Transportation of Older Adults: Common Behaviors Interfering With Safety

There is a dearth of evidence on safely transporting frail older adults in the community. Therefore, the purpose of the current study was to gain a better understanding of behavioral expression exhibited by older adults during van transportation and to learn what actions van assistants and van drivers take to prevent or address behavioral expressions, which can create potential challenges to safe transportation. A qualitative descriptive approach was used and included four focus groups of van assistants and van drivers (N = 32) at one urban Program of All-Inclusive Care for the Elderly (PACE), which routinely transports approximately 90% of enrollees to and from the PACE center. Conventional content analysis was used to analyze the data. Four themes emerged. The first two themes were common behaviors: Removing Seat Belts and Verbal Behaviors. The remaining two themes addressed unusual behaviors that left lasting impressions: Physical Aggression and Conflict Between Passengers. Van assistants and van drivers used redirection and reassurance as preventive interventions to keep everyone safe. Transportation of PACE enrollees requires well-trained and astute van assistants and van drivers skilled with preventing and diffusing potentially unsafe behaviors. [Res Gerontol Nurs. 2019; 12(4):184-192.].

Assessing tether anchor labeling and usability in pickup trucks

OBJECTIVE

The objective of this study was to investigate vehicle factors associated with child restraint tether use and misuse in pickup trucks and evaluate 4 labeling interventions designed to educate consumers on proper tether use.

METHODS

Volunteer testing was performed with 24 subjects and 4 different pickup trucks. Each subject performed 8 child restraint installations among the 4 pickups using 2 forward-facing restraints: a Britax Marathon G4.1 and an Evenflo Triumph. Vehicles were selected to represent 4 different implementations of tether anchors among pickups: plastic loop routers (Chevrolet Silverado), webbing routers (Ram), back wall anchors (Nissan Frontier), and webbing routers plus metal anchors (Toyota Tundra). Interventions included a diagram label, Quick Response (QR) Code linked to video instruction, coordinating text label, and contrasting text tag.

RESULTS

Subjects used the child restraint tether in 93% of trials. However, tether use was completely correct in only 9% of trials. An installation was considered functional if the subject attached the tether to a tether anchor and had a tight installation (ignoring routing and head restraint position); 28% of subjects achieved a functional installation. The most common installation error was attaching the tether hook to the anchor/router directly behind the child restraint (near the top of the seatback) rather than placing the tether through the router and attaching it to the anchor in the adjacent seating position. The Nissan Frontier, with the anchor located on the back wall of the cab, had the highest rate of correct installations but also had the highest rate of attaching the tether to components other than the tether anchor (seat adjustor, child restraint storage hook, around head restraint). None of the labeling interventions had a significant effect on correct installation; not a single subject scanned the QR Code to access the video instruction. Subjects with the most successful installations spent extensive time reviewing the vehicle manuals.

CONCLUSION

Current implementations of tether anchors among pickup trucks are not intuitive for child restraint installations, and alternate designs should be explored. Several different labeling interventions were ineffective at achieving correct tether use in pickup trucks.

Analysis of mechanics of side impact test defined in UN/ECE Regulation 129

OBJECTIVE

This article discusses differences between a side impact procedure described in United Nations/Economic Commission for Europe (UN/ECE) Regulation 129 and scenarios observed in real-world cases.

METHODS

Numerical simulations of side impact tests utilizing different boundary conditions are used to compare the severity of the Regulation 129 test and the other tests with different kinematics of child restraint systems (CRSs). In the simulations, the authors use a validated finite element (FE) model of real-world CRSs together with a fully deformable numerical model of the Q3 anthropomorphic test device (ATD) by Humanetics Innovative Solution, Inc.

RESULTS

The comparison of 5 selected cases is based on the head injury criterion (HIC) index. Numerical investigations reveal that the presence of oblique velocity components or the way in which the CRS is mounted to the test bench seat fixture is among the significant factors influencing ATD kinematics. The results of analyses show that the side impact test procedure is very sensitive to these parameters. A side impact setup defined in Regulation 129 may minimize the effects of the impact.

CONCLUSIONS

It is demonstrated that an artificial anchorage in the Regulation 129 test does not account for a rotation of the CRS, which should appear in the case of a realistic anchorage. Therefore, the adopted procedure generates the smallest HIC value, which is at the level of the far-side impact scenario where there are no obstacles. It is also shown that the presence of nonlateral acceleration components challenges the quality of a CRS and its headrest much more than a pure lateral setup.

Paired vehicle occupant analysis indicates age and crash severity moderate likelihood of higher severity injury in second row seated adults in frontal crashes

The majority of advances in occupant protection systems for motor vehicle occupants have focused on occupants seated in the front row of the vehicle. Recent studies suggest that these systems have resulted in lower injury risk for front row occupants as compared to those in the second row. However, these findings are not universal. In addition, some of these findings result from analyses that compare groups of front and second row occupants exposed to dissimilar crash conditions, raising questions regarding whether they might reflect differences in the crash rather than the front and second row restraint systems. The current study examines factors associated with injury risk for pairs of right front seat and second row occupants in frontal crashes in the United States using paired data analysis techniques. These data indicate that the occupant seated in the front row frequently experiences the more severe injury in the pair, however there were no significant differences in the rate of occurrence of these events and events where the more severe injury occurs in the second row occupant of the pair. A logistic regression indicated that the likelihood of the more severe injury occurring in the second row seated occupant of the pair increased as crash severity increased, consistent with data from anatomic test dummy (ATD) tests. It also indicated that the second row occupant was more likely to have the more severe injury in the pair if that occupant was the older occupant of the pair. These findings suggest that occupant protection systems which focus on providing protection specifically for injuries experienced by older occupants in the second row in higher severity crash conditions might provide the greatest benefit.

Seat and seatbelt accommodation in fire apparatus: Anthropometric aspects

This study developed anthropometric information on U.S. firefighters to guide fire-apparatus seat and seatbelt designs and future standards development. A stratified sample of 863 male and 88 female firefighters across the U.S. participated in the study. The study results suggested 498 mm in width, 404 mm in depth, and 365-476 mm in height for seat pans; 429-522 mm in width and 542 mm in height for seat back; 871 mm in height for head support; a seat space of 733 mm at shoulder and 678 mm at hip; and a knee/leg clearance of 909 mm in fire truck cab. Also, 1520 mm of lap belt web effective length and 2828 mm of lap-and-shoulder belt web effective length were suggested. These data for fire-truck seats and seatbelts provide a foundation for fire apparatus manufacturers and standards committees to improve firefighter seat designs and seatbelt usage compliance.

Factors affecting tether use and correct use in child restraint installations

INTRODUCTION

Field studies show that top tethers go unused in half of forward-facing child restraint installations.

METHOD

In this study, parent volunteers were asked to use the Lower Anchors and Tethers for Children (LATCH) to install child restraints in several vehicles to identify tether anchor characteristics that are associated with tether use. Thirty-seven volunteers were assigned to four groups. Each group tested two forward-facing child restraints in four of 16 vehicle models. Logistic regression models were used to identify predictors of tether use and correct use.

RESULTS

Subjects used the tether in 89% of the 294 forward-facing child restraint installations and attached the tether correctly in 57% of the installations. Tethers were more likely to be used when the anchor was located on the rear deck as typically found in sedans compared with the seatback, floor, or roof. Tethers were less likely to be attached correctly when there was potentially confusing hardware present. No vehicle tether hardware characteristics or vehicle manual directions were associated specifically with correct tether routing and head restraint position.

CONCLUSION

This study provides laboratory evidence that specific vehicle features are associated with tether use and correct use.

PRACTICAL APPLICATIONS

Modifications to vehicles that make tether anchors easier to find and identify likely will result in increases in tether use and correct use.

Structural Design Strategies for Improved Small Overlap Crashworthiness Performance

In 2012, the Insurance Institute for Highway Safety (IIHS) began a 64 km/h small overlap frontal crash test consumer information test program. Thirteen automakers already have redesigned models to improve test performance. One or more distinct strategies are evident in these redesigns: reinforcement of the occupant compartment, use of energy-absorbing fender structures, and the addition of engagement structures to induce vehicle lateral translation. Each strategy influences vehicle kinematics, posing additional challenges for the restraint systems. The objective of this two-part study was to examine how vehicles were modified to improve small overlap test performance and then to examine how these modifications affect dummy response and restraint system performance. Among eight models tested before and after design changes, occupant compartment intrusion reductions ranged from 6 cm to 45 cm, with the highest reductions observed in models with the largest number of modifications. All redesigns included additional occupant compartment reinforcement, one-third added structures to engage the barrier, and two modified a shotgun load path. Designs with engagement structures produced greater glance-off from the barrier and exhibited lower delta Vs but experienced more lateral outboard motion of the dummy. Designs with heavy reinforcement of the occupant compartment had higher vehicle accelerations and delta V. In three cases, these apparent trade-offs were not well addressed by concurrent changes in restraint systems and resulted in increased injury risk compared with the original tests. Among the 36 models tested after design changes, the extent of design changes correlated to structural performance. Half of the vehicles with the lowest intrusion levels incorporated aspects of all three design strategies. Vehicle kinematics and dummy and restraint system characteristics were similar to those observed in the before/after pairs. Different combinations of structural improvement strategies for improving small overlap test performance were found to be effective in reducing occupant compartment intrusion and improving dummy kinematics in the IIHS small overlap test with modest weight increase.

Observational study of child restraining practice on Norwegian high-speed roads: restraint misuse poses a major threat to child passenger safety

OBJECTIVE

Restraint misuse and other occupant safety errors are the major cause of fatal and, severe injuries among child passengers in motor vehicle collisions. The main objectives of the present, study were to provide estimates of restraining practice among children younger than 16 years, traveling on Norwegian high-speed roads, and to uncover the high-risk groups associated with, restraint misuse and other safety errors.

METHODS

A cross-sectional observational study was performed in conjunction with regular traffic, control posts on high-speed roads. The seating and restraining of child occupants younger than 16, years were observed, the interior environment of the vehicles was examined, and a structured, interview of the driver was conducted according to a specific protocol.

RESULTS

In total, 1260 child occupants aged 0-15 years were included in the study. Misuse of restraints, was observed in 38% of cases, with this being severe or critical in 24%. The presence of restraint, misuse varied significantly with age (p<0.001), with the frequency being highest among child, occupants in the age group 4-7 years. The most common error in this group was improperly routed, seat belts. The highest frequency of severe and critical errors was observed among child occupants in, the age group 0-3 years. The most common errors were loose or improperly routed harness straps and, incorrect installations of the child restraint system. Moreover, 24% of the children were seated in, vehicles with heavy, unsecured objects in the passenger compartment and/or the trunk that were, likely to move into the compartment upon impact and cause injury. No totally unrestrained children, were observed.

CONCLUSIONS

This study provides a detailed description of the characteristics of restraint misuse and, the occupant's exposure to unsecured objects. Future education and awareness campaigns should, focus on children aged <8 years. The main challenges are to ensure correct routing and tightness of, harness straps and seat belts, correct installation of child restraints, and avoidance of premature, graduation from child restraints to seat belts only. Information campaigns should also advocate the use, of chest clips and address the potential risks of hard, heavy objects in the passenger compartment and, the importance of the placement and strapping of heavy objects in the trunk.

Optimizing the rear seat environment for older children, adults, and infants

OBJECTIVE

Our recent rear seat safety research found that more-forward and higher lap belt anchorage locations and much shorter and stiffer seat cushions can improve the protection of older children from 6 to 12 years old who are using the vehicle belt without a booster. The objective of this study was to investigate whether the optimal rear seat restraint systems for adults and infants are consistent with those for older children.

METHODS

We conducted sensitivity analyses and design optimizations for adults and for infants in a rear-facing child restraint system (CRS) using a set of MADYMO models, an automated simulation framework, and occupant belt-fit and posture prediction models from our previous studies. A series of 12 sled tests was also used to validate the computational models.

RESULTS

The optimal belt anchorage locations and the seat cushion length for older children, adults, and rear-facing CRS-seated infants conflict with each other. In particular, more-forward lap belt anchorage locations that prevent submarining for older children would reduce the protection to both adults and CRS-seated infants, although the protection is still acceptable based on regulated injury criteria. A shorter seat cushion could provide optimal protection to older children and adults but would significantly increase the CRS rotation.

CONCLUSIONS

The findings of this study suggested that adaptive/adjustable restraint systems are necessary to simultaneously improve the rear seat occupant protection for all age groups. Supplemental materials are available for this article. Go to the publisher's online edition of Traffic Injury Prevention to view the supplemental file.

Rear seat restraint system optimization for older children in frontal crashes

OBJECTIVE

Analyses of crash injury data have shown that injury risk increases when children transition from belt-positioning boosters to the vehicle seat belt alone. The objective of this study is to investigate how to improve the restraint environment for these children.

METHODS

A parametric analysis was conducted to investigate the effects of body size, seat belt anchorage locations, and rear seat design parameters on the injury risks in frontal crashes of children aged 6 to 12 years old using a newly developed parametric child anthropomorphic test dummy (ATD) model. Restraint design optimizations were also conducted to obtain ranges of optimal restraint system configurations that provide best protections for 6-, 9-, and 12-year-old children.

RESULTS

Simulation results showed that child body size was the dominant factor affecting outcome measures. In general, lower and more rearward D-rings (upper belt anchorages), higher and more forward lap belt anchorages, and shorter, stiffer, and thinner seat cushions were associated with improved restraint performance. In these simulations, children with smaller body sizes require more-forward D-rings, inboard anchors, and outboard anchor locations to avoid submarining. However, these anchorage locations increase head excursions relative to more-rearward anchorages.

CONCLUSIONS

The balance of reducing head and knee excursions and preventing submarining indicates that an optimization approach is necessary to improve protection for 6- to 12-year-old child occupants. The findings of this study provided design guidelines for future rear seat restraint system.

Comparing the performance of residential fire sprinklers with other life-safety technologies

Residential fire sprinklers have long proven themselves as life-safety technologies to the fire service community. Yet, about 1% of all one- and two-family dwelling fires occur in homes protected by sprinklers. It has been argued that measured sprinkler performance has ignored factors confounding the relationship between sprinkler use and performance. In this analysis, sprinkler performance is measured by comparing 'like' structure fires, while conditioning on smoke detection technology and neighborhood housing and socioeconomic conditions, using propensity score matching. Results show that residential fire sprinklers protect occupant and firefighter health and safety, and are comparable to other life-safety technologies.

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.

Are airbags a dangerous safety measure? A meta-analysis of the effects of frontal airbags on driver fatalities

A meta-analysis has been conducted of the effectiveness of frontal airbags in reducing driver fatalities, and some potential moderator variables for airbag effectiveness have been investigated. The results confirm the assumption that airbags reduce accident fatalities among belted drivers, but the results are too heterogeneous for drawing conclusions about the size of the overall effect. No support has been found for the hypothesis that airbags increase overall fatality risk, as has been found in the study by Meyer and Finney (Meyer, M., Finney, T., 2005. Who wants Airbags? Chance, 18 (19) 3-16). The results do not seem to be affected by publication bias, and no indications of confounding effects of vehicle characteristics or impact velocity have been found. In frontal collisions belted driver fatalities were found to be reduced by about 22% when all types of airbags are regarded together. The revision of the test criteria for airbags in the USA in 1997 has improved airbag effectiveness. For unbelted drivers airbags are neither effective nor counterproductive, but may increase fatality risk in single vehicle accidents. The results show that there is a lack of knowledge about the effects of airbags in accidents that are not frontal collisions.

A matched-cohort analysis of belted front and rear seat occupants in newer and older model vehicles shows that gains in front occupant safety have outpaced gains for rear seat occupants

Previous studies have suggested that rear seat occupants are at lower risk of serious injury and death in crashes. However, over the last 10-15 years there have been significant changes in front seat safety systems. The aim of this study was to determine whether there is still a benefit for rear seated occupants compared to front seat occupants. A matched-cohort approach, using data on restrained occupants from the US National Automotive Sampling System (data years 1993-2007), was adopted. Conditional poisson regression modeling was used to evaluate the relative risk of AIS3+ injury in front (passenger and driver) and rear seat occupants, in vehicles of model year 1990-1996 compared to newer vehicles. Occupant age, belt type, and intrusion were additional variables in the model. The relative risk of AIS3+ injury for front and rear occupants was influenced by age and model year. For those aged 16-50 years in older vehicles, the front and rear seat offered similar levels of protection (RR=1.14, CI=1.09-1.19), however in newer model vehicles (1997-2007), the rear seat carried a higher risk of injury (RR=1.98, CI=1.90-2.06). For adults over 50 years, the rear seat carried a higher risk in both older and newer vehicles, and for 9-15 year olds, the rear seat carried a lower risk. These findings suggest that safety for front seat occupants has improved over the last decade, to the point where, for occupants over 15 years of age, the front seat is safer than the rear seat. While the benefit of rear seating for children aged 9-15 years has decreased over time, they are still at lower risk in the rear seat.

Effects of seat belts worn by pregnant drivers during low-impact collisions

OBJECTIVE

The aim of this study was to understand the injury mechanisms of pregnant drivers and associated fetal outcomes.

STUDY DESIGN

Frontal and rear impact tests using a dummy representing the anthropometry of a pregnant woman were conducted.

RESULTS

In frontal impact tests without a seat belt, abdominal pressure peaked at the point where the dummy contacted the steering wheel. Rear impact tests without a seat belt showed that the dummy moved forward because of rebound and contacted the steering wheel, which was avoided when a seat belt was worn.

CONCLUSION

Wearing a seat belt reduces abdominal pressure or prevents contact with the steering wheel during collisions.

WC19: a wheelchair transportation safety standard--experience to date and future directions

ANSI/RESNA WC19 (i.e., WC19) is a voluntary standard that specifies design and performance requirements for wheelchairs that are suitable for use as seats in motor vehicles. The guiding principles for the standard originate from automotive crash-protection principles that are effective in reducing occupant injuries and fatalities. In addition to frontal-impact testing of wheelchairs, the standard includes tests for securement-point accessibility, tiedown-strap clear paths, lateral stability, and accommodation of vehicle-anchored belt restraints. Results from testing wheelchairs to WC19 reveal that the most common wheelchair problems include: a lack of structural integrity during frontal-impact loading; sharp rigid edges; and wheelchair structures that interfere with achieving proper positioning of vehicle-anchored belt restraints. Data from 8 years of experience with WC19 indicate where changes are needed to further improve transportation safety for wheelchair-seated travelers. These include expanding WC19 to include wheelchairs for smaller children who require a five-point harness restraint, and requiring wheelchairs to achieve a minimal rating for the ease of achieving proper positioning of vehicle-anchored belt restraints.

Optimising product advice based on age when design criteria are based on weight: child restraints in vehicles

The motivation for this paper is the high rate of inappropriate child restraint selection in cars that is apparent in published surveys of child restraint use and how the public health messages promoting child restraints might respond. Advice has increasingly been given solely according to the child's weight, while many parents do not know the weight of their children. A common objection to promoting restraint use based on the age of the child is the imprecision of such advice, given the variation in the size of children, but the magnitude of the misclassification such advice would produce has never been estimated. This paper presents a method for estimating the misclassification of children by weight, when advice is posed in terms of age, and applies it to detailed child growth data published by the Centers for Disease Control and Prevention. In Australia, guidelines instructing all parents to promote their children from an infant restraint to a forward-facing child seat at 6 months, and then to a belt-positioning booster at 4 years, would mean that 5% of all children under the age of 6 years would be using a restraint not suited to their weight. Coordination of aged-based advice and the weight ranges chosen for the Australian Standard on child restraints could reduce this level of misclassification to less than 1%. The general method developed may also be applied to other aspects of restraint design that are more directly relevant to good restraint fit.

Evaluation of the Boost 'em in the Back Seat Program: using fear and efficacy to increase booster seat use

OBJECTIVES

Recent research supports the use of high-threat messages when they are targeted appropriately and designed to promote high efficacy as well as fear. This research examined the effectiveness of using a novel threat-appeal approach to encourage parents to place their children in booster seats and rear seats of vehicles.

METHOD

A 6-min video-intervention was created and evaluated at after-school/daycare centers via an interrupted time series design with similar control sites for comparison. Caregivers (N=226) completed knowledge and practice surveys and fear and efficacy estimations related to childhood motor vehicle hazards. Researchers observed booster-seat and rear-seat use in study site parking lots.

RESULTS

Compared to baseline and control assessments, the treatment groups' child passenger safety knowledge, risk-reduction attitudes, behavioral intentions, sense of fear related to the hazard, and sense of efficacy related to the recommended behaviors increased significantly. Further, observed overall restraint use and booster-seat use increased significantly following the intervention.

CONCLUSIONS

Applying high-threat messages to child passenger safety interventions is promising and has the potential to be adapted to other health risk areas.

Use of fatal real-life crashes to analyze a safe road transport system model, including the road user, the vehicle, and the road

OBJECTIVE

To evaluate if the Swedish Road Administration (SRA) model for a safe road transport system, which includes the interaction between the road user, the vehicle, and the road, could be used to classify fatal car crashes according to some safety indicators. Also, to present a development of the model to better identify system weakness.

METHODS

Real-life crashes with a fatal outcome were classified according to the vehicle's safety rating by Euro NCAP (European Road Assessment Programme) and fitment of ESC (Electronic Stability Control). For each crash, the road was also classified according to EuroRAP (European Road Assessment Programme) criteria, and human behavior in terms of speeding, seat belt use, and driving under the influence of alcohol. Each crash was compared with the model criteria, to identify components that might have contributed to fatal outcome. All fatal crashes where a car occupant was killed that occurred in Sweden during 2004 were included: in all, 215 crashes with 248 fatalities. The data were collected from the in-depth fatal crash data of the Swedish Road Administration (SRA).

RESULTS

It was possible to classify 93% of the fatal car crashes according to the SRA model. A number of shortcomings in the criteria were identified since the model did not address rear-end or animal collisions or collisions with stationary/parked vehicles or trailers (18 out of 248 cases). Using the further developed model, it was possible to identify that most of the crashes occurred when two or all three components interacted (in 85 of the total 230 cases). Noncompliance with safety criteria for the road user, the vehicle, and the road led to fatal outcome in 43, 27, and 75 cases, respectively.

CONCLUSIONS

The SRA model was found to be useful for classifying fatal crashes but needs to be further developed to identify how the components interact and thereby identify weaknesses in the road traffic system. This developed model might be a tool to systematically identify which of the components are linked to fatal outcome. In the presented study, fatal outcomes were mostly related to an interaction between the three components: the road, the vehicle, and the road user. Of the three components, the road was the one that was most often linked to a fatal outcome.

LATCH (Lower Anchors and Tethers for CHildren) usability in school buses and passenger vehicles

OBJECTIVE

The present study was designed to assess LATCH (Lower Anchors and Tethers for CHildren) usability in both cars and school buses. Despite being designed to make child restraint system (CRS) installation in vehicles easier and with fewer opportunities for misuse, there have been reports that LATCH is not as easy to use, or as effective, as hoped. To date, there have been few systematic or experimental studies evaluating LATCH usability. Further, based on research demonstrating that small children in school buses are not protected from injury in the same manner as larger children, motor vehicle safety regulations now require LATCH anchorages to be installed on a proportion of seats in all school buses, allowing for the installation of CRS. The main objectives of the study were to assess LATCH usability in cars and school buses and to make recommendations to improve its design and labeling.

METHODS

Forty-eight paid participants (younger vs. older; experienced vs. not experienced) installed CRS in a car and a school bus using three different types of lower anchorage connectors and top tethers. Dependent measures included time to install and remove the CRS, frequency and seriousness of errors, and subjective usability reports.

RESULTS

Surprisingly, many participants were not familiar with the LATCH system and believed that CRS should only be installed using the seat belt. Over 40% of participants did not know where the lower anchorage connectors were located in the car. While installation performance using LATCH was generally satisfactory (all CRS were installed correctly between 70 and 92% of the time), LATCH design improvements in terms of the CRS and both vehicles were identified.

CONCLUSIONS

The study results generated a number of recommended design improvements that would improve LATCH usability in cars and school buses. These include: 1) clearly identifying LATCH anchors in both vehicle types by using clear, conspicuous labels or pictograms; 2) making LATCH anchors in all vehicles more accessible; 3) designing LATCH components for CRS that are easy to use correctly, provide adequate feedback to users, and are difficult to misuse; 4) anticipating, and designing to minimize, incompatibility between CRS and vehicles; 5) using maximum seat spacing in school buses for seats equipped with LATCH anchors; and, most importantly, 6) raising awareness of LATCH in the driving public.

The safest seat: effect of seating position on occupant mortality

INTRODUCTION

This study investigated the survival rates of occupants of passenger cars involved in a fatal crash between 2000 and 2003.

METHODS

The information from every fatal crash in the United States between 2000 and 2003 was analyzed. Variables such as seat position, point of impact, rollover, restraint use, vehicle type, vehicle weight, occupant age, and injury severity were extracted from the Fatality Analysis Reporting System (FARS). Univariate and a full logistic multivariate model analyses were performed.

RESULTS

The data show that the rear middle seat is safer than any other occupant position when involved in a fatal crash. Overall, the rear (2(nd) row) seating positions have a 29.1% (Univariate Analysis, p<.0001, OR 1.29, 95% CI 1.22 - 1.37) increased odds of survival over the first row seating positions and the rear middle seat has a 25% (Univariate Analysis, p<.0001, OR 1.25, 95% CI 1.17 - 1.34) increased odds of survival over the other rear seat positions. After correcting for potential confounders, occupants of the rear middle seat have a 13% (Logistic Regression, p<.001, 95% CI 1.02 - 1.26) increased chance of survival when involved in a crash with a fatality than occupants in other rear seats.

CONCLUSION

This study has shown that the safest position for any occupant involved in a motor-vehicle crash is the rear middle seat.

IMPACT ON INDUSTRY

The results of this research may impact how automobile manufacturers look at future rear middle seat designs. If the rear seat was to be designed exactly like its outboard counterparts (headrest, armrests, lap and shoulder belt, etc.) people may choose to sit on it more often rather than waiting to use it out of necessity due to multiple rear seat occupants.

[Seatbelts on school buses: are they safe for our children?]

In Israel, 280,000 pupils travel daily to school and back home by means of school transportation. In an effort to increase school transportation safety, the installation of lap belts in school transportation vehicles is required since September 1, 2006. In Israel, laws are often passed with good intentions, but frequently without exploring the potential outcomes. Traffic regulation 364a states that "lap belts or other seatbelts" are required in all vehicles used for school transportation. The objective of this study is to review the world-wide literature regarding seatbelts on school buses with an emphasis to identify the risks associated with lap restraints. Over 50 studies, articles and position papers referring to the efficacy of seatbelts, with an emphasis on school transportation, were reviewed. According to the literature, this new traffic regulation could produce more devastating outcomes than previously. Seatbelts were designed to prevent passenger injuries during a motor vehicle crash. Researchers have not proven efficacy of seatbelts in school buses. Lap-only belts have shown to increase the risk of severe injury among children, even in mild crashes. Since young children are not adequately developed to take the force of a lap-only restraint, these belts have been associated with internal injuries, lumbar fracture-dislocations, abdominal contusions and head injuries. The National Highway Traffic Safety Administration (NHTSA) in the USA has reported that lap belts are not effective in preventing injury among children traveling by bus. Children have a two to three fold risk of severe injury when using lap only restraints. On the contrary, lap-shoulder belts may reduce the risk of abdominal injuries by up to 50% relative to lap-only belts. In conclusion, policy makers aimed to implement regulations which will reduce injuries and fatalities. However, neglecting to carry out an in-depth professional review has brought about a regulation requiring lap belts in school buses; a decision which, according to international research studies, can potentially increase the injury risks among pupils.

Analysis of seating position and anthropometric parameters of pregnant Japanese drivers

OBJECTIVE

An anthropometric study was performed to understand the quantitative characteristics of the seating posture of Japanese pregnant drivers.

METHODS

Twenty pregnant women with a mean gestation of 31.4 +/- 1.9 weeks and 20 age-matched, non-pregnant women provided written informed consent to participate in this study. A mid-sized, sedan-type passenger vehicle was used for measurement. The subjects, wearing light clothing, sat in the driver's seat of the vehicle and fastened the seatbelt after adjusting the seat to their usual driving posture. Longitudinal displacement of the slide adjuster and the reclining angle of the seat back were measured, relative to the reference position. Seating posture was investigated by measuring the coordinates of the anthropometric datum points of the drivers (head, shoulder, hip joint, knee joint, and the clearance between the steering wheel and the upper torso).

RESULTS

The mean horizontal clearance between the lower rim of the steering wheel and the abdomen of the pregnant women was 146 +/- 56 mm, significantly smaller than that of the non-pregnant women (251 +/- 51 mm), due to the protrusion of the abdomen. There was no significant difference in seat adjustment position between the two groups. The height of the pregnant women and the horizontal distance from the lower rim of the steering wheel to the abdomen showed a moderate linear correlation in the pregnant group (R2 = 0.56).

CONCLUSIONS

Compared to previous studies, the differences of longitudinal distance were found between American and Japanese subjects without significant differences of body heights, due to the difference of body weights and abdominal circumferences. This is the first report to analyze the seating position and anthropometric parameters of pregnant drivers in an Asian population.

Using head-on collisions to compare risk of driver death by frontal air bag generation: a matched-pair cohort study

US air bag regulations were changed in 1997 to allow tests of unbelted male dummies in vehicles mounted and accelerated on sleds, resulting in longer crash pulses than rigid-barrier crashes. This change facilitated depowering of frontal air bags and was intended to reduce air bag-induced deaths. Controversy ensued as to whether sled-certified air bags could increase adult fatality risk. A matched-pair cohort study of two-vehicle, head-on, fatal collisions between drivers involving first-generation versus sled-certified air bags during 1998-2005 was conducted by using Fatality Analysis Reporting System data. Sled certification was ascertained from public information and a survey of automakers. Conditional Poisson regression for matched-pair cohorts was used to estimate risk ratios adjusted for age, seat belt status, vehicle type, passenger car size, and model year for driver deaths in vehicles with sled-certified air bags versus first-generation air bags. For all passenger-vehicle pairs, the adjusted risk ratio was 0.87 (95% confidence interval: 0.77, 0.98). In head-on collisions involving only passenger cars, the adjusted risk ratio was 1.04 (95% confidence interval: 0.85, 1.29). Increased fatality risk for drivers with sled-certified air bags was not observed. A borderline significant interaction between vehicle type and air bag generation suggested that sled-certified air bags may have reduced the risk of dying in head-on collisions among drivers of pickup trucks.

Deaths among drivers and right-front passengers in frontal collisions: redesigned air bags relative to first-generation air bags

OBJECTIVE

After automakers were allowed the option of using sled tests for unbelted male dummies to certify the frontal crash performance of vehicles, most frontal air bags were depowered, starting in model year 1998, to reduce deaths and serious injuries arising from air bag deployments. Concern has been expressed that depowering air bags could compromise the protection of adult occupants. This study aimed to determine the effects of changes in air bag designs on risk of death among front-seat occupants.

METHODS

Deaths among drivers and right-front passengers per involvement in frontal police-reported crashes during calendar years 1998-2004 were compared among vehicles with sled-certified air bags (model years 1998-2004) and first-generation air bags (model years 1994-97). Frontal crash deaths were identified from the Fatality Analysis Reporting System. National estimates of police-reported crashes were derived from the National Automotive Sampling System/General Estimates System. Sled certification status for model years 1998-2004 was ascertained from published federal data and a survey of automobile manufacturers. Passenger cars, pickup trucks, sport utility vehicles, and minivans were studied. Stratified analyses were done to compute risk ratios (RR) and 95% confidence intervals (95% CI) for driver and right-front passenger deaths by air bag generation and crash, vehicle, and driver characteristics.

RESULTS

In frontal crashes, overall RRs were 0.89 for driver deaths (95% CI = 0.74-1.08) and 0.89 for right-front passenger deaths (95% CI = 0.74-1.07) in sled-certified vehicles compared with first-generation air bag-equipped vehicles. Child right-front passengers (ages 0-4, 5-9) in vehicles with sled-certified air bags had statistically significant reductions in risk of dying in frontal collisions, including a 65% reduced risk among ages 0-4 (RR = 0.35; 95% CI = 0.21-0.60). No differences in effects of sled-certified air bags were observed between drivers ages 15-59 and 60-74 in sled-certified vehicles, both of whom had RRs slightly below 0.90 (non-significant). Among occupants killed in sled-certified vehicles, police-reported belt use was somewhat higher than in first-generation vehicles.

CONCLUSIONS

No differences in risk of frontal crash deaths were observed between adult occupants with sled-certified and first-generation air bags. Consistent with reports of decreases in air bag-related deaths, this study observed significant reductions in frontal deaths among child passengers seated in the right-front position in sled-certified vehicles. Higher restraint use rates among children in sled-certified vehicles and other vehicle design changes might have contributed partially to these reductions.

Premature graduation of children in child restraint systems: an observational study

This study investigated the use and misuse of child restraint systems (CRS) in Flanders (Belgium). Observations were conducted at a random sample of primary school and recreation areas. In total 1376 children were observed. A logistic regression model was constructed in order to determine the variables involved. The parameter-estimates of this model have shown that children are more often restrained when the driver buckles up, the ride takes less than 1h, the children are younger, the children sit in the front seat of the car, a recreational area is the destination of the trip and there are less than five children in the car. Also premature graduation to CRS was analysed. More than half of the children are not appropriately restrained, according to their age, weight or height. Improper shoulder belt use (putting the shoulder belt behind the back or under the arm) was observed in 8.99% of the children being restrained with high back booster seats, in 32.73% of the children being restrained with backless booster seats and finally in 19.07% of the children being restrained with seat belts. The risk of incorrectly using the shoulder belt increases when children are prematurely graduated in a CRS. The results are discussed in the light of other studies on this matter.

School transportation safety

This policy statement replaces the previous version published in 1996. It provides new information, studies, regulations, and recommendations related to the safe transportation of children to and from school and school-related activities. Pediatricians can play an important role at the patient/family, community, state, and national levels as child advocates and consultants to schools and early education programs about transportation safety.

A pilot survey of child restraint and seating position in cars in Florence Health Authority area

To investigate the use of child restraint and seating position in Florence, in the Centre of Italy, after the introduction of the New Italian road traffic law, a survey has been conducted. Direct observations were made in the areas related to three schools attended by children of different age groups, to determine the presence of child car seats and their positioning as well as child positioning in case of absence of the seat. A total of 328 vehicles have been observed; in 48.5% of the cars, seats for children were present, 39% were used, and 9% were not used. The presence of child restraint and its use differed according to age, school opening and closing time and number of children on board. When restraints were not present, children were mostly (38%) located on the front seat without an accompanying adult. Child seats were prevalently located in the rear. In spite of the introduction of New Italian road traffic law, in the study area the modality of children's transport in cars was frequently not correct, which constitutes a risk for the health of this specific target group.

Effectiveness of child safety seats vs safety belts for children aged 2 to 3 years

OBJECTIVE

To compare the effectiveness of child safety seats and lap-shoulder belts in rear passenger vehicle seats for 2- to 3-year-old crash survivors.

DESIGN

Cohort study.

SETTING

The January 1, 1998, to December 31, 2004, US data on a nationally representative sample of crashes that resulted in at least 1 vehicle being towed away.

PARTICIPANTS

Toddlers who were sitting in rear vehicle seats and using lap-shoulder belts or child seats when involved in highway crashes.

INTERVENTION

Child safety seat vs safety belt.

OUTCOME MEASURE

Presence of any injury after a crash.

RESULTS

The adjusted odds of injury were 81.8% lower (95% confidence interval, 58.3%-92.1% lower) for toddlers in child seats than belted toddlers.

CONCLUSIONS

Child safety seats seem to be more effective rear seat restraints than lap-shoulder safety belts for children aged 2 to 3 years. Laws requiring that children younger than 4 years travel in child safety seats have a sound basis and should remain in force.

Misuse study of latch attachment: a series of frontal sled tests

This study was initiated to quantify the effects of the misuse in LATCH lower webbing. In the short period since the implementation of the LATCH system several cases of potential misuses have been reported. A series of sled tests in frontal impact mode were conducted with various misuse conditions (loose attachment of LATCH lower webbing, misrouting of LATCH lower webbing and child seat back inclination) for both forward and rearward facing child safety seats (FFCSS and RFCSS). Results from these tests are compared and discussed with that of the standard test with no misuse and showed that as the slack in the lower LATCH webbing increased, ATD injury measures exceeded the limits. The FFCSS tests in the reclined condition yielded lower injury values for all except the chest G's when compared to the standard upright test. In the misrouting tests the ATD kinematics depended on the routing pivot point, the lower the pivot point the better the ATD kinematics. Similar findings were also observed in the RFCSS tests. The use of top tether with the FFCSS substantially improved the performance of the Hybrid III 3 year old ATD in spite of misuse conditions and the injury values were lower than the corresponding tests with no top tether. The effective reduction was 37% in the HIC values, 6% in the chest G's, 30% in the head excursion, 22 % in the knee excursion and finally 37 % reduction in the Nij values.

An evaluation of the EuroNCAP crash test safety ratings in the real world

We investigated whether the rating obtained in the EuroNCAP test procedures correlates with injury protection to vehicle occupants in real crashes using data in the UK Cooperative Crash Injury Study (CCIS) database from 1996 to 2005. Multivariate Poisson regression models were developed, using the Abbreviated Injury Scale (AIS) score by body region as the dependent variable and the EuroNCAP score for that particular body region, seat belt use, mass ratio and Equivalent Test Speed (ETS) as independent variables. Our models identified statistically significant relationships between injury severity and safety belt use, mass ratio and ETS. We could not identify any statistically significant relationships between the EuroNCAP body region scores and real injury outcome except for the protection to pelvis-femur-knee in frontal impacts where scoring "green" is significantly better than scoring "yellow" or "red".

Performance of booster seats in side impacts: effect of adjacent passengers and ISOfix attachment

This study examined the performance of a booster seat in different seating configurations in side-impact hyGe sled tests (crash severity 30 km/h) with two attachment systems: a standard seatbelt and ISOfix (rigid). The objectives of the study were twofold: (i) to identify the relative benefits of ISOfix attachment compared with seatbelt attachment of a near-side booster seat in a 3-abreast seating configuration with adjacent occupants in child restraints (CRS); and (ii) to examine the effects of 3-abreast seating configurations compared with no adjacent passengers on booster seat crash protection characteristics. Overall, the findings confirmed the superior performance of the rigid anchorages in reducing lateral motion of the booster as well as the two adjacent CRS. However, the expected benefits of the rigid attachment in reducing head accelerations were not uniformly observed across the three occupants/seating positions and also appeared to be influenced by seating configuration (3-abreast versus no adjacent occupant). Further research is warranted to explore the applicability of the findings for different CRS types and seating configurations.

Factors influencing occupant-to-seat belt interaction in far-side crashes

Seat belt interaction with a far-side occupant's shoulder and thorax is critical to governing excursion towards the struck-side of the vehicle in side impact. In this study, occupant-to-belt interaction was simulated using a modified MADYMO human model and finite element belts. Quasi-static tests with volunteers and dynamic sled tests with PMHS and WorldSID were used for model validation and comparison. Parameter studies were then undertaken to quantify the effect of impact direction, seat belt geometry and pretension on occupant-to-seat belt interaction. Results suggest that lowering the D-ring and increasing pretension reduces the likelihood of the belt slipping off the shoulder. Anthropometry was also shown to influence restraint provided by the shoulder belt. Furthermore, the belt may slip off the occupant's shoulder at impact angles greater than 40 degrees from frontal when no pretension is used. However, the addition of pretension allowed the shoulder to engage the belt in all impacts from 30 to 90 degrees.

Misuse of child restraint systems in crash situations - danger and possible consequences

Based on real-world crash data and recent field studies, an ad-hoc group was set up in order to have a better comprehension of the effects of misuse of Child Restraint Systems (CRS) on child protection. A testing programme of 60 single misuse situations was conducted. Test results confirmed that, in frontal impact, children have higher risk of being injured on a number of different body regions when CRS's are misused. This work provides material for educational and training purposes to help parents understand that child restraints need to be correctly fitted in order to provide the level of protection they are designed for.

Correct and incorrect use of child restraints: Results from an urban survey in New Zealand

This study describes the incorrect use of child restraints among car drivers with young children and examines factors that may influence their misuse. A cross-sectional survey was undertaken in supermarket car parks with car drivers travelling with children under the age of 8 years. The main measure was errors in child restraint use. Short interviews were conducted with 1113 drivers with a close inspection of the child restraints used in the vehicles. Only 4% of children were unrestrained but 64% of drivers made at least one error in restraint use. Most respondents thought using a restraint was easy, but 65% of these drivers made at least one error. Child restraints are used, but many are incorrectly fitted and/or have the child incorrectly placed in them. Correct use is a moderately complex task. Restraint systems need to be designed to minimize the opportunity for error and maximize safety.

A survey of tractors and rollover protective structures in Washington State

A survey of farms in Washington State was conducted to determine tractor characteristics and the presence of rollover protective structures (ROPS) in a state with more inclusive rules on tractor retrofitting than federal regulations. A total of 544 valid surveys were completed from a proportional random sample across different types of farms. Responders indicated that 58% of tractors overall were equipped with ROPS, and 42% of the tractors without ROPS were exempt from the state rules. Seatbelts on tractors equipped with ROPS were reportedly used "sometimes" or more 30% of the time, and 17% of these tractors had no seatbelt installed. Tractors used for row crop farming were significantly more likely to be equipped with ROPS than those used for tree, vine, or hops farming. Older tractors were used for fewer hours, were less likely to be ROPS-equipped, and were less likely to be operated while wearing a seatbelt. The results were consistent with a positive effect of the Washington State ROPS requirements, demonstrated by the increased percentage of ROPS-equipped pre-1976 tractors, as compared to other states, and by the difference between ROPS-equipped tractors in exempt and non-exempt types of farming. The results point to the need for prevention activities to increase seatbelt use on ROPS-equipped tractors, and for further development of practical protection for tractors operating under overhead obstacles.

Impact of domestic violence posters on female caregivers' opinions about domestic violence screening and disclosure in a pediatric emergency department

OBJECTIVES

The objectives of this study were to examine female caregivers' attitudes about the display of domestic violence (DV) resources in a pediatric emergency department (ED) and to explore whether these resources engendered positive feelings about DV screening and encouraged disclosure.

METHODS

We conducted a cross-sectional survey in a pediatric ED during 2 distinct periods, comparing responses of female caregivers before (pre) and after (post) displaying DV posters and cards. Women were surveyed about (1) personal experience with DV, (2) the appropriateness of DV posters and screening in a pediatric ED, and (3) willingness to divulge DV, if abused.

RESULTS

The 2 groups (pre, n = 133; post, n = 136) did not significantly differ with respect to age, race, education, or personal DV history. The majority endorsed that "it is appropriate to have DV posters," with the post group responding in this manner more often than the pre group (pre, 85%; post, 95%; odds ratio [OR], 3.3; 95% confidence interval [CI], 1.3-8.5). The post group was less likely to prefer pediatric ED DV screening (pre, 76%; post, 63%; OR, 0.5; 95% CI, 0.3-0.9) and tended to be less likely to say that they would divulge (pre, 85%; post, 75%; OR, 0.6; 95% CI, 0.3-1.1). In both groups, women with a DV history were less likely than women without this history to say that they would disclose DV to their pediatric ED provider (P < 0.001).

CONCLUSIONS

These results suggest the need for further exploration of how to most effectively help and provide resources for abused women in this setting.

Child and provider restraints in ambulances: knowledge, opinions, and behaviors of emergency medical services providers

BACKGROUND

Approximately 16,000 children are transported by ambulances each day, and there are an estimated 4,500 ambulance crashes each year. Information about emergency medical services (EMS) provider knowledge, opinions, and behaviors regarding occupant restraint is lacking.

OBJECTIVES

To measure the knowledge, opinions, and behaviors of EMS personnel regarding child and provider restraint use in ambulances.

METHODS

A survey was given to all EMS providers in two large ambulance-service organizations and in a hospital-based pediatric ambulance service in a midsized urban area.

RESULTS

A total of 302 EMS providers were surveyed, for a return rate of 67.7%. Nearly half were involved in an ambulance crash at least once; of those, 7.6% were injured and 1% had patients in their care injured. The majority (91%) reported some training in child-restraint use in ambulances, and half reported that they know a lot or very much about securing a critically ill child for transport. However, 30% did not identify the correct method of transport for a stable 2-year-old, and 40% did not choose the correct method of securing a child seat to the ambulance cot. Securing a child seat to the cot was viewed by 81% to not take too much time from patient care, and 63% did not view caring for a child in a car seat as difficult. Although 80% of providers regularly transported children in a car seat, 23% transported them on an adult's lap at least sometimes. Specialized pediatric-transport providers were more likely to report safe pediatric and occupant restraint practices than were community EMS providers. Pediatric restraint behaviors were not associated with years of service or history of a crash. Two thirds of respondents reported not wearing their seatbelt on the squad bench while treating patients, and half believe that wearing a seatbelt interferes with patient care. A total of 95% report wearing seatbelts in the front seat of the ambulance. Provider seatbelt use in the patient compartment was not associated with years of service, with number of crashes, or with reporting correct use of pediatric restraints.

CONCLUSIONS

This study indicates that the frequency of crashes in ambulances, and therefore the potential for injury, may be underappreciated. Current restraint practices of some of the study group are outside recommendations and may be placing at risk some children who are being transported by ambulances. This problem is complicated by the relative infrequency of pediatric ambulance transports compared with adults. Improved equipment and education may help providers safely transport pediatric patients. In addition, providers are risking their own safety by not wearing seatbelts in the rear ambulance compartment. Improved equipment may help alleviate this risk and allow providers to take care of patients safely.

Are restrained children under 15 years of age in cars as effectively protected as adults?

AIM

To compare the injury distribution between children and adults, injured as restrained car passengers.

METHODS

Population based study of data from a French road trauma registry in 1996-2002. Children under 15 years old were compared with adult casualties according to the distribution of serious injuries in three distinct body regions (head, chest, and abdomen) when they were restrained car passengers. A multivariate logistic regression was performed to quantify the risk of AIS2+ injury (Abbreviated Injury Scale of 2 or more).

RESULTS

Among the 7568 casualties who were injured as restrained car passengers in car accidents, 1033 were less than 15 years old. Overall, 35.4% of children and 25.2% of adults were unrestrained. For children and adults, the risk of fatality was significantly reduced when they were restrained, but the percentages of children with Injury Severity Score (ISS) > or =16, were not significantly different between restrained and not restrained casualties. Compared to adults, restrained children aged 5-9 were 2.7 times (OR 2.74; 95% CI 1.17 to 6.43) as likely to sustain an AIS2+ abdominal injury, and tended to be more at risk of AIS2+ head injuries, but were less at risk of AIS2+ chest injuries.

CONCLUSIONS

Children aged 5-9 years injured in road accidents as restrained car passengers were more likely to sustain an AIS2+ abdominal injury than adults. This emphasises the need to reinforce educational campaigns aimed not only at getting children into restraint systems, but also insisting on their correct use.

Child safety seat counseling: three keys to safety

The number one cause of death for children younger than 14 years is vehicular injury. Child safety seats and automobile safety belts protect children in a crash if they are used correctly, but if a child does not fit in the restraint correctly, it can lead to injury. A child safety seat should be used until the child correctly fits into an adult seat belt. It is important for physicians caring for children to know what child safety seats are available and which types of seats are safest. Three memory keys will help guide appropriate child safety seat choice: (1) Backwards is Best; (2) 20-40-80; and (3) Boost Until Big Enough. "Backwards is Best" cues the physician that infants are safest in a head-on crash when they are facing backward. "20-40-80" reminds the physician that children may need to transition to a different seat when they reach 20, 40, or 80 lb. "Boost Until Big Enough" emphasizes that children need to use booster seats until they are big enough to fit properly into an adult safety belt.

Risk of pediatric head injury after motor vehicle accidents

OBJECT

Injury to the brain as a result of motor vehicle accidents (MVAs) represents a frequent cause of pediatric disability. The authors analyze the correlation between the relative risk of pediatric brain injury and the use of child safety seats (CSSs).

METHODS

A national database of MVAs was examined to provide data for the analysis of four age categories (infant, toddler, young child, and adolescent) and four restraint categories (unrestrained, properly restrained, improperly restrained, and other). The Abbreviated Injury Scale (AIS) was used to assess the severity of head injury; children with no injuries and children with moderate-to-maximum head injuries were evaluated. The data confirm that proper use of a CSS substantially increases the likelihood of not sustaining head injury in an MVA. The data are most dramatic for infants (the likelihood of sustaining no head injury was 15.2% for unrestrained infants compared with 92.8% for properly restrained infants) but the protective effect is seen in all age categories, with the least difference observed in the adolescent category. For children who sustain a moderate-to-maximum head injury, proper use of a CSS reduces the incidence of injury, again most dramatically for the infant category (unrestrained infants had a 7% risk of moderate-to-maximum head injury compared with only 0.5% for properly restrained infants).

CONCLUSIONS

Improvements in CSSs have reduced the risk of moderate-to-maximum head injuries in children of all age categories. Overall, a CSS is most protective for the infant and toddler categories. The improperly restrained child still has substantial protection, although the properly restrained child has more. Detailed parental education regarding appropriate restraint system installation and use should be required.