. However, TBI is similar among properly restrained and improperly/unrestrained infants involved in higher speed MVCs who present to a trauma center.

Validation of a parent survey for reporting child injuries

OBJECTIVE

To evaluate the validity of a parent-reported survey to identify children's moderate and serious injuries in seven specific body regions using medical records as the 'gold standard'.

METHODS

A prospective validation study was conducted in three urban paediatric emergency departments (EDs). 798 parents of 859 children treated for injuries at participating EDs between August 2010 and July 2011 completed either a telephone interview or self-administered paper survey at 2 weeks post-ED visit. Parents were asked to report child injuries to seven body regions: head, face, neck/spine/back, thorax, abdomen, upper extremities and lower extremities. Injury data were abstracted from medical records using a standardised protocol. Body region injury severity levels of none/minor, moderate or serious were assigned to each subject based on the Abbreviated Injury Scale.

RESULTS

The overall sensitivity, reflecting parents' ability to identify a documented moderate or greater severity injury, was 0.95 (95% CI 0.92 to 0.97). Sensitivities were >0.90 for the face, upper extremity and lower extremity regions; 0.80-0.90 for head, abdomen and neck/back/spine regions; and <0.60 for the thorax region. The overall sensitivity for identification of a serious injury was 0.71 (0.60 to 0.80).

CONCLUSIONS

This survey enables parents to accurately identify moderate and greater severity injuries to body regions, though it does not accurately identify serious injuries in most body regions except the extremities. The survey could serve as a screening tool to identify moderate and greater severity injuries in population-based surveillance systems, or as the primary outcome of interest in injury prevention studies.

Importance of muscle activations for biofidelic pediatric neck response in computational models

OBJECTIVE

During dynamic injury scenarios, such as motor vehicle crashes, neck biomechanics contribute to head excursion and acceleration, influencing head injuries. One important tool in understanding head and neck dynamics is computational modeling. However, realistic and stable muscle activations for major muscles are required to realize meaningful kinematic responses. The objective was to determine cervical muscle activation states for 6-year-old, 10-year-old, and adult 50th percentile male computational head and neck models. Currently, pediatric models including muscle activations are unable to maintain the head in an equilibrium position, forcing models to begin from nonphysiologic conditions. Recent work has realized a stationary initial geometry and cervical muscle activations by first optimizing responses against gravity. Accordingly, our goal was to apply these methods to Duke University's head-neck model validated using living muscle response and pediatric cadaveric data.

METHODS

Activation schemes maintaining an upright, stable head for 22 muscle pairs were found using LS-OPT. Two optimization problems were investigated: a relaxed state, which minimized muscle fatigue, and a tensed activation state, which maximized total muscle force. The model's biofidelity was evaluated by the kinematic response to gravitational and frontal impact loading conditions. Model sensitivity and uncertainty analyses were performed to assess important parameters for pediatric muscle response. Sensitivity analysis was conducted using multiple activation time histories. These included constant activations and an optimal muscle activation time history, which varied the activation level of flexor and extensor groups, and activation initiation and termination times.

RESULTS

Relaxed muscle activations decreased with increasing age, maintaining upright posture primarily through extensor activation. Tensed musculature maintained upright posture through coactivation of flexors and extensors, producing up to 32 times the force of the relaxed state. Without muscle activation, the models fell into flexion due to gravitational loading. Relaxed musculature produced 28.6-35.8 N of force to the head, whereas tensed musculature produced 450-1023 N. Pediatric model stiffnesses were most sensitive to muscle physiological cross-sectional area.

CONCLUSIONS

Though muscular loads were not large enough to cause vertebral compressive failure, they would provide a prestressed state that could protect the vertebrae during tensile loading but might exacerbate risk during compressive loading. For example, in the 10-year-old, a load of 602 N was produced, though estimated compressive failure tolerance is only 2.8 kN. Including muscles and time-variant activation schemes is vital for producing biofidelic models because both vary by age. The pediatric activations developed represent physiologically appropriate sets of initial conditions and are based on validated adult cadaveric data.

Grandparents driving grandchildren: an evaluation of child passenger safety and injuries

OBJECTIVES

To compare restraint-use practices and injuries among children in crashes with grandparent versus parent drivers.

METHODS

This was a cross-sectional study of motor vehicle crashes that occurred from January 15, 2003, to November 30, 2007, involving children aged 15 years or younger, with cases identified via insurance claims and data collected via follow-up telephone surveys. We calculated the relative risk of significant child-passenger injury for grandparent-driven versus parent-driven vehicles. Logistic regression modeling estimated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for several child occupant, driver, vehicle, and crash characteristics.

RESULTS

Children driven by grandparents comprised 9.5% of the sample but resulted in only 6.6% of the total injuries. Injuries were reported for 1302 children, for an overall injury rate of 1.02 (95% CI: 0.90-1.17) per 100 child occupants. These represented 161 weighted injuries (0.70% injury rate) with grandparent drivers and 2293 injuries (1.05% injury rate) with parent drivers. Although nearly all children were reported to have been restrained, children in crashes with grandparent drivers used optimal restraint slightly less often. Despite this, children in grandparent-driven crashes were at one-half the risk of injuries as those in parent-driven crashes (OR: 0.50 [95% CI: 0.33- 0.75]) after adjustment.

CONCLUSIONS

Grandchildren seem to be safer in crashes when driven by grandparents than by their parents, but safety could be enhanced if grandparents followed current child-restraint guidelines. Additional elucidation of safe grandparent driving practices when carrying their grandchildren may inform future child-occupant driving education guidelines for all drivers.

Factors associated with clinically significant head injury in children involved in motor vehicle crashes

OBJECTIVE

Head injury is the most common cause of death for child occupants in motor vehicle crashes (MVCs). The morbidity associated with nonlethal MVC-related head injuries is of great clinical consequence as well. The purpose of this study was to identify the frequency of, and risk factors for, clinically significant head injury (CSHI) in child occupants in MVCs.

METHODS

A large, child-specific crash surveillance system linking insurance claims data to telephone survey data was utilized. Qualifying crashes involved model year 1990 or newer vehicles in crashes with one or more child occupants (age 4 to 15 years) occurring in 15 U.S. states. Data were accrued between March 2000 and December 2007. A probability sample of crashes was selected for telephone survey with the driver of the insured vehicle. A clinically significant head injury, as reported by the child's parent using a validated survey, included concussions, skull fractures, and intracranial hemorrhages. Multivariate logistic regression was used to identify factors associated with a CSHI.

RESULTS

During the period of study, completed interviews were obtained on 19,075 children aged 4-15, representing 318,527 children involved in 219,511 crashes. The overall rate of CSHI in child occupants was 1.08 percent. Factors associated with an increased risk of head injury included rollover (odds ratio [OR] = 8.60, 95% confidence interval [CI] 6.40-11.57) and near-side impact crashes (OR = 2.39, 95% CI 1.73-3.30) vs. frontal impact; lack of restraint (OR = 3.13, 95% CI 2.26-4.33) vs. restrained; and driver age < 25 years (OR = 1.43, 95% CI 1.12-1.81) vs. driver age ≥ 25 years. Some factors varied based on occupant age, and younger child age had a protective effect on the risk for head injury.

CONCLUSION

The risk of CSHI for 4- to 15-year-old child occupants was 1.08 percent. Several demographic and crash factors were associated with CSHI in child occupants. This information may help inform design safety initiatives.

Restraint use and seating position among children less than 13 years of age: Is it still a problem?

INTRODUCTION

The purpose of this study was to calculate national estimates and examine the extent to which children prematurely use adult seat belts and ride in the front seat of a vehicle during a 30 day period.

METHODS

Data were obtained from a nationally representative cross-sectional random-digit-dial telephone survey that included child-specific questions on motor vehicle restraint use and seating position.

RESULTS

Among children less than 13 years, parents reported an estimated 618,337 who rode unrestrained and more than one million who rode in the front seat of a vehicle at least some of the time in the past 30 days. During the same time period, close to 11 million children 8 years and younger reportedly used only adult seat belts.

DISCUSSION

Our results highlight the need for continued outreach to parents regarding optimal restraint use and rear seating position for children every trip, every time.

Making the most of the worst-case scenario: should belt-positioning booster seats be used in lap-belt-only seating positions?

OBJECTIVE

Examine real-world crash injury data to determine whether children seated with lap belts only are better protected with or without belt-positioning booster seats.

METHODS

Crash injury rates among booster-age children were examined for three restraint categories: lap belt only, belt-positioning booster seat with lap belt, and booster seat with lap/shoulder belt. Data were drawn from the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) and the Partners for Child Passenger Safety (PCPS) crash surveillance system for years 1997-2006 and 1998-2006, respectively. Main outcome measures were the percentage of crash-involved booster-age children with moderate or greater injury (maximum abbreviated injury score [MAIS] 2+).

RESULTS

The estimated risk of MAIS 2+ injury among children restrained with lap belts and boosters was 0.12 percent (NASS-CDS) and 0.96 percent (PCPS), compared with 1.21 and 1.74 percent, respectively, for lap belts only. This difference was not significant due to small numbers of children in lap belts with boosters. In PCPS, children restrained by lap/shoulder belts and boosters had lower injury risk than children restrained by lap belts, with or without boosters.

CONCLUSIONS

Although data for children secured in lap belts with boosters are limited, the results suggest that boosters are not harmful. This finding is inconsistent with the current recommendation that booster seats not be used when children must be buckled with lap belts only. Data also confirm that booster seats with lap/shoulder belts remain the optimal protection for booster-age children.

Effectiveness of belt positioning booster seats: an updated assessment

OBJECTIVE

The objective of this study was to provide an updated estimate of the effectiveness of belt-positioning booster (BPB) seats compared with seat belts alone in reducing the risk for injury for children aged 4 to 8 years.

METHODS

Data were collected from a longitudinal study of children who were involved in crashes in 16 states and the District of Columbia from December 1, 1998, to November 30, 2007, with data collected via insurance claims records and a validated telephone survey. The study sample included children who were aged 4 to 8 years, seated in the rear rows of the vehicle, and restrained by either a seat belt or a BPB seat. Multivariable logistic regression was used to determine the odds of injury for those in BPB seats versus those in seat belts. Effects of crash direction and booster seat type were also explored.

RESULTS

Complete interview data were obtained on 7151 children in 6591 crashes representing an estimated 120646 children in 116503 crashes in the study population. The adjusted relative risk for injury to children in BPB seats compared with those in seat belts was 0.55.

CONCLUSIONS

This study reconfirms previous reports that BPB seats reduce the risk for injury in children aged 4 through 8 years. On the basis of these analyses, parents, pediatricians, and health educators should continue to recommend as best practice the use of BPB seats once a child outgrows a harness-based child restraint until he or she is at least 8 years of age.

Front versus rear seat injury risk for child passengers: evaluation of newer model year vehicles

OBJECTIVE

Design improvements to frontal air bags for vehicles of model year 1998 and newer have reduced the risk of injury to child occupants exposed to their deployment. These changes in conjunction with other improvements in the protection of front seat occupants give impetus for the reconsideration of rear seating recommendations for child occupants. Thus, the objective of this study was to evaluate the association between seating row (front vs. rear) and risk of injury to children in newer model year vehicles.

METHODS

Data was collected on child occupants from December 1, 1998, to November 30, 2007, via insurance claim records and a validated telephone survey. The study sample included child occupants aged 0 to 15 years seated in the front and rear rows of vehicles model year 1998 or newer, involved in a crash in sixteen states. Children were classified as injured if a parent or driver reported an injury corresponding with Abbreviated Injury Scale scores of > or =2. The age-specific relative risk of injury by seat row was calculated for the whole data set and then further stratified by model year.

RESULTS

Complete interview data were obtained on 10,670 crashes involving 16,920 children, representing an estimated 205,408 crashes with 314,968 child passengers in the study population. The adjusted relative risk of injury to children in the rear seat compared to those in the front was 0.36 (0.23-0.57) and 0.69 (0.49-0.98) for 0- to 8-year-olds and 9- to 12-year-olds, respectively. For 13- to 15-year-olds, the reduced injury risk associated with rear row seating narrowly missed statistical significance. When stratified by model year (1998 to 2002 and 2003+), all age group/model year combinations demonstrated a crude rear row injury risk that was lower than that of the front row.

CONCLUSIONS

This analysis, conducted on a set of vehicles with advanced front seat safety systems including second-generation and newer air bags, strongly confirmed the recommendation that all children 0-12 years should be seated in the rear row(s) of their vehicles. Children in the rear row(s) were one half to two thirds as likely to sustain injury than those in the front after adjusting for potentially confounding crash, vehicle, and child factors.

Short-term physical limitations in children following motor vehicle crashes

This study describes frequency of injury and short-term physical limitation among child occupants </=15 years in motor vehicle crashes and examines the association between age, restraint use, seating position, and type of crash on the presence of physical limitations. Conducted from 1/1/2005-11/30/2007, as part of a child-specific crash surveillance system in 15 U.S. states; data were collected using claims records and parent/driver telephone surveys. Respondents were asked whether children sustained physical limitations from the crash and the duration limitations persisted. Overall, 3.3% had>or=1 physical limitations. Limitations increased with age, from 0.7% for children<or=3 years to 7.6% for adolescents 13-15 years (p<0.001). Among children with AIS>or=2 injuries, the proportion with physical limitations ranged from 58% to 91% depending on injury diagnosis. Among children with whiplash, 47% resulted in physical limitations. Suboptimally restrained children were nearly twice as likely to have a limitation compared to optimally restrained children. After adjusting for driver characteristics and vehicle type, child's age, restraint use, and type of initial impact were independently associated with the presence of physical limitations. Our results show the importance of assessing children for physical limitations following motor vehicle crashes. We also observed that children with whiplash were at risk for physical limitations.

Injuries to belted older children in motor vehicle crashes

CONTEXT

The American Academy of Pediatrics and the National Highway Traffic Safety Administration currently recommend that, unless they are under 57in. in height, 8-12-year-old children use seat belts and all should ride in the rear seats of vehicles. These recommendations assume that the vehicle seat belt should provide adequate protection for these older children in the event of a crash.

OBJECTIVES

To describe characteristics of older children in the rear seat using seat belts in crashes, to estimate their risk and body region distribution of injury, and to identify risk factors for injury.

METHODS

A representative sample of 6680 seat belt-restrained occupants, 8-12 years of age, seated in the rear seat during crashes involving insured vehicles in 16 US states between December 1998 and December 2007. A telephone interview was conducted with the driver of each vehicle. The main outcome was the parent-reported injury defined as Abbreviated Injury Scale (AIS) 2 or greater injuries.

RESULTS

The risk of injury for belted 8-12 year olds in the rear seat was 1.3%. Head injury was the most common injury (60%), followed by injuries to the face (9%), upper extremity (9%) and abdomen (9%). One out of five (21%) 8-12 year olds either did not use the shoulder portion of the vehicle seat belt or placed it incorrectly behind their back or under their arm. Bivariate analyses indicated a higher risk of injury for these children (1.8%) as compared to children using both the lap and shoulder portions of the seat belt (1.1%). However, this difference was not statistically significant when other risk factors such as crash severity and characteristics of the driver were considered.

CONCLUSIONS

Injuries to the head, face, abdomen and upper extremity are the most common injuries to target for improved protection among 8-12 year olds in seat belts. Driver and crash characteristics are important risk factors for injury. A recent federal motor vehicle safety standard requiring lap and shoulder belts in all rear seat positions has the potential to further decrease the risk of injury to older children using seat belts.

Seating patterns and corresponding risk of injury among 0- to 3-year-old children in child safety seats

OBJECTIVE

Current guidelines for optimal restraint of children in motor vehicles recommend the center rear seating location for installing a child-restraint system. However, recent research on child occupants in child-restraint system has brought this into question. The objective of this study was to describe seating position patterns among appropriately restrained child occupants aged 0 to 3 years in the rear row of vehicles. In addition, we determined the association between rear row seating location and risk of injury.

METHODS

We studied data collected on child occupants from December 1, 1998, to December 31, 2006, via insurance claim records and a validated telephone survey. The study sample included child occupants aged 0 to 3 years seated in a child-restraint system in the rear row of the vehicle, model year 1990 or newer, involved in a crash in 16 states. Children were classified as injured if a parent or driver reported an injury corresponding with Abbreviated Injury Scale scores of > or = 2.

RESULTS

Seating position distribution for child occupants was as follows: left outboard (31%), center (28%), and right outboard (41%). There was an inverse relationship between the center position and increasing child age (39% for occupants < 1 year old versus 18% for occupants 3 years old), independent of the number of additional row occupants. Child occupants seated in the center had an injury risk 43% less than children seated in either of the rear outboard positions.

CONCLUSIONS

The most common seating position for appropriately restrained child occupants in a child-restraint system is the right rear outboard. The center rear seating position is used less often by children restrained by a child-restraint system as they get older. Children seated in the center rear have a 43% lower risk of injury compared with children in a rear outboard position.

Medicaid-based child restraint system disbursement and education and the vaccines for children program: comparative cost-effectiveness

OBJECTIVE

Low-income children are disproportionately at risk for preventable motor-vehicle injury. Many of these children are covered by Medicaid programs placing substantial economic burden on states. Child restraint systems (CRSs) have demonstrated efficacy in preventing death and injury among children in crashes but remain underutilized because of poor access and education. The objective of this study was to evaluate the cost-effectiveness of Medicaid-based reimbursement for CRS disbursement and education for low-income children and compare it with vaccinations covered under the Vaccines For Children (VFC) program.

METHODS

A cost-effectiveness analysis was performed of Medicaid reimbursement for CRS disbursement/education for low-income children based on data from public and private databases. Primary outcomes measured include cost per life-year saved, death, serious injury, and minor injury averted, as well as medical, parental work loss, and future productivity loss costs averted. Cost-effectiveness calculations were compared with published cost-effectiveness data for vaccinations covered under the VFC program.

RESULTS

The adoption of a CRS disbursement/education program could prevent up to 2 deaths, 12 serious injuries, and 51 minor injuries per 100,000 low-income children annually. When fully implemented, the program could save Medicaid over $1 million per 100,000 children in direct medical costs while costing $13 per child per year after all 8 years of benefit. From the perspective of Medicaid, the program would cost $17,000 per life-year saved, $60,000 per serious injury prevented, and $560,000 per death averted. The program would be cost saving from a societal perspective. These data are similar to published vaccination cost-effectiveness data.

CONCLUSION

Implementation of a Medicaid-funded CRS disbursement/education program was comparable in cost-effectiveness with federal vaccination programs targeted toward similar populations and represents an important potential strategy for addressing injury disparities among low-income children.

Mechanisms of abdominal organ injury in seat belt-restrained children

BACKGROUND

Previous research has identified key predictors of elevated abdominal injury risk in seat belt-restrained child vehicle occupants; however these data cannot be used to isolate specific mechanisms or sources of injury to suggest strategies for prevention.

METHODS

Using a large child-focused crash surveillance system, cases of seat belt-restrained children who sustained an internal abdominal injury in a frontal crash were studied using standard crash investigation protocols. A second group of cases of restrained children in similar crashes without abdominal injury was investigated. Medical, crash, and child characteristics of each case were analyzed in the context of known biomechanics of abdominal injury to determine the mechanisms of injury and associated kinematics.

RESULTS

Review of 21 cases of abdominal injury identified belt loading directly over the injured organ as the most common mechanism of injury. Three unique kinematic patterns were identified that varied by the initial position of the lap belt and kinematics of the upper torso. Sixty percent of the drivers and 90% of the other child occupants in these crashes sustained either no or minor injury. In the 16 no abdominal injury cases, all but one sustained external bruising to their abdomen and contact injury to the head and face.

CONCLUSIONS

This evaluation of crashes in which belted children did and did not sustain abdominal injuries revealed key characteristics about their mechanism. In this data set, belt compression directly on the abdomen, manifested by improper initial placement of the seat belt, poor child posture, or misuse of the shoulder belt, resulted in abdominal injury in low-severity crashes in which other occupants sustained little injury. The cases pointed to control of torso excursion by consistent use of the shoulder belt and suggested that technologies such as lap belt pretensioners or belt-positioning booster seats might be a possible strategy, among others, for prevention.

Parent driver characteristics associated with sub-optimal restraint of child passengers

OBJECTIVES

To identify parent driver demographic and socioeconomic characteristics associated with the use of sub-optimal restraints for child passengers under nine years.

METHODS

Cross-sectional study using in-depth, validated telephone interviews with parent drivers in a probability sample of 3,818 vehicle crashes involving 5,146 children. Sub-optimal restraint was defined as use of forward-facing child safety seats for infants under one or weighing under 20 lbs, and any seat-belt use for children under 9.

RESULTS

Sub-optimal restraint was more common among children under one and between four and eight years than among children aged one to three years (18%, 65%, and 5%, respectively). For children under nine, independent risk factors for sub-optimal restraint were: non-Hispanic black parent drivers (with non-Hispanic white parents as reference, adjusted relative risk, adjusted RR = 1.24, 95% CI: 1.09-1.41); less educated parents (with college graduate or above as reference: high school, adjusted RR = 1.27, 95% CI: 1.12-1.44; less than high school graduate, adjusted RR = 1.36, 95% CI: 1.13-1.63); and lower family income (with $50,000 or more as reference: <$20,000, adjusted RR = 1.23, 95% CI: 1.07-1.40). Multivariate analysis revealed the following independent risk factors for sub-optimal restraint among four-to-eight-year-olds: older parent age, limited education, black race, and income below $20,000.

CONCLUSIONS

Parents with low educational levels or of non-Hispanic black background may require additional anticipatory guidance regarding child passenger safety. The importance of poverty in predicting sub-optimal restraint underscores the importance of child restraint and booster seat disbursement and education programs, potentially through Medicaid.

A Latent Class Analysis of Injury Patterns Among Rear-Seated, Seat-Belted Children

BACKGROUND

The objective of the study was to determine the constellation of injury patterns in rear-seated, seat-belt-restrained children using data-driven latent class methodology novel to injury prevention research.

METHODS

A cross-sectional probability sample of rear-seated, belt-restrained children aged 5 to 15 years in crashes was obtained via insurance claims records and a telephone survey. Eight body regions of AIS 2 or greater injury (concussion, nonconcussive head injury, face, chest, abdomen, neck/spine/back, upper extremity, lower extremity) were determined, and a latent class model was fit to determine whether underlying "injury clusters" were present.

RESULTS

A three-class model appears to best fit to observed data: an "abdominal/spine" cluster that contained 11% of the population, a "concussion" cluster that contained 56% of the population, and a residual "mixture" cluster that contained the remaining 33% of the population. When compared with the mixture cluster, the abdomen/spine cluster was associated with 4 to 8 year old children, lap-only belt restraint, frontal impacts, and minivans. The concussion cluster was also more common among 4 to 8 and 9 to 12 year olds, with side or rear impact crashes, and with pickup trucks.

CONCLUSIONS

Latent class analysis allows injury clusters to be estimated from the data, not predetermined by the investigator, and suggests that distinct mechanisms of abdominal injury and concussive head injury exist in a population-based sample of children in motor vehicle crashes.

Tipping the scales: obese children and child safety seats

OBJECTIVE

To shed light on the extent to which childhood obesity affects the types of appropriate child safety seats for young children, by providing an estimate of the number of US children whose weight renders them unable to use safely the majority of child safety seat types currently available.

METHODS

The types of appropriate child safety seats were assessed by using National Highway Traffic Safety Administration 2005 Child Safety Seat Ease of Use Ratings. Estimates of the numbers of children weighing above the maximal weight for those child safety seats were calculated by using the tabulations of growth curves based on National Health and Nutrition Examination Survey 1999 to 2000 data that were assembled by the National Center for Health Statistics and the US Census for the year 2000.

RESULTS

A total of 283,305 children 1 to 6 years of age would have a difficult (if not impossible) time finding a safe child safety seat because of their age and weight. The vast majority of these children are 3 years of age and weigh >40 lb (182,661 children). For these children, there are currently only 4 child safety seat types available, each of which costs between $240 and $270.

CONCLUSIONS

This study determined that there is limited availability of child safety seat types for the ever-increasing number of obese young children. There are substantial numbers of children who weigh more than the upper weight limit for most currently available child safety seats. While we await reductions in the childhood obesity epidemic, options for maximizing the protection of obese children in automobiles must be identified.

Delta V as a predictor of significant injury for children involved in frontal motor vehicle crashes

OBJECTIVE

The objective of this study was to examine the association between delta V and risk of injury to children involved in frontal motor vehicle crashes.

BACKGROUND

Previous studies, primarily focused on adult occupants, have demonstrated the relationship between crash severity, as measured by delta V and injury severity. As children have unique safety needs, these results cannot be directly applied to the pediatric population.

METHODS

Case series crash investigation data and clinical injury information were reviewed from a child-focused crash surveillance system. Analyses were performed examining the relationship between the estimated delta V and any AIS > or = 2 or any AIS > or = 3 injury.

RESULTS

Detailed crash investigation and clinical data were available on 407 children involved in 235 frontal crashes. The average delta V for all crashes was 29 +/- 16.9 kph [18 +/- 10.5 mph (range, 5-123 kph)]. Delta V was strongly and positively associated with the odds of both an AIS > or = 2 and AIS > or = 3 injury (P < 0.0001). The adjusted odds of at least one AIS > or = 2 injury increased on average by 56% (95% confidence interval [CI], 33%-85%) for each 10 kph increase in delta V. Similarly, the adjusted odds of at least one AIS > or = 3 injury increased on average by 67% (95% CI, 40%-102%) for each 10 kph increase in delta V. The delta V at which 50% of child occupants would be expected to sustain any AIS > or = 2 injury was 37 kph [23.0 mph (95% CI, 32-45 kph)], and any AIS > or = 3 injury was 63 kph [39.1 mph (95% CI, 51-infinity kph)].

CONCLUSION

Delta V is strongly predictive of injury risk for child occupants. As many newer generation cars are now fitted with event data recorders, this information is increasingly available and may become useful as a clinical predictor.

Trip characteristics of vehicle crashes involving child passengers

OBJECTIVES

To describe the trip characteristics of vehicle crashes involving children, and to examine the effect of situational factors on front row seating or inappropriate restraint for young children.

METHODS

A cross sectional study was conducted on children <16 years in crashes of insured vehicles in 15 US states, with data collected using insurance claims records and a telephone interview. A descriptive analysis of the characteristics of vehicle crashes involving children was performed. Multivariate Poisson regression was used to identify situational factors associated with inappropriate restraint or front row seating.

RESULTS

These data suggest that children were traveling in vehicles involved in crashes that occurred under usual driving circumstances-that is, closer to home (60%), on a local road (56%), during normal daytime hours (71%), within areas with relatively lower posted speed limits (76%). Compared with children involved in morning crashes, those in daytime crashes (RR = 1.65, 95% CI 1.13 to 2.49) or in night-time crashes (RR = 1.63, 95% CI 1.09 to 2.67) were more likely to be sitting in the front seat. Children involved in night-time crashes were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.01 to 1.22) than those in daytime crashes. Children riding with two or more additional passengers were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.02 to 1.27) than those with no other passengers.

CONCLUSIONS

Educational initiatives should aim to increase the perception that parents have about the potential crash risk of everyday trips. Some situational characteristics of trips were associated with inappropriate restraint and front row seating behaviors for young children.

Child passenger injury risk in motor vehicle crashes: a comparison of nighttime and daytime driving by teenage and adult drivers

INTRODUCTION

To examine the association between child passenger injury risk, restraint use, and crash time (day vs. night) for children in crashes of vehicles driven by teenage versus adult drivers.

METHODS

Cross-sectional study involving telephone interviews with insured drivers in a probability sample of 6,184 crashes involving 10,028 children.

RESULTS

Child passengers in teen nighttime crashes had an increased injury risk and an increased risk of restraint nonuse compared with those in teen daytime crashes. This increased injury risk can be explained by differences in the age of child passengers, collision type, and child passenger's restraint status associated with time of day.

CONCLUSIONS

In order to limit the risk of injury to child passengers driven by teens, Graduated Driver Licensing (GDL) laws should include provisions restricting nighttime driving, as well as mandates for age-appropriate restraint for child passengers. Consideration should also be given for education in child passenger safety for novice teen drivers as part of the licensing process.

IMPACT ON INDUSTRY

Results of this study can be used to support advocacy efforts by the automotive industry and others to promote nighttime driving restrictions on novice drivers. In addition, given that both driver groups were more likely to be involved in a single-vehicle collision during the night, technologies such as electronic stability control may offer opportunities for protection. Further reseach on specific circumstances of teen nighttime crashes is needed to inform industry efforts to improve visibility or vehicle operation under poor lighting conditions.

Risk of injury to child passengers in sport utility vehicles

OBJECTIVE

The popularity of sport utility vehicles (SUVs) is growing, and they are increasingly being used as family vehicles. Because of the large size of SUVs, relative to passenger cars, parents may perceive that they are safer family vehicles. However, little is known about the safety of children in SUVs, compared with passenger cars. The objective of this study was to determine the relative risk of injury to children involved in crashes in SUVs, compared with those in passenger cars.

DESIGN

From an on-going motor vehicle crash surveillance system, a probability sample of 3922 child occupants 0 to 15 years of age, representing 72396 children in crashes of either SUVs or passenger cars (model year 1998 or newer), from 3 large US regions, was identified between March 1, 2000, and December 31, 2003. Injuries were defined as concussions and other brain injuries, spinal cord injuries, facial fractures and lacerations, internal organ injuries, extremity fractures, and scalp lacerations. Logistic regression modeling was used to compute the odds ratio (OR) of injury for children in SUVs versus passenger cars, both unadjusted and adjusted for several potential confounders, including differences in child seating position, restraint use, vehicle weight, exposure of the child to a passenger airbag, and whether the vehicle rolled over.

RESULTS

A total of 38.2% of children were in SUVs and 61.8% were in passenger cars. The average weight of SUVs was 1317 lb greater than the average weight of passenger cars. Among all children in the study, those restrained appropriately were less likely to be injured (OR: 0.25; 95% confidence interval [CI]: 0.15-0.45) and those in the front seat were more likely to be injured (OR: 2.06; 95% CI: 1.33-3.21). In both vehicle types, children exposed to a passenger airbag were more likely to be injured than were those who were not (OR: 4.70; 95% CI: 2.36-9.37). Rollover crashes increased the risk of injury in both vehicle types (OR: 3.29; 95% CI: 1.88-5.76) and occurred more than twice as frequently with SUVs (2.9%, compared with 1.2% with passenger cars). There was a trend for increasing vehicle weight being a protective factor with both vehicle types (OR: 0.86; 95% CI: 0.73-1.01). After adjustment for all of the aforementioned factors, the risk of injury was not significantly different for children in SUVs versus passenger cars (adjusted OR: 1.50; 95% CI: 0.88-2.57). Especially detrimental for children in SUVs was being unrestrained versus restrained in a rollover crash (OR: 24.99; 95% CI: 6.68-93.53).

CONCLUSIONS

Despite the greater vehicle weight of SUVs, the risk of injury for children in SUVs is similar to that for children in passenger cars. The potential advantage offered by heavier SUVs seems to be offset by other factors, including an increased tendency to roll over. Age-appropriate child restraint and rear seat positioning are important, particularly for children in SUVs, given the very high risk of injury for children restrained inappropriately in rollover crashes.

Field investigation of child restraints in side impact crashes

OBJECTIVE

Various test procedures have been suggested for assessing the protection afforded by child restraints (CRS) in lateral collisions. Analyses of real world crashes can be used to identify relevant characteristics of the child, restraint, collision, and injury mechanisms that should be incorporated into the design of the test procedures as well as in the design of related ATDs and injury metrics. The objective of this work is to use in-depth crash investigations of children restrained in CRS in side impacts to elucidate specific sources and mechanisms of injuries and explore the role of crash severity variables such as magnitude and location of intrusion and specific impact angle.

METHODS

Real world crashes involving children restrained in forward facing CRS in side impacts were analyzed from Partners for Child Passenger Safety, an on-going child specific crash surveillance system in which insurance claims are used to identify cases. In-depth crash investigations using standardized protocols were used to calculate the crash severity and determine the mechanisms and sources of the injuries sustained.

RESULTS

Cases of 32 children restrained in CRS in 30 side impact crashes were examined. Twenty-five percent sustained AIS 2+ injuries. The most common injuries sustained by children restrained in CRS in side impact crashes were to the face, head, and lower extremity. Characteristics of the crashes that appeared related to injury were intrusion that entered the child's occupant space or caused an interior part of the vehicle to enter the child's occupant space, forward component of the crash, and the rotation of the CRS, restrained by a seat belt, towards the side of the impact.

CONCLUSIONS

The ability to assess the injury potential in a laboratory setting for the body regions of common injury, the head, face, and lower extremity, must be explored. Characteristics of a regulatory-based test procedure to assess injury risk should include a frontal component to the crash and intrusion into the occupant's seating position. Design enhancements of the CRS should address rotation during lateral impacts. These results provide guidance to current efforts to design and regulate these restraints for the safety of child passengers in side impacts.

Child passenger safety and the immunity fallacy: Why what we are doing is not working

Motivating parents to take certain safety precautions when traveling with their children remains an elusive challenge for advocates, as caregiver naiveté contributes to poor parental participation in safety-seat checks, low booster-seat use, poor adherence to rear-seat positioning, and intermittent safety-belt use. Because of inherent human biases and unfortunate characteristics of vehicle travel, it is argued that most caregivers possess an immunity fallacy, or a reduced perception of risk for motor vehicle injury to their children. Consequently, traditionally designed child passenger safety campaigns, which are primarily informational, fail to have an impact on most parents. Rather, for maximum behavioral success, injury prevention messages must shock and surprise parents into paying attention to something they would normally dismiss as unimportant.

Teen drivers and the risk of injury to child passengers in motor vehicle crashes

OBJECTIVES

The first aim was to examine the relationship between driver's age (novice teens, older teens, and adults) and child passenger's restraint status, front row seating, and injury risk. The second aim was to explore whether there was an excess injury risk to child passengers in teen crashes compared to those in adult crashes by examining the contributing factors.

METHODS

A cross sectional study involving telephone interviews with insured drivers in a probability sample of 12 163 crashes involving 19 111 children was conducted. Sequential logistic regressions were employed.

RESULTS

Among child passengers aged 4-8, appropriate restraint was <1% for novice teens, 4.5% for older teens, and 23.6% for adults. Front row seating for children <13 years was more common in the novice teen group (26.8%) than in the other two groups. Compared with children riding with adults, those with both teen groups experienced excess injury risk. After adjusting for crash severity, there was a 43% reduction in the odds ratio (OR) for novice teens (OR 1.58, 95% confidence interval (CI) 1.14 to 2.19) and a 24% reduction for older teens (OR 2.15, 95% CI 1.42 to 3.26). After adjusting for vehicle type, child's restraint status and front row seating, there was a further 19% reduction in the OR for novice teens (OR 1.37, 95% CI 1.00 to 1.88) and a further 13% reduction for older teens (OR 1.74, 95% CI 1.14 to 2.66).

CONCLUSION

These findings suggest ways in which graduated driver licensing laws may be further enhanced to better protect child passengers from the excess injury risk associated with teen crashes.

Effects of seating position and appropriate restraint use on the risk of injury to children in motor vehicle crashes

BACKGROUND

Currently, many states are upgrading their child restraint laws to include provisions for the use of age-appropriate restraints through 6 to 8 years of age, with some also requiring rear seating for children, enabling the laws to be in closer alignment with best-practice recommendations.

OBJECTIVE

To evaluate the relationships of seating position and restraint status to the risk of injury among children in passenger vehicle crashes.

METHODS

This was a cross-sectional study of children <16 years of age who were involved in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 17980 children in 11506 crashes, representing 229106 children in 146613 crashes, was collected between December 1, 1998, and November 30, 2002. Parent reports were used to define restraint status, seating position, and occurrence of clinically significant injuries, with the use of a previously validated instrument.

RESULTS

Approximately 62% of the children used seat belts, 35% used child restraints, and 3% used no restraint. Nearly 4 of 5 children sat in the rear seat, with one half of all children being restrained appropriately for their age in the rear, although this varied according to the age of the child. Overall, 1.6% of children suffered serious injuries, 13.5% had minor injuries, and 84.9% did not have any injury. Unrestrained children in the front were at the highest risk of injury and appropriately restrained children in the rear were at the lowest risk, for all age groups. Inappropriately restrained children were at nearly twice the risk of injury, compared with appropriately restrained children (odds ratio [OR]: 1.8; 95% confidence interval [CI]: 1.4-2.3), whereas unrestrained children were at >3 times the risk (OR: 3.2; 95% CI: 2.5-4.1). The effect of seating row was smaller than the effect of restraint status; children in the front seat were at 40% greater risk of injury, compared with children in the rear seat (OR: 1.4; 95% CI: 1.2-1.7). Had all children in the study population been appropriately restrained in the rear seat, 1014 serious injuries (95% CI: 675-1353 injuries) would have been prevented (with the assumption that restraint effectiveness does not depend on a variety of other driver-related, child-related, crash-related, vehicle-related, and environmental factors).

CONCLUSIONS

Age-appropriate restraint confers relatively more safety benefit than rear seating, but the 2 work synergistically to provide the best protection for children in crashes. These results support the current focus on age-appropriate restraint in recently upgraded state child restraint laws. However, it is important to note that considerable added benefit would be realized with additional requirements for rear seating.

Critical gaps in child passenger safety practices, surveillance, and legislation: Georgia, 2001

OBJECTIVE

Motor vehicle crashes remain the leading cause of death among US children 1 year of age and older. Although age-appropriate child passenger restraint use and back seating position are effective injury prevention strategies, many children 12 years of age and younger ride inappropriately restrained and seated in the front seat. In Georgia and in most states, surveillance of child passenger restraint use is less than optimal. Although child safety seat legislation is 1 of the most effective mechanisms for increasing correct restraint use and back seating position, Georgia's child occupant restraint law, like the laws in most states, falls short of practices recommended by government and child advocacy safety groups. The objective of this study was to document child passenger restraint use and seating position among children aged 0 to 12 years in Georgia and to use these study results to evaluate the efficacy of Georgia's child restraint surveillance and legislation.

METHODS

In May and June 2001, police roadblocks were used to collect information about child passenger age, restraint use, and seating position.

RESULTS

Data were collected on 1858 children who were riding in 1221 vehicles in 24 different Georgia counties. Results showed that 56% of children were inappropriately restrained and/or in the front seat. The most problematic age groups included infants who were in forward-facing child safety seats (28%) and/or in the front seat (22%); children who were 5 to 8 years of age in car seat belts alone (88%), rather than age- and size-appropriate child safety seats (6%); and children who were 9 to 12 years of age and riding in the front seat (39%). We compared our results with the existing Georgia passenger restraint surveillance system and found that it would have missed 77% of the children in our study who were inappropriately restrained and/or riding in the front seat. In a similar comparison, Georgia's restraint law did not cover over 74% of the children in our study who were riding at risk.

CONCLUSION

The results of this study highlight 3 important areas for improving child passenger safety: targeted interventions to promote booster seat use and riding in the back seat, expanded child passenger restraint and seating position surveillance, and expanded legislation to mandate booster seat use and back seating position.

Acute healthcare utilization by children after motor vehicle crashes

This study, describing the overall patterns of acute healthcare resource utilization by child crash victims (age 15 years and younger), was conducted between 28 July 1999 and 30 November 2000 as part of an on-going large-scale, child-specific crash surveillance system, Partners for Child Passenger Safety: insurance claims from 15 states and the District of Columbia function as the source of subjects, with telephone survey and on-site crash investigations serving as the primary sources of data. A probability sample of 4862 eligible crashes with 7368 child occupants formed the study sample. Our results suggest that for every 1000 children involved in crashes, 3 are hospitalized; 108 are treated and released from an emergency department (ED); 48 are evaluated in a physician's office, urgent care center, or other facility; and 841 receive no care at all. Comprehensive surveillance systems for motor vehicle crashes must capture children treated in physicians' offices, emergency departments, and other healthcare facilities in order to provide accurate estimates of the impact on the health care system related to motor vehicle trauma.

An evaluation of the effectiveness of forward facing child restraint systems

The objective of this study was to determine the effectiveness of forward facing child restraint systems (FFCRS) in preventing serious injury and hospitalization to children 12-47 months of age as compared with similar age children in seat belts. Data were obtained from a cross-sectional study of children aged 12-47 months in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. Effectiveness estimates were limited to those children between 12 and 47 months of age seated in the back row(s) of vehicles, restrained in FFCRS, regardless of misuse, or seat belts of all types and usage. Completed survey information was obtained on 1207 children, representing 12632 children in 11619 crashes between 1 December 1998 and 31 May 2002. Serious injuries occurred to 0.47% of all 12-47-month olds studied, including 1.72% of those in seat belts and 0.39% of those in child restraint systems. The risk of serious injury was 78% lower for children in FFCRS than in seat belts (odds ratio (OR) = 0.22, 95% confidence interval (CI) = 0.11-0.45, P = 0.001). The risk of hospitalization was 79% lower for children in FFCRS than in seat belts (OR = 0.21, 95% CI = 0.09-050, P = 0.001). There was no difference between the restraint types in preventing minor injuries. As compared with seat belts, CRS are very highly effective in preventing serious injuries and hospitalization, respectively. This effectiveness estimate is substantially higher than older estimates, demonstrating the benefits of current CRS designs. These results provide those educating parents and caregivers population-based data on the importance of child restraint use.

Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes

BACKGROUND

Children involved in motor vehicle crashes (MVC) can sustain bruising of the abdominal wall associated with seat belt restraint. The incidence of bruising and its relationship with significant intraabdominal injuries are not known.

METHODS

An analysis of children involved in MVC between December 1998 and November 2002 was performed, using the crash surveillance database from the Partners for Child Passenger Safety (PCPS) project. Optimally (OR) or suboptimally (S-OR) restrained children aged 4 to 15 years were selected. The incidence of abdominal wall bruising was calculated then correlated with the type of restraint as well as any intraabdominal injury with an Abbreviated Injury Scale score > or =2.

RESULTS

A total of 147,985 children in 102,548 crashes met study criteria. An abdominal bruise was noted in 1.33% of the children (n = 1,967; 881 OR and 1,086 S-OR). Significant intraabdominal injury was present in 309 children (0.21%, 95% CI 0.13 to 0.33), including 69 OR and 240 S-OR. The sensitivity, specificity, and positive and negative predictive values of abdominal wall bruising for a significant intraabdominal injury were 73.5%, 98.8%, 11.5%, and 99.9%, respectively. Children with a bruise were substantially more likely to have an intraabdominal injury than children without a bruise. (Odds Ratio 232.1, 95% CI, 75.9 to 710.3) Among those children with an abdominal bruise, 1% required an abdominal operation (n = 20).

CONCLUSIONS

Abdominal wall bruising was relatively uncommon in both OR and S-OR children. Among restrained children involved in MVC, those with a bruise were 232 times more likely to have a significant intraabdominal injury when compared with those without a bruise. It is imperative to pursue intraabdominal injury in children with a bruise of the abdominal wall after MVC.

Recent trends in child restraint practices in the United States

OBJECTIVE

To assess the success of recent outreach activities to promote appropriate child restraint in motor vehicles by examining trends in restraint types used by children under age 9 in 3 large regions of the United States.

METHODS

Cross-sectional study was conducted of children who were under age 9 and in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 8730 crashes involving 10,195 children, representing 128 291 crashes involving 149,820 children, was collected between December 1, 1998, and November 30, 2002. Parent report was used to determine restraint type used in the crash. Logistic regression models were used to analyze the secular trend of restraint type use.

RESULTS

Overall, for children under age 9, seat belt use decreased significantly from 49% to 36% between 1998 and 2002; for 7- and 8-year-olds, from 97% to 92%; and for 3- to 6-year-olds, from 63% to 34%. Concurrently, gains were achieved in overall child restraint use from 49% to 63%, for 7- and 8-year-olds, from 2% to 5%; and for 3- to 6-year-olds, from 35% to 65%. Child restraint use remains stable for children from birth to 2 years of age (from 97% in 1998 to 98% in 2002). Both the use of child safety seat and belt positioning booster seat increased significantly, whereas shield booster seat use decreased significantly.

CONCLUSION

Although considerable achievements have been realized over a short period of time, substantial inappropriate restraint still remains: 62% of children aged 4 to 8 remain inappropriately restrained in adult seat belts. Parents hear safety messages when they are relevant to their children. As a result, sustained efforts about appropriate restraint must continue to maintain and improve the gains achieved in appropriate child restraint use. The additional benefits realized by recent changes in child restraint laws remain to be evaluated.

Factors Associated With Front Row Seating of Children in Motor Vehicle Crashes

BACKGROUND

Current safety guidelines recommend that children age 12 or younger sit in the rear seat of passenger vehicles. However, front row seating among these children remains common. To develop future educational and other interventions to decrease front row seating of young children, it is important to examine factors associated with this behavior.

METHODS

We identified factors associated with front row seating of children 12 years of age or younger using data from a cross-sectional study of children who were the single passenger in crashes of insured vehicles in 15 U.S. states. Data were collected by insurance claims records and a telephone interview. A probability sample of 3775 crashes representing 27678 crashes with child occupants was collected between 1 December 1998, and 30 November 2002. Multivariate Poisson regression was used to identify specific child, driver, and vehicle characteristics associated with front row seating.

RESULTS

When children were the sole occupants in the vehicle, approximately 1 in 3 (31%) sat in the front seat. The child's age and restraint use, the driver's age and relationship to the child passenger, the type of vehicle, and the presence of a passenger airbag were all associated with front row seating.

CONCLUSIONS

Educational interventions can be tailored to address the specific needs of subgroups of drivers and children to reduce front row seating. In addition, these data could be used to support legislative interventions to limit front row seating of younger children when a teenager is driving.

Optimal restraint reduces the risk of abdominal injury in children involved in motor vehicle crashes

BACKGROUND

The American Academy of Pediatrics has established guidelines for optimal, age-appropriate child occupant restraint. While optimal restraint has been shown to reduce the risk of injuries overall, its effect on specific types of injuries, in particular abdominal injuries, has not been demonstrated.

METHODS

Cross-sectional study of children aged younger than 16 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 10927 crashes involving 17132 restrained children, representing 210926 children in 136734 crashes was collected between December 1, 1998 and May 31, 2002. Restraint use was categorized as optimal or suboptimal based on current American Academy of Pediatrics guidelines. The outcome of interest, abdominal injury, was defined as any reported injury to an intra-abdominal organ of Abbreviated Injury Scale >or=2 severity.

RESULTS

Among all restrained children, optimal was noted in 59% (n = 120473) and suboptimal in 41% (n = 83555). An associated abdominal organ injury was noted in 0.05% (n = 62) of the optimal restrained group and 0.17% (n = 140) of the suboptimal group. After adjusting for age and seating position (front vs. rear), optimally restrained children were more than 3 times less likely [odds ratio 3.51 (95% confidence interval, 1.87-6.60, P < 0.001)] as suboptimally restrained children to suffer an abdominal injury. Of note, there were no abdominal injuries reported among optimally restrained 4- to 8-year-olds.

CONCLUSIONS

Optimally restrained children are at a significantly lower risk of abdominal injury than children suboptimally restrained for age. This disparity emphasizes the need for aggressive education efforts aimed not only at getting children into restraint systems, but also the importance of optimal, age-appropriate restraint.

Accuracy of self-reported data for estimating crash severity

Estimated traveling speed and speed limit have typically been used in population-based surveillance data to estimate crash severity. The accuracy of these measures in predicting crash severity is unknown. The Partners for Child Passenger Safety (PCPS) surveillance system offers a unique opportunity to compare these measures, as well as a novel measure of crash severity, "self-report" delta-V, to the accepted measure of delta-V estimated during detailed crash-investigations in 118 crashes. This "self-report" delta-V was computed from the estimated traveling speeds and direction of impact obtained from telephone interviews with drivers. These "self-reported" delta-V estimates are modestly associated with crash-investigation delta-V estimates, with the degree of association a function of the direction of impact: when the respondent was struck from the rear, the degree of association is strong; frontal, side, and single-vehicle crashes yield weaker associations. This "self-reported" delta-V measure, however, is a substantial improvement over use of estimated traveling speed or speed limit only.

Suboptimal restraint affects the pattern of abdominal injuries in children involved in motor vehicle crashes

BACKGROUND

Both solid and hollow visceral abdominal injuries have been associated with the use of seat belts in children involved in motor vehicle crashes. The relationship between the types of restraint used and the pattern of abdominal injury is unknown.

METHODS

A probability sample of restrained children involved in crashes was enrolled in an ongoing crash surveillance system (1998 through 2002) linking insurance claims data to telephone survey and crash investigation data. Significant abdominal injuries were considered when the Abbreviated Injury Scale (AIS) score was > or =2 and were defined as hollow visceral (HV; intestine, bladder), or solid visceral (liver, spleen, pancreas, kidney). Restraint type was categorized as optimal restraint (OR) or suboptimal restraint (S-OR) based on the child's age and size.

RESULTS

For the 33 months of review, interviews were obtained for 13,558 restrained children aged 0 to 15 years, of which, 56% were OR (n = 7,591) and 44% were S-OR (n = 5,967). A significant abdominal injury was recorded in 78 children. A hollow visceral injury was recorded in 38 (9 OR and 29 S-OR), and a solid visceral injury in 32 (18 OR and 14 S-OR). Both hollow and solid visceral injuries were present in 8 children (2 OR and 6 S-OR). Suboptimally restrained children had a higher risk for hollow visceral injury when compared with optimally restrained children (Odds Ratio, 4.14 [95% Confidence Interval 1.33 to 13.22, P <.01]).

CONCLUSIONS

Among restrained children with intraabdominal injuries, those who were suboptimally restrained were 4 times more likely to have a hollow visceral than a solid visceral injury when compared with those who were optimally restrained. This suggests that the mechanism of injury for hollow viscus may be directly related to the improper positioning of the restraint.

Risk of injury to restrained children from passenger air bags

The objectives of this study were to estimate the prevalence of children's exposure to passenger air bag (PAB) deployments and to determine the relative risk of both minor and more serious nonfatal injuries to restrained children exposed to PABs in frontal impact collisions. Data were collected from 1 December 1998 to 30 November 2001 from a large-scale, child-specific crash surveillance system based on insurance claims, a telephone survey, and on-site crash investigations. Vehicles qualifying for inclusion were State Farm-insured, model year 1990 or newer, and involved in a crash with at least one child occupant < or =15 years of age. Qualifying crashes were limited to those that occurred in 15 states and the District of Columbia. A stratified cluster sample was designed in order to select vehicles (the unit of sampling) for the conduction of a telephone survey with the driver. For cases in which child occupants were seriously injured or killed, in-depth crash investigations were performed. The prevalence of exposure to PABs was calculated as the number of children occupying the right front seat in a PAB deployment crash among all children occupying the right front seat in vehicles equipped with PABs. Complete interview data were obtained on 9,779 vehicles involving 15,341 children. Among PAB-exposed children, 175 (14%) suffered serious injuries versus 41 (7.5%) of those in the comparison group (OR 2.0; 95% CI, 1.1-3.7). The overall risk of any injury (both minor and serious) was 86% among children exposed to PABs, compared to 55% among the comparison group (OR 5.3; 95% CI, 2.1-13.4). Exposure to PABs increased the risk of both minor injuries, including facial and chest abrasions, and more serious injuries, particularly upper extremity fractures.

Acute stress disorder symptoms in children and their parents after pediatric traffic injury

OBJECTIVE

The American Academy of Pediatrics highlights the important role of pediatricians in recognizing adverse child responses to tragic events, such as traffic crashes. One challenge in effectively identifying children and their parents with troubling psychological responses to trauma is that little is known about the normal range of acute psychological responses in children and their parents in the immediate aftermath of traumatic events, making identification of adverse child responses difficult. Within the first month after a traumatic event, individuals may display reexperiencing, avoidance, and hyperarousal symptoms as well as dissociation (eg, feelings of unreality or emotional numbing). The presence of these responses, collectively known as acute stress disorder (ASD), alerts providers to those who may be at risk for ongoing difficulties. For beginning to develop an evidence base to guide pediatric care providers in addressing acute traumatic responses, the aim of the current investigation was to describe systematically the range and type of symptoms of ASD in children and their parents after pediatric traffic injury.

METHODS

A prospective cohort study was conducted of traffic-injured children, who were 5 to 17 years of age and admitted to the hospital for treatment of injuries from traffic crashes, and their parents. All children who met eligibility criteria between July 1999 and May 2000 were invited to participate in the study. After consent/assent was obtained, children and their custodial parents (or guardians) were interviewed within 1 month after injury via a structured assessment to determine the circumstances of the crash and the presence of ASD symptoms. Relevant demographic and clinical information (eg, age, race, gender, date of injury) was abstracted from the medical records of subjects. A survey instrument to assess the presence of ASD symptoms was completed by both the child and his or her guardian. All children completed the Child Acute Stress Questionnaire, and all parents completed the Stanford Acute Stress Reaction Questionnaire. Responses were scored for the presence of dissociation, reexperiencing, avoidance, and/or hyperarousal symptoms as well as broad distress (symptoms present in every category).

RESULTS

Symptoms of ASD were commonly observed in the children and parents. Eighty-eight percent of children and 83% of parents reported having at least 1 clinically significant symptom; this affected 90% of the families. Broad distress was observed for a large minority: 28% of children and 23% of parents. No statistically significant association was found between child broad distress and either child age (r = -0.12) or child injury severity score (r = -0.05). chi(2) analyses revealed no significant association between broad distress and child gender, child race, or mechanism of injury. No statistically significant association was found between parent broad distress and child age (r = -0.06) or child injury severity score (r = 0.09). chi(2) analyses revealed no significant association between parent broad distress and child gender or parent presence at the crash scene. Associations were found between parent broad distress and race in that fewer white parents reported broad distress. In addition, mechanism of injury was associated with parent broad distress: more parents reported broad distress when their children were involved in pedestrian-motor vehicle crashes, and fewer parents reported broad distress when their children were injured in a bicycle fall.

CONCLUSIONS

Pediatric care providers can expect to see some ASD symptoms in most children and parents in the immediate aftermath of traffic-related injury. Brief education is appropriate to explain that these symptoms are normal reactions that are likely to resolve. If symptoms persist for >1 month or are particularly distressing in their intensity, then referral for psychological care may be necessary for treatment of posttraumatic stress disorder. Given the high prevalence of pediatric traffic crashes and the underdiagnosis of posttraumatic stress disorder, probing for recent crash exposure might be appropriate during routine child health maintenance. The following are recommendations for pediatricians: 1) routinely call the family several days and 1 to 2 weeks after a traffic injury and ask about behavioral symptoms and family function; 2) make use of the ongoing physician-patient relationship to explore symptom presence and intensity and any functional impairment in the injured child; a brief office visit with the child and parents could serve this purpose; 3) be sure to explore the effect that the child's injury has had on the family; remember that the parent's experience posttraumatic stress symptoms after pediatric traffic-related injuries and these symptoms may limit the parent's ability to support the child; 4) provide supportive care and give families the opportunity to discuss the crash and their current feelings; do not force families to talk about the crash; 5) although any child in a traffic crash or his or her parent is at risk for posttraumatic symptomatology, regardless of injury severity, particular attention should be paid to the parents of child pedestrians who are struck by motor vehicles. These parents experience posttraumatic symptoms more commonly than parents of children in other traffic crashes.

The role of restraint and seat position in pediatric facial fractures

BACKGROUND

Recently, head and brain injuries were identified as consequences of the inappropriate use of seat belts by children. The proposed mechanism of these injuries might also place a child at risk for facial fracture.

METHODS

A probability sample of children under age 16 involved in crashes were enrolled in an ongoing crash surveillance system (1998-2001) that links insurance claims data to telephone survey and crash investigation data (unweighted, n = 12,659; weighted, n = 131,717). Incidence of facial fracture was estimated and a series of cases were examined using in-depth crash investigation to identify the mechanisms of these injuries, specifically, the role of seating position and restraint use in the mechanism of injury.

RESULTS

Ninety-two children suffered a fracture of the facial bones (0.07% of all children in crashes). Among restrained children with facial fractures (n = 68), those inappropriately restrained were at a 1.6-fold higher risk (95% confidence interval, 1.2-2.1; p = 0.001) of significant injury than those appropriately restrained for their age. The in-depth investigations revealed that excessive head excursion resulting from suboptimal torso restraint caused facial impact, which resulted in the facial injuries described.

CONCLUSION

The potential for disfigurement associated with these facial injuries may resonate strongly with parents, and prevention of disfigurement may provide additional motivation for proper restraint, in particular, booster seats and rear seat location, for this pediatric population.

Seat belt syndrome in children: a case report and review of the literature

Characteristic patterns of injury to children in automobile crashes resulting from lap and lap-shoulder belts have been described for many years. These injuries are known as the "seat belt syndrome." We present a typical case of seat belt syndrome involving a 4-year-old boy and review the current literature on the topic, highlighting proposed mechanisms of intra-abdominal and spine injuries. In addition, recent research findings identifying a new pattern of injuries associated with inappropriate seat belt use in young children are reviewed. Emergency physicians must consider these seat belt-related injuries in the initial evaluation of any child involved in a motor vehicle crash who was restrained with the vehicle seat belt.

Trends in booster seat use among young children in crashes

INTRODUCTION

Booster seat use in the United States is extremely low among 4- to 8-year-old children, the group targeted for their use. However, more recent attention has been paid to the role of booster seats for children who have outgrown their forward-facing child safety seat. In particular, several states are currently considering upgrades to their child restraint laws to include the use of booster seats for children over 4 years of age.

OBJECTIVE

To examine recent trends in booster seat use among children involved in automobile crashes in 3 large regions of the United States.

DESIGN

This study was performed as part of the Partners for Child Passenger Safety project, an ongoing, child-specific crash surveillance system that links insurance claims data to telephone survey and crash investigation data. All crashes occurring between December 1, 1998, and November 30, 2000, involving a child occupant between 2 to 8 years of age riding in a model year 1990 or newer vehicle reported to State Farm Insurance Companies from 15 states and Washington, DC, were eligible for this study. A probability sample of eligible crashes was selected for a telephone survey with the driver of the vehicle using a previously validated instrument. The study sample was weighted according to each subject's probability of selection, with analyses conducted on the weighted sample.

RESULTS

The weighted study sample consisted of 53 834 children between 2 to 8 years old, 11.5% of whom were using a booster seat at the time of the crash. Booster seat use peaked at age 3 and dropped dramatically after age 4. Over the period of study, booster seat use among 4- to 8-year-olds increased from 4% to 13%. Among 4-year-olds specifically, booster use increased from 14% to 34%. Among children using booster seats, approximately half used shield boosters and half used belt-positioning boosters.

CONCLUSIONS

Although overall booster seat use among the targeted population of 4- to 8-year-old children remains low, significant increases have been noted among specific age groups of children over the past 2 years. These data may be useful to pediatricians, legislators, and educators in efforts to target interventions designed to increase appropriate booster seat use in these children.

Factors influencing pediatric injury in side impact collisions

BACKGROUND

Side impact collisions pose a great risk to children in crashes, but information about the injury mechanisms is limited.

METHODS

This study involves a case series of children in side impact collisions who were identified through Partners for Child Passenger Safety, a large, child-focused crash surveillance system. The aim of the current study was to use in-depth crash investigations to identify injury mechanisms to children in side impact collisions.

RESULTS

Ninety-three children in 55 side impact crashes were studied. Twenty-three percent (n = 22) of the children received an Abbreviated Injury Scale (AIS) score > or = 2 (clinically significant) injury. In these 22 children, head (40%), extremity (23%), and abdominal injuries (21%) were the most common significant injuries. Cases that illustrate body region-specific injury mechanisms are discussed.

CONCLUSION

The cases revealed that serious injuries, particularly head injuries, occur even in minor crashes, and efforts should be made to make the interiors of vehicles more child occupant friendly. Lower extremity and abdominal injuries occurred because of contact with the intruding door. Design of vehicles to minimize crush should mitigate the occurrence and severity of these injuries.