Use of booster seats by Michigan children 4-8 years of age

Using Crash Outcome Data Evaluation System (CODES) to examine injury in front vs. rear-seated infants and children involved in a motor vehicle crash in New York State

Background

In New York State (NYS), motor vehicle (MV) injury to child passengers is a leading cause of hospitalization and emergency department (ED) visits in children aged 0–12 years. NYS laws require appropriate child restraints for ages 0–7 years and safety belts for ages 8 and up while traveling in a private passenger vehicle, but do not specify a seating position.

Methods

Factors associated with injury in front-seated (n = 11,212) compared to rear-seated (n = 93,092) passengers aged 0–12 years were examined by age groups 0–3, 4–7 and 8–12 years using the 2012–2014 NYS Crash Outcome Data Evaluation System (CODES). CODES consists of Department of Motor Vehicle (DMV) crash reports linked to ED visits and hospitalizations. The front seat was row 1 and the rear rows 2–3. Vehicle towed from scene and air bag deployed were proxies for crash severity. Injury was dichotomized based on Maximum Abbreviated Injury Severity (MAIS) scores greater than zero. Multivariable logistic regression (odds ratios (OR) with 95% CI) was used to examine factors predictive of injury for the total population and for each age group.

Results

Front-seated children had more frequent injury than those rear-seated (8.46% vs. 4.92%, p < 0.0001). Children in child restraints experienced fewer medically-treated injuries compared to seat belted or unrestrained children (3.80, 6.50 and 13.62%, p < 0.0001 respectively). A higher proportion of children traveling with an unrestrained vs. restrained driver experienced injury (14.50% vs 5.26%, p < 0.0001). After controlling for crash severity, multivariable adjusted predictors of injury for children aged 0–12 years included riding in the front seat (1.20, 1.10–1.31), being unrestrained vs. child restraint (2.13, 1.73–2.62), being restrained in a seat belt vs. child restraint (1.20, 1.11–1.31), and traveling in a car vs. other vehicle type (1.21, 1.14–1.28). Similarly, protective factors included traveling with a restrained driver (0.61, 0.50–0.75), a driver aged < 25 years (0.91, 0.82–0.99), being an occupant of a later vehicle model year 2005–2008 (0.68, 0.53–0.89) or 2009–2015 (0.55, 0.42–0.71) compared to older model years (1970–1993).

Conclusions

Compared to front-seated children, rear-seated children and children in age-appropriate restraints had lower adjusted odds of medically-treated injury.

Child Passenger Restraint System Misuse in Rural Versus Urban Children: A Multisite Case-Control Study

OBJECTIVES

Motor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population.

METHODS

A multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions.

RESULTS

Four hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02).

CONCLUSIONS

In this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified.

Parents' knowledge, attitude, and use of child restraints, Shantou, China

BACKGROUND

China has not adopted national policies for child safety restraints in cars, although children are increasingly traveling in cars.

OBJECTIVE

To describe child restraint use, and parents' knowledge of and attitude toward child restraint in Shantou, China.

METHODS

An observational study and driver survey on child restraint use was conducted in the Southeast China city of Shantou in 2012. Observational sites included 22 middle schools, 31 primary schools, 24 kindergartens, and 4 hospitals. Drivers were asked about their knowledge of and attitude toward the use of child restraints. In September 2012, multivariate regression was used to evaluate the factors associated with increased child restraint use.

RESULTS

Of 3333 children observed in vehicles, only 22 (0.6%) children were secured in child safety seats or booster seats and 292 (8.7%) children were wearing seatbelts. More than half (n=508, 56.1%) of the infants or toddlers were riding on the laps of adults. Of 1069 drivers who responded to the survey, more than 62% thought it was necessary to use child restraint while traveling in a car. The drivers' higher education status (OR=1.56, 95% CI=1.07, 2.27) and seatbelt use (OR=4.00, 95% CI=2.56, 6.25) were associated with increased child restraint use. Parents (OR=0.55, 95% CI=0.34, 0.88) and male drivers (OR=0.61, 95% CI=0.46, 0.81) had reduced odds of children properly rear-seated.

CONCLUSIONS

Child restraint use is very low in China, although the majority of drivers had positive attitudes about child restraint. These findings indicate that child restraint policies and educational approaches are urgently needed in China.

Tweens at risk: examining car safety practices in four economically disadvantaged urban elementary schools in Virginia

INTRODUCTION

Children aged 8- to 12-years-old ("tweens") are at high risk for crash injury, and motor vehicle crashes are their leading cause of death.

METHOD

Data are presented from behavioral observations (N=243), surveys (N=677), and focus groups (N=26) conducted with tweens attending four urban elementary schools in Virginia. The populations assessed were predominantly black (77.9%) and economically disadvantaged (61.9%).

RESULTS

Focus groups revealed a number of inconsistencies in and misconceptions about safety practices. Among the 677 tweens who completed anonymous surveys, the majority (58.1%) reported wearing their seat belts "not very much at all" or "never." Many students (47.8%) reported usually sitting in the front seat or sitting in the front and back seats equally. This is despite the fact that most (92.0%) knew that the back seat was the safest place to sit. Of the 243 tweens observed in vehicles, 65.0% were unrestrained and 60.1% were seated in the front passenger seat.

IMPACT ON INDUSTRY

Findings of this study shed light on the great disparity between the national rates for child safety practices and those of children living in an economically disadvantaged urban school district. Additional intervention programs that are culturally appropriate and specifically target this age group are needed.

Association between child restraint systems use and injury in motor vehicle crashes

OBJECTIVES

The objective was to estimate the fatal and nonfatal injury risk associated with inappropriate or no use of child restraint systems (CRS) for children younger than 13 years of age involved in motor vehicle crashes (MVC) in the United States.

METHODS

This was a cross-sectional study of children aged 0 to 12 years involved in MVCs based on a nationally representative probability sample from 1996 to 2005 in the United States. A total of 7,633 children were included in the analysis, weighted to represent 3,798,830 children. Logistic regression models were used to examine the association between restraint use and fatal or nonfatal injury.

RESULTS

In all age groups, failure to use a restraint increased the risk of fatal injury (odds ratio [OR] ranged from 9.81 to 23.79, all p < 0.05). In children aged 1 to 3 years, inappropriate use of a restraint was associated with fatal injury (OR = 6.28, 95% confidence interval [CI] = 2.40 to 16.48). Restrained children aged 4 to 7 years in rear seats with seat belts only (OR = 0.33, 95% CI = 0.11 to 0.94) and infants in front seats using child safety seats (OR = 0.26, 95% CI = 0.07 to 0.99) were associated with decreased nonfatal but not fatal injury compared to children with the recommended use of CRS in the two age groups.

CONCLUSIONS

Failure to use child restraints was associated with increased fatal injury. Our findings raise questions regarding current recommendations for specific CRS use in infants and children 4 to 7 years old. Further research is needed to identify the most effective CRS and seating location for children of each age.

Modeling improvements in booster seat use: a discrete choice conjoint experiment

Automobile crashes are the leading cause of death in children aged 1-14 years. Many children, however, are not properly restrained in safety seats that reduce serious injury and death. This study used a discrete choice conjoint experiment to study factors influencing the decision to use booster seats. Parents of 1714 children aged 4-9 years from nine Canadian provinces completed choice tasks presenting experimentally varied combinations of 15 4-level booster seat promotion attributes. Latent class analysis yielded three segments of parents. The choices of the Benefit Sensitive segment (50%) were most sensitive to the injury prevention benefits of booster seats. The choices of parents in the Context Sensitive segment (33.5%) were more likely to be influenced by installation complexity, oppositional behavior, and the prospect that their child may be teased for riding in booster seats. Parents in the High Risk segment (16.5%) were younger, less educated, and less knowledgeable about vehicle safety legislation. They anticipated fewer benefits, expected more barriers and were less likely to use booster seats. Simulations suggest that consistent enforcement coupled with advertising focusing on injury prevention and the use of booster seats by other parents would increase adoption.

Methodology of estimating restraint use in children: roadside observation or parking lot interview survey

OBJECTIVE

To compare the differences in Canadian national estimates of correct child restraint use obtained using the standard roadside observation method compared to a detailed parking lot interview.

DESIGN

A multi-stage stratified survey design was used to conduct roadside observational and interview data collection at 182 randomly selected sites across Canada. For each site, a roadside intersection location and a parking lot location were used for the roadside observational survey and the interview respectively. Weighted estimates of correct restraint use from both locations were compared.

RESULTS

Estimates of correct restraint use were significantly higher for all children under the age of 9 in the parking lot sample. The largest discrepancy between the two samples was in booster seat aged children (ages 4-8) where 29.1% versus 67.8% of children were observed to be correctly restrained using the roadside and the parking lot methodology respectively. There was a 67% participation refusal rate in the parking lot survey.

CONCLUSIONS

There are specific advantages and limitations to both survey designs. The purpose of the data collection must be considered when selecting the methodology. Parking lot surveys provide richer data regarding restraint use/misuse. Estimates of correct restraint use must be approached with caution due to the effect of consent bias resulting in over inflation of estimates. Roadside observation is adequate and appropriate for providing national estimates of correct restraint use.

Driver characteristics associated with child safety seat usage in Malaysia: a cross-sectional study

BACKGROUND

The rapidly motorizing environment in Malaysia has made child occupant safety a current public health concern. The usage of child safety seats (CSS) is a widely regarded intervention to enhance child occupant safety, yet no study has been conducted on CSS in Malaysia. This study aims to determine the CSS usage rates in Malaysia and to assess driver characteristics that are associated with CSS usage.

METHODS

Nine variables - urban versus rural study location, age, gender, marital status, educational status, monthly family income, number of children present in the vehicle, distance traveled to the study location, and attitude - were examined through a cross-sectional study of interviewing drivers of 230 vehicles transporting at least one child <10 years of age at the time of the study. The vehicles were also observed for whether or not there was a CSS present. The interviews were conducted at six sampling locations - three urban and three rural - in the state of Melaka.

RESULTS

27.4% of the drivers were found to be using at least one CSS at the time of the survey. Among the nine variables studied, three of the driver characteristics showed statistical significance (p<0.05) with CSS usage: age (p=0.047), educational status (p=0.009), and attitude (p=0.009).

DISCUSSION

This study begins to create knowledge on child occupant safety in Malaysia. The results indicate that interventional efforts should focus on educational programs geared toward drivers that are less educated or extended family members who inconsistently transport young children. Furthermore, any educational efforts could be strongly enhanced by legislation mandating the use of CSS. Every effort should be made to thoroughly assess the effectiveness of any educational or legislative activities that are implemented.

Factors influencing premature graduation from the use of child restraints in Japan

This study examined the association of child passenger restraint use by younger and older children taking into account situational factors and driver/child passenger characteristics. The Japanese national traffic accident data pertaining to children injured in rear-end collisions where the drivers were not-at-fault was analyzed, while applying the quasi-induced exposure method. Multivariate logistic regression analyses were conducted to examine the adjusted effects of predictors for proper restraint use by 0-5, 6-9, and 10-12-year-old children. Unbelted drivers, child's seating position, the number of total occupants, and the child's age were significantly associated with restraint use by both younger and older children. Riding in the rear seats was strongly associated with older SB-age children not being properly restrained, suggesting a link between the lack of booster seat-use requirements and the generally low restraint use rate in rear seats as well as the premature graduation from CRS use in general. The results were discussed in light of other international findings in this field.

Evaluation of community-based programs to increase booster seat use

This manuscript reports the results of an evaluation of two community-based booster seat promotion programs in Michigan; one program focused on a low-income community, while the other focused on a Hispanic community. Each community received funding to develop and implement a booster seat intervention program specific to their community. To determine the effectiveness of each program, direct observation surveys of booster seat use were conducted in each community, as well as in similarly composed comparison communities, before and after program implementation. A process evaluation documented activities and provided additional information for interpreting the results of the direct observation survey. Target age children (4-8 years) were observed traveling in cars, vans/minivans, sport-utility vehicles, and pickup trucks in each community. Baseline booster seat use was 19.0+/-5.3% and 9.7+/-2.5% for the low-income and Hispanic program communities, respectively. Post program results showed no significant change for the low-income program community, and a significant increase within the Hispanic program community. The process evaluation revealed challenges for each program and suggestions to overcome those challenges. Findings from the study can be useful to other communities interested in implementing programs to increase the use of booster seats.

Epidemiology and outcomes of pediatric traumatic brain injury

Traumatic brain injury is a leading cause of death and disability in the pediatric age group. Causes of injury vary with child developmental age, with more inflicted injuries in infants, fall-related injuries among toddlers, sports-related injuries among middle-school-aged children and motor vehicle crashes in older children. Prevention strategies exist for some pediatric traumatic brain injury; however, all suffer from lack of compliance and enforcement. Neuropsychological and behavioral outcomes for injured children vary with the severity of injury, child age at injury, premorbid child characteristics, family factors and the families' socioeconomic status. Each of these factors needs to be taken into account when designing rehabilitation strategies and assessing factors related to outcome.