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

The Effects of Restraint Type on Pattern of Spine Injury in Children

INTRODUCTION

While the use of vehicular restraints has reduced the morbidity and mortality of children involved in motor vehicle collisions (MVC), to our knowledge, no study has examined the relationship between restraint type and patterns of pediatric spinal injuries. The purpose of this study is to evaluate this association and review the spinal injuries sustained in children involved in MVC.

METHODS

We completed an IRB-approved, retrospective chart review of all patients below 10 years of age presenting to a level 1 pediatric trauma hospital with spine injuries sustained in MVC from 2003 to 2011. We reviewed prehospital data, medical records, and radiographs to establish the restraint type and characterize the spinal injuries sustained.

RESULTS

A total of 97 patients were identified with spinal trauma secondary to MVC with appropriate and documentation of restraint type. Results are reported regardless of whether the restraint employed was properly used per established guidelines. Car seat/booster seat (C/B) patients sustained significantly higher rates of cervical spine (62%) and ligamentous (62%) injuries than the 2-point (2P) (10%) and 3-point (3P) restraint (24%) groups (P<0.001). Two-point and 3P restraint use was associated with significantly higher rates of thoracolumbar injuries (67% and 62%, respectively) than the C/B (14%) and unrestrained (0%) groups (P<0.001). Two-point and 3P passengers also had a higher rate of flexion-distraction injuries (P<0.001). Patients in the unrestrained group sustained a significantly higher rate of cervical spine (80%) and ligamentous (40%) injuries than the 2P and 3P groups (P<0.001). No differences were found in the type or location of injury between the 2P and 3P groups. Significant differences in proper restraint use were identified between age groups with younger children demonstrating higher rates of proper restraint use (P<0.01).

CONCLUSIONS

Two-point or 3P seatbelt use is associated with lower rates of cervical spine trauma but higher rates of thoracic and lumbar trauma, particularly flexion-distraction injuries, when compared with car or booster seats. Children in C/B and those who are unrestrained sustain high rates of cervical spine injury.

LEVEL OF EVIDENCE

Level III-prognostic study.

Traveling with children: beyond car seat safety

OBJECTIVE

To spread knowledge and instigate the health professional to give advice on childcare during travels and on child transport safety.

SOURCES OF DATA

Literature review through the LILACS and MEDLINE(®) databases, using the terms: travel, safety, protective equipment, child, preventive medicine, retrieving articles published in the last 21 years.

SUMMARY OF THE FINDINGS

The authors analyzed 93 articles, of which 66 met the inclusion criteria after summaries were read. For drafting this article, the following sub-themes were proposed: getting ready to travel with children; knowing some of the transfer risks (air, land and water transportation) and exploring the destination with children (sun exposure, accommodations, altitude, food, traveler's diarrhea, insect bites) and return from the trip with children.

CONCLUSIONS

Over the years, there has been an increase in the number of children who travel around the world. However, this population is still subject to health problems while traveling and may be even more susceptible than the adult age group. These problems arise from a variety of factors, including exposure to infectious organisms, the use of certain types of transportation, and participation in some activities, such as hiking at high altitudes, among others. However, when traveling with children, these risk factors can be overlooked; a trip that is considered safe for an adult might not be a good choice for this age group. The pediatric consultation should be a good opportunity to optimize preventive guidelines at the pre-trip planning.

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.

Child passenger restraints in relation to other second-row passengers: an analysis of the 2007-2009 National Survey of the Use of Booster Seats

OBJECTIVE

Child restraint systems (CRS) are increasingly being designed to accommodate larger children and to mitigate side impact injuries. Little is known about the impact of CRS on the safety of other vehicle passengers due to limitations of existing crash databases. This study provides the first assessment of the seating positions occupied by child passengers and the relationship between CRS and other second-row passengers in a national sample of vehicles transporting children.

METHODS

A secondary analysis was conducted of data from the 2007-2009 National Survey of the Use of Booster Seats (NSUBS), a direct in-vehicle observational study of child passenger restraint use. Passengers riding in the same vehicle were identified and passenger position was determined. Vehicles with second-row child passengers were included in analyses of seat positions occupied by child passengers with and without CRS. Frequency counts for the different combinations of CRS and passengers in second rows were calculated.

RESULTS

Of the 17,065 vehicles observed in 2007-2009 NSUBS, 14,506 (85%) vehicles contained at least 1 child passenger in a second row that contained no more than 3 total passengers. Of these 14,506 vehicles, 55 percent contained a lone child passenger in the second row. A CRS was in use in 4656 (59%) of the 7949 vehicles with a lone child passenger in the second row compared to 4077 (62%) of the 6557 vehicles with multiple passengers in the second row (P < .001). A passenger was adjacent to a CRS within 1333 (33%) of the 4077 vehicles containing a CRS in the second row. There were 3 second-row passengers in nearly 1 in 5 vehicles containing a CRS in the second row.

CONCLUSION

Adults and children not using CRS are frequently seated in vehicle second rows adjacent to a child restrained in a CRS. These findings should be used to inform the regulation, design, and testing of CRS and to determine the risks of larger CRS designs to other passengers seated in the same vehicle row relative to the benefits of the CRS for the passenger it restrains.

Challenges and Opportunities for Promoting Booster Seat Use

Motivating parents to take certain safety precautions when traveling with their children remains challenging for advocates. Caregivers of booster-aged children are particularly difficult to reach because they do not consider their children to be of “safety-seat” age and have inherently low perceptions of vulnerability to crash injury. Unfortunately, most booster seat programs fail to adequately motivate their intended population because they are primarily informational in nature and rely on caregivers to seek out and attend to the information. In this article, interventions using threat appeal tactics and progressive dissemination methods are recommended to effectively target participation and perceptions of vulnerability among this population. Recent research on risk communication indicates that threat appeals are supported when they contain high threat and high efficacy components. Threat appeal tactics are particularly desirable when perception of vulnerability is low, as is the case with parents of booster-aged children. In addition to theoretical arguments for more aggressive intervention approaches, a case example is presented wherein such techniques were used to promote booster seat use. The intervention resulted in significant increases in knowledge, risk-reduction attitudes, sense of efficacy, and observed booster seat use. Through use of progressive dissemination methods, the intervention has reached an audience of 431,600 people and counting.

Child passenger safety practices in the U.S.: disparities in light of updated recommendations

BACKGROUND

Children are best protected in motor vehicle collisions when properly using the appropriate restraint and sitting in a rear row. Racial and ethnic disparities have been reported in injury statistics and use of any restraint; however, predictors of safety seat use, being unrestrained, and sitting in the front seat have not been explored previously.

PURPOSE

To determine factors associated with child passenger safety practices by race/ethnicity in a national sample of child passengers aged <13 years.

METHODS

Secondary analysis conducted in 2011 of the 2007, 2008, and 2009 National Survey of the Use of Booster Seats in which child passenger restraint use was observed directly. Age-stratified, survey-weighted chi-square and logistic regression analyses were conducted.

RESULTS

Restraint use was observed for 21,476 children aged <13 years. A decline in child safety seat use and increase in being unrestrained were observed with increasing child age. In multivariate analyses, race/ethnicity, unrestrained drivers, and sitting in the front seat were associated with lower odds of child safety seat use among children aged <8 years. Older child age was associated with sitting in the front seat and being unrestrained. The presence of multiple child passengers was associated with lower odds of sitting in the front but higher odds of being unrestrained.

CONCLUSIONS

Few children use the recommended child passenger restraints. Understanding the reasons for the suboptimal child passenger restraint practices identified in this study is essential for the development of effective programs to reduce or eliminate preventable motor vehicle collision-related injuries.

Front versus rear seat placement of children aged 12 or younger within vehicles: a rural/urban comparison in North Dakota

OBJECTIVE

Research has shown that rear-seated children are 36 to 40 percent safer than front-seated children. Because of the substantial differences in traffic safety culture that appear to exist in rural areas and the limited research regarding seat placement and rurality, this study seeks to contribute to the safety literature by determining at what rate children are riding in the front seat and whether differences exist between rural and urban areas in regards to child front seat placement.

METHODS

Current child placement frequencies within vehicles were ascertained through direct observations of morning child drop-offs at randomly selected urban and rural elementary schools in eastern North Dakota during November and December of 2009, with a focus on children aged 12 or younger. Two observers wearing orange safety vests and carrying observation sheets were stationed at each elementary school a minimum of 45 min prior to each school's designated start time. Based on the vehicles that entered the school's parking lot/drop-off circle and from which a minimum of one child exited, observers were instructed to record vehicle type, presence of children in the front seat appearing to be younger than 13 years old, availability of room in the back seat, and placement of other children in the vehicle.

RESULTS

During November and December of 2009 a total of 537 vehicles were observed at urban schools and 150 vehicles were observed at rural schools. Of the 537 vehicles observed at urban schools, 28.7 percent had children seated in the front seat, whereas 41.3 percent of the 150 vehicles observed at rural schools had front-seated children. Significant urban/rural differences exist in child seat placement, with vehicles in rural areas much more likely to be carrying front-seated children than vehicles in urban areas.

CONCLUSIONS

Based on a sample of vehicles observed at urban and rural elementary schools in North Dakota, the results of this study indicate that there are significant rural/urban differences in child seat placement.

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.

Children with special health care needs: patterns of safety restraint use, seating position, and risk of injury in motor vehicle crashes

OBJECTIVES

Special health care needs associated with behavioral conditions may influence a child's safety in motor vehicle crashes. The aim of this study was to describe and compare variation in restraint use, seating position, and injury risk in motor vehicle crashes among children with and without special health care needs likely to affect behavior.

PATIENTS AND METHODS

This study uses data collected between December 1, 1998, and November 30, 2002, in a cross-sectional study of children <16 years of age who were involved in crashes of State Farm-insured vehicles in 15 states. Parent reports via a validated telephone survey were used to define precrash special health care needs, restraint status, seating position, and the occurrence of clinically significant injuries by using a previously validated survey instrument.

RESULTS

Complete data were collected for 14654 children aged 4 to 15 years, representing 171633 children in crashes. Of these, 152 children were reported to have a special need likely to affect behavior, representing 1883 children. A greater proportion of children with special needs likely to affect behavior were appropriately restrained, particularly among children aged 4 to 8 years. Drivers of children with special needs likely to affect behavior were more often restrained and more often were the child passenger's parent. There were no differences in the rates of front-row seating. There was no significant association between the presence of a special need likely to affect behavior and risk of injury, after adjustment for child/driver characteristics and crash severity.

CONCLUSIONS

Despite a greater proportion of children with special needs likely to affect behavior using proper vehicle restraint, their injury risk was similar to that of children without these special needs. Primary care pediatricians providing best practices for vehicle safety should consider the unique riding experience and risk of injury among children with special health care needs likely to affect behavior.

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.

Compliance with seat belt use in Benin City, Nigeria

INTRODUCTION

Trauma is a major cause of death and disability worldwide. A quarter of all fatalities due to injury occur due to road traffic crashes with 90% of the fatalities occurring in low- and medium-income countries. Poor compliance with the use of seat belts is a problem in many developing countries. The aim of this study was to evaluate the level of seatbelt compliance in motor vehicles in Benin City, Nigeria.

METHODS

A five-day, observational study was conducted in strategic locations in Benin City. The compliance rates of drivers, front seat passengers, and rear seat passengers in the various categories of vehicles were evaluated, and the data were subjected to statistical processing using the Program for Epidemiology.

RESULTS

A total of 369 vehicles were observed. This consisted of 172 private cars, 64 taxis, 114 buses, 15 trucks, and four other vehicles. The seat belt compliance rate for drivers was 52.3%, front seat passengers 18.4%, and rear seat passengers 6.1%. Drivers of all categories of vehicles were more likely to use the seat belt compared to front seat passengers (p = 0.000) and rear seat passengers (p = 0.000). Drivers of private cars were more likely to use seat belts compared to taxi drivers (p = 0.000) and bus drivers (p = 0.000). Front seat passengers in private cars were more likely to use the seat belt compared to front seat passengers in taxis (p = 0.000) and buses (p = 0.000). Rear seat passengers in private cars also were more likely to use seat belts compared to rear seat passengers in taxis (p = 0.000) and buses (p = 0.000).

CONCLUSIONS

Compliance with seat belt use in Benin City is low. Legislation, educational campaigns, and enforcement of seat belt use are needed.

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.

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.