Effect of seating position and restraint use on injuries to children in motor vehicle crashes

A study of students' use of restraint systems in school transportation services in primary and secondary schools in northern Iran: an observational study

Background

Traffic accidents are one of the leading causes of death and severe injury among child occupants of vehicles in most countries. This has led to the consideration of how to use restraint systems for students in school buses. The purpose of the present study was to determine the percentage of students’ use of restraint systems in school transportation services in 2020.

Methods

In the present cross-sectional observational study, seatbelt use was assessed in 400 students in school transport vehicles using a checklist. The observation team sat at their vehicle, at the nearest location on one of the three sides of the school’s entrance: they had by manually registering the variable in the checklist. They focused on exactly the first vehicle parked next to the school entrance. There were two other observers to validate the observations. Data were analyzed by SPSS software (version 21).

Results

The rate of using restraint systems was 11.3%, use of restraint systems in the Sport Utility Vehicles (SUVs) was significantly higher (P < 0.03), in areas with medium income (P < 0.009) and low income (p < 0.012) as well as when the students were sitting in the rear seats, using the seatbelt were significantly lower (P < 0.001). Seatbelt use in students was less in services driven by drivers over the age of 40 (P < 0.01) and more in vehicles driven by female drivers (P < 0.003) and newer vehicles (p < 0.001).

Conclusion

School authorities must enforce traffic safety rules for school transportation services. These rules should be taught to drivers, families, and students. A restraint system must be mandatory for all students. School officials must equip their buses with seatbelts and employ school bus assistants to encourage wearing seatbelts and prevent students from standing.

Factors Affecting Death and Severe Injury in Child Motor Vehicle Passengers

Saving children from motor vehicle collisions is a high priority because the injury rate among motor vehicle passengers has been increasing in Japan. This study aimed to examine the factors that influence death and serious injury in child motor vehicle passengers to establish effective preventive measures. To identify these factors, we performed a retrospective study using a nationwide medical database. The data of child motor vehicle passengers younger than 15 years (n = 1084) were obtained from the Japanese Trauma Data Bank, registered from 2004 to 2019. Physiological variables, outcomes, and injury severity were compared between fatal and non-fatal patients and between those with and without severe injuries. Multivariate logistic regression analysis was performed to determine factors affecting fatality and severe injury. The Glasgow Coma Scale score (odds ratio (OR): 1.964), body temperature (OR: 2.578), and the Abbreviated Injury Scale score of the head (OR: 0.287) were identified as independent predictors of a non-fatal outcome. Systolic blood pressure (OR: 1.012), the Glasgow Coma Scale score (OR: 0.705), and Focused Assessment with Sonography for Trauma positivity (OR: 3.236) were identified as independent predictors of having severe injury. Decreasing the severity of head injury is the highest priority for child motor vehicle passengers to prevent fatality and severe injury.

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.

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair

Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.

Study protocol: a randomised non-inferiority trial using interactive virtual presence to remotely assist parents with child restraint installations

BACKGROUND

Motor vehicle crashes are the third-leading cause of death to American children aged 1-5 years. When installed correctly, child restraints (car seats) reduce risk of serious injury and death. However, most restraints are installed incorrectly. The current gold standard for correct installation is systematic car seat checks, where certified technicians help parents, but car seat checks are highly underused due to barriers in access, scheduling and resources.

METHODS

The present study protocol describes plans to evaluate use of interactive virtual presence technology (interactive merged reality)-joint, simultaneous remote verbal and visual interaction and exposure to the same 3D stimuli-to assist remotely located parents installing child restraints. If effective, this technology could supplement or replace in-person checks and revolutionise how government, industry and non-profits help parents install child restraints properly. Building from preliminary studies, we propose a randomised non-inferiority trial to evaluate whether parents who install child restraints while communicating with remote expert technicians via interactive virtual presence on their smartphones achieve installations and learning not inferior in safety to parents who install restraints with on-site technicians. We will randomly assign 1476 caregivers at 7 US sites to install child restraints either via interactive virtual presence or live technicians. Correctness of installation will be assessed using objective checklists, both following installation and again 4 months later.

CONCLUSION

We aim to demonstrate that child restraint installation is accurate (>90% correct) when conducted remotely, that such installations are not inferior to installation accuracy with live experts and that parents learn and retain information about child restraint installation.

Rear seating position is associated with a higher risk of mortality in motor vehicle crashes: analysis of Japanese Trauma Data Bank

Aim

The study examined the association of vehicle seating positions with the risk of death in serious motor vehicle crashes (MVCs) in Japan.

Methods

Data from the Japan Trauma Data Bank between 2004 and 2015 were analyzed. All MVC drivers with the legal age for driving and all copassengers were enrolled (n = 23,040). The cases were divided into three groups based on their seating position during the crash: the driver seat, front passenger seat, and rear passenger seats. The primary outcome variable was in‐hospital mortality. Multivariable logistic regression analysis was used to assess the association between the seating position and in‐hospital mortality. Potential factors associated with each seating position and in‐hospital mortality were also assessed.

Results

The odds ratios (ORs) for deaths were estimated for front and rear passengers compared to those for the driver in MVCs. The adjusted ORs (95% confidence interval [CI]) for death were 0.96 (0.84–1.11) and 1.22 (1.04–1.42) for front and rear passengers, respectively. Factors significantly associated with MVC deaths were age over 71 years (OR = 3.38; 95% CI, 2.58–4.41), male gender (OR = 1.54; 95% CI, 1.39–1.71), and night driving (OR = 1.17; 95% CI, 1.06–1.29).

Conclusions

This hospital‐based study suggested that rear seating increased the risk of MVC‐related death. Further studies are needed in order to find mechanisms of the increase in mortality by the seating position.

Seating position and patterns of severely injured body parts among child passengers in motor vehicle crashes: Japan as a distinct case

This study describes injury patterns and outcomes related to the seating position of child passengers involved in motor vehicle crashes in Japan. Using data obtained from a national trauma registry database, we compared the occurrence of injuries by body parts, length of hospital stay and in-hospital deaths between front-seating and rear-seating among children. We analysed 166 children aged 0-5 years and 205 children aged 6-12 years. No significant differences were observed between front- and rear-seating for injured body parts, length of hospital stay or in-hospital deaths in the 0-5-year-old victims. Among those aged 6-12 years, rear-seating was associated with a higher incidence of head and chest injuries but the length of stay or in-hospital deaths did not differ. These findings contrast those of previous studies, which found that rear-seating reduces injury risk, possibly attributed to low age-appropriate restraint use among school-aged children in Japan.

A comparative analysis of child passenger restraint use in China and the United States

BACKGROUND

Few published studies have examined child passenger safety practices across countries. This study compared the prevalence and associated factors of child passenger restraint use among children, aged 0 to 17 in the state of Iowa in the United States, and the city of Shantou in China.

METHODS

Child restraint use observations were conducted in Iowa and in Shantou in 2012, respectively, among child passengers. Observations in Iowa were conducted at randomly selected gas stations, while in Shantou observations were completed at randomly selected schools or medical clinics. Research observers approached the driver, observed restraint use, and collected brief survey data.

RESULTS

A total of 3049 children from Iowa and 3333 children aged 0 to 17 years from Shantou were observed. For children aged 0 to 3 years, only 0.1% were compliantly restrained in Shantou as compared to 95.9% in Iowa. The proportion of children who were compliantly restrained in Shantou increased with age, but generally decreased with age in Iowa. In Shantou, 36.0% of children aged 0 to 3 were sitting in the front seat as compared to only 1.7% of children of the same age in Iowa. Driver seat belt use was significantly associated with child restraint in both Iowa and Shantou; the association was stronger in Iowa than Shantou for all age groups.

CONCLUSIONS

A significantly higher prevalence of children who were not appropriately restrained was observed in Shantou than in Iowa. Our findings support the need of mandatory child safety restraint use legislation in China.

Using interactive virtual presence to support accurate installation of child restraints: Efficacy and parental perceptions

INTRODUCTION

Child restraint systems (car seats) reduce injury risk for young children involved in motor-vehicle crashes, but parents experience significant difficulty installing child restraints correctly. Installation by certified child passenger safety (CPS) technicians yields more accurate installation, but is impractical for broad distribution. A potential solution is use of interactive virtual presence via smartphone application (app), which permits "hands on" teaching through simultaneous and remote joint exposure to 3-dimensional images.

METHOD

In two studies, we examined the efficacy of remote communication via interactive virtual presence to help parents install child restraints. Study 1 was conducted at existing car seat checkpoints and Study 2 at preschools/daycare centers. In both cases, existing installations were assessed by certified CPS technicians using an objective coding scheme. Participants then communicated with remotely-located certified CPS technicians via a smartphone app offering interactive virtual presence. Technicians instructed participants to install child restraints and then the installation was inspected by on-site technicians. Both before and after the remote interaction, participants completed questionnaires concerning perception of child restraints and child restraint installation, self-efficacy to install child restraints, and perceived risk of injury to children if they were in a crash.

RESULTS

In both studies, accuracy of child restraint installations improved following the remote interaction between participants and certified CPS technicians. Together, the two samples achieved a weighted average of 90% correct installations across a multi-point inspection. Both samples reported increased self-efficacy to install child restraints and altered perceptions about the accuracy of the child restraint installations in their vehicles.

CONCLUSIONS

Findings support use of interactive virtual presence as a strategy to realize accurate installation of child restraints.

PRACTICAL APPLICATIONS

Interactive virtual presence between certified CPS technicians and the public via smartphone app has potential to improve proper child restraint installations broadly, including to vulnerable and underserved rural populations.

Elderly road collision injury outcomes associated with seat positions and seatbelt use in a rapidly aging society-A case study in South Korea

INTRODUCTION

Aging has long been regarded as one of the most critical factors affecting crash injury outcomes. In South Korea, where the elderly population is projected to reach 35.9% by 2050, the implications of an increasing number of elderly vehicle users on road safety are evident. In this research, the confounding effect of occupant age in a vehicle in terms of seat position and seatbelt use was investigated. In addition, elderly occupants were divided into a younger-old group aged between 65 and 74 years and an older-old group aged 75 years and older in an effort to assess whether the conventional elderly age standard of 65 years should be reconsidered.

METHODS

A multinomial logit framework was adopted to predict two-level injury severity using collision data between 2008 and 2015. Predictor variables included gender, age group, seat position, seatbelt, road type, road slope, road surface, road line, and type of vehicle. Five models, a base model with no interactions and four interaction models which were combinations of age group, seatbelt use and seat position, were devised and evaluated.

RESULTS

With no interacting term, age was the most prominent predictor. Elderly occupants were most likely to suffer from severe injury without a seatbelt in all seat positions, and the use of a seatbelt reduced this likelihood the most in the elderly group as well. Front passenger seats had the highest risk to elderly occupants, while the driver seat was statistically insignificant. When the elderly group was divided into the younger-old group and the older-old group, the older-olds were found to be much more vulnerable compared to the younger-olds. In particular, older drivers were five times more likely to suffer a severe injury without a seatbelt.

CONCLUSIONS

The degree of injury severity of elderly occupants was reduced the most with the use of a seatbelt, demonstrating the importance of using seat restraints. The sharp increase in the risk of injury of the older-old group suggests that the age standard of 65 years as the elderly group with regard to traffic safety may require reconsideration due to the growing number of elderly vehicle users on the road. Our results provide practical evidence with which to formulate new safety policies, including mandatory seatbelt use, driving age limits and insurance pricing.

Teaching infant car seat installation via interactive visual presence: An experimental trial

OBJECTIVE

A large portion of child restraint systems (car seats) are installed incorrectly, especially when first-time parents install infant car seats. Expert instruction greatly improves the accuracy of car seat installation but is labor intensive and difficult to obtain for many parents. This study was designed to evaluate the efficacy of 3 ways of communicating instructions for proper car seat installation: phone conversation; HelpLightning, a mobile application (app) that offers virtual interactive presence permitting both verbal and interactive (telestration) visual communication; and the manufacturer's user manual.

METHODS

A sample of 39 young adults of child-bearing age who had no previous experience installing car seats were recruited and randomly assigned to install an infant car seat using guidance from one of those 3 communication sources.

RESULTS

Both the phone and interactive app were more effective means to facilitate accurate car seat installation compared to the user manual. There was a trend for the app to offer superior communication compared to the phone, but that difference was not significant in most assessments. The phone and app groups also installed the car seat more efficiently and perceived the communication to be more effective and their installation to be more accurate than those in the user manual group.

CONCLUSIONS

Interactive communication may help parents install car seats more accurately than using the manufacturer's manual alone. This was an initial study with a modestly sized sample; if results are replicated in future research, there may be reason to consider centralized "call centers" that provide verbal and/or interactive visual instruction from remote locations to parents installing car seats, paralleling the model of centralized Poison Control centers in the United States.

Age-related differences in fatal intersection crashes in the United States

OBJECTIVE

Given the aging U.S. population and resulting number of older drivers in the coming years, it is important to understand the factors leading to their involvement in vehicle crashes and develop counter-measures to reduce their frequency and severity. This is also useful for helping older adults "age in place" in terms of accessibility, mobility, quality of life and safety. Thus, the objective of this study was to provide up-to-date data on differences in age-related risks and rates for involvement in fatal intersection motor-vehicle crashes in the US.

METHODS

Pooled data for the years 2011-2014 from the FARS, a census of fatal traffic crashes within the 50 States, the District of Columbia, and Puerto Rico, created by the US National Highway Traffic Safety Administration (NHTSA) were used to calculate summary statistics including annualized crash rates. Multivariate logistic regression models were used to evaluate age and gender-related differences in fatal intersection crash risk, controlling for covariates. An induced exposure analysis was conducted to calculate crash involvement ratios (CIRs) for all two-vehicle fatal intersection crashes. Older and younger drivers were compared with respect to the presence of factors related to intersection crashes using a multivariate Poisson regression model.

RESULTS

During the period of 2011-2014, among the reported 120,809 fatal accidents in the US involving 178,489 drivers of vehicles, 48,733 (28%) were drivers involved in fatal intersection crashes. Age-adjusted annualized fatal intersection crash rates per 100,000 licensed drivers were highest for drivers aged 85 or older (9.89/100,000), followed by 20 years of age (8.93/100,000). Teen and older drivers (55+ years of age) were over-involved in fatal intersection crashes, drivers from 20 to 54 years old were under-involved. Male and female drivers, 70-74 years of age, were 20% and 21%, respectively, more likely to be involved in a fatal intersection crash than 20-24year olds (of same gender). By age 85, fatal intersection crash risk for all drivers was almost doubled. Significant differences in factors related to crashes involving younger (<65) and older (65+ years) drivers were time of day, lighting and weather conditions, day of week, roadway type and number of lanes, presence of visible traffic controls, speed limit and estimated driving speed, and whether the driver was deemed at fault for the crash CONCLUSION: The results provide the most up-to-date analysis of aging and fatal intersection crash risk in the US, and underscore several trends worthy of further investigation. Older adults face a number of challenges associated with natural aging, including sensory, perceptual, cognitive and motor declines that may impact their driving. As with younger drivers, expanded or renewed approaches to driver training at licensing renewals, as well as safety-based technological advances are viable avenues toward improving the safety outlook for older adults.

Factors behind not using child restrain(t) among hospital employees and general population: A case control study

BACKGROUND

Motor vehicle crash (MVC) related injury has been identified as a major public health concern. Child restrain (CR) seat belts can minimize the mortality and morbidity from MVC. The use for seat belts is substantially low in developing countries like Pakistan even though its use has been shown to decrease morbidity and mortality by a significant extent.

METHODS

This was a case control study with cases from the general population (GP) and controls from the Aga Khan University (AKU) employees in a 3:1 ratio. The study questionnaire was based on parameters like gender, education level, awareness and presence of CR and also assessed the frequency of usage, reasons for not using CR and the source of knowledge regarding CR use.

RESULTS

Out of 848 respondents, 212 were from AKU and 636 were from the GP. 96.7% from AKU had at least a bachelor's degree while less than half (42.6%) of those from the GP were graduate or above (P<0.001). A statistically significant difference was found between the two groups with drivers from AKU being generally more aware about CR and its use. 81.1% of the group from AKU compared to 59.7% from the general population were found to be aware of child restraint use (P<0.001). Media (40.6%) was found to be the most common source of information amongst the AKU employees.

CONCLUSION

Most motor vehicle related injuries in children can be prevented or their severity may be reduced by the use of appropriate child restraint seat belts.

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.

Educación vial y movilidad en la Infancia

Resumen:La motorización creciente de los desplazamientos ha convertido al ambiente urbano en un lugar cada vez más hostil para los niños y niñas, quienes se encuentran entre los grupos humanos más vulnerables del tránsito. En esta etapa del desarrollo, la educación puede ser una herramienta clave para prevenir comportamientos de riesgo y promocionar hábitos de movilidad más saludables. El presente trabajo discute algunos aspectos relacionados con la educación vial en la infancia. Se destaca la importancia de considerar los patrones de movilidad típicos de cada edad, y de promover el uso de medios de transporte más saludables, equitativos y sustentables. Se señala además la necesidad de complementar las acciones educativas con intervenciones multi-sectoriales a diferente nivel.

Factors associated with mortality in rear-seated adult passengers involved in fatal motor vehicle crashes on US roadways

BACKGROUND

Recent efforts to pass rear seat belt laws for adults have been hampered by large gaps in the scientific literature. This study examines driver, vehicle, crash, and passenger characteristics associated with mortality in rear-seated adult passengers.

METHODS

The Fatality Analysis Reporting System (FARS) 2010 to 2011 was used to examine motor vehicle occupant mortality in rear-seated adult passengers 18 years and older. Side crash vehicle safety ratings were assessed in a subset analysis of vehicles struck on the same side as the rear-seated passenger. Multilevel logistic regression models used SAS GLIMMIX.

RESULTS

Of the 7,229 rear-seated adult passengers, 2,091 (28.9%) died. Multivariable predictors of increased mortality were advancing passenger age, younger driver age, excessive speed, ejection, being unbelted, rear impact, and same-side crash. Belt use was associated with a 67.0% reduction in total mortality. Despite this, belt wearing was low (48.1%) and differed by seating position, with less than one third of middle-seated passengers belted. Multivariable analysis showed mortality to be nearly three times higher in same-side crashes than other impact locations (odds ratio (OR) = 2.76, 2.22, 3.44). In a multivariable subpopulation analysis of same-side crashes, right-seated passengers had an increased mortality (52.7% vs. 43.2%, p < 0.01) compared to left-seated passengers (OR = 1.55, 1.02, 2.36). Vehicle side crash safety ratings, available for 27.7% (n = 172) of same-side crashes, were not predictive of mortality.

CONCLUSIONS

Except for same-side crashes, seat belts were associated with significantly lowered mortality. Despite this, seat belt wearing was low and represents one of several areas where further improvements in mortality might be realized.

Advocacy for booster seat legislation in Florida: a lesson in politics and policy formation

MVCs are a major contributor to child injury and death. Infant restraint seats and child booster seats have been shown to reduce the odds of severe injury or death when used correctly. While all states have mandated the use of these restraint systems, the age at which a child can be legally restrained using an adult seat belt varies from state to state. Efforts to strengthen Florida's weak child restraint laws have failed for more than a decade; in the 2014 legislative session, advocates succeeded in raising the state's age requirement from 3 years to 5  years. While many factors contributed to this year's success, some key elements included efficient communication of supporting data, a strong and broad advocacy network and the leveraging of election year political rivalries. Efforts to further strengthen the law will continue into future legislative sessions.

Attitudes towards child restrains and seat belts usage in the learned population of Karachi, Pakistan

BACKGROUND

Motor vehicles crashes (MVCs) are the leading cause of injury related morbidity and mortality in developed countries. Recent evidence proves that properly used child seat belts can dramatically reduce the risk of severe and life-threatening injury from MVCs. There are rarities of thought and inspiration regarding the use of child seat belts in our society and region, therefore we lack of data regarding factors and paucity of usage of child seat belts in motor vehicles. This study aimed to assess the knowledge and attitudes of child seat belt usage among the educated population in Karachi, Pakistan.

METHODS

Altogether 304 employees were investigated. They were employees of Aga Khan University who were using their cars and having children younger than 10 years old. A cross sectional observational study was designed, and a 36-item questionnaire in English was used to collect data on participants' demographic details, designation, educational level, economic status, validity of driving license, number of children and cars, availability of adult seat belts and child seat belts along with their functionality, awareness, knowledge and attitude toward its use, and reason of not using these devices. SPSS version 20 for Windows was used to analyze the data and the Chi-square test was used.

RESULTS

Totally 290 participants were recruited with a response rate of 72% (212). Of 212 participants, 126 (59%) were male. 154 (72.6%) participants had valid driver licenses, and 154 (72.6%) had adult seat belts in their vehicles. Only 32 (15%) reported regular use of adult seat belts. Although 168 (79.2%) participants had some knowledge about child restrains (CRs), only 65 (22%) had CRs in their cars. Eighty-two (38.7%) participants got the knowledge about CRs and seat belts from media. Mothers were more concerned about the use of CRs than fathers. Only 14 (6.6%) parents were found to use both adult and child seat belts all the time. Of the 157 parents who did not us use CRs, 42 considered unnecessary, 35 lacked relevant knowledge. But 15 parents used CR against their children's wills.

CONCLUSIONS

The pattern of CR usage among the employees at Aga Khan University, Karachi is dictated by the unavailability of CR, followed by ignorance, inconvenience, and non-acceptance by their children. The important issue of CR has consistently been ignored over the years and it has never gained enough popularity in Pakistan.

High strength steels, stiffness of vehicle front-end structure, and risk of injury to rear seat occupants

Previous research has shown that rear seat occupant protection has decreased over model years, and front-end stiffness is a possible factor causing this trend. In this research, the effects of a change in stiffness on protection of rear seat occupants in frontal crashes were investigated. The stiffness was adjusted by using higher strength steels (DP and TRIP), or thicker metal sheets. Finite element simulations were performed, using an LS Dyna vehicle model coupled with a MADYMO dummy. Simulation results showed that an increase in stiffness, to the extent it happened in recent model years, can increase the risk of AIS3+ head injuries from 4.8% in the original model (with a stiffness of 1,000 N/mm) to 24.2% in a modified model (with a stiffness of 2,356 N/mm). The simulations also showed an increased risk of chest injury from 9.1% in the original model to 11.8% in the modified model. Distribution of injuries from real world accident data confirms the findings of the simulations.

Gunshot injuries in children served by emergency services

OBJECTIVE

To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms.

METHODS

This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age ≤ 19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥ 16, major surgery, blood transfusion, mortality, and average per-patient acute care costs.

RESULTS

A total of 49,983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100,000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28,510 per patient, 95% CI 22,193-34,827).

CONCLUSIONS

Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.

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.

A comparison of injuries, crashes, and outcomes for pediatric rear occupants in traffic motor vehicle collisions

BACKGROUND

This study was initiated was initiated to describe pediatric rear-occupant motor vehicle collision (MVC) injuries, including injury patterns and outcomes as well as characteristics associated with severe injury to the head and abdomen.

METHODS

A retrospective cohort of severely injured (Injury Severity Score [ISS] > 12) pediatric (age <18 years) patients involved in a traffic MVC as a rear occupant and treated at one of two Ontario trauma centers (2001-2010) was studied was studied. Demographic, injury, crash and outcome data were obtained from the trauma registries. Data were statistically compared by two pediatric age groups: children (0-8 years; requiring a child or booster seat) versus adolescents (9-17 years; requiring a lap-shoulder belt).

RESULTS

There were 36 children (34%) and 70 adolescents (66%) severely injured as rear occupants in MVCs. Despite similar ISS (p = 0.716) and mortality rates (p = 0.680) between age groups, there were significant differences in injury patterns and risk factors. Children were more likely to have severe head injuries (78% vs. 39%, p < 0.001) associated with a lack of an age-appropriate child restraints (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1-10.8; p = 0.029), middle seating (OR, 6.2; 95% CI, 1.5-26.1; p = 0.013), and side-impact crashes (p = 0.007). Adolescents were more likely to have severe abdominal injuries (23% vs. 6%, p < 0.001) associated with the use of lap-shoulder belts (OR, 3.8; 95% CI, 1.1-13.3; p = 0.034), single-vehicle MVCs (p = 0.007), and vehicle extrications (p = 0.035).

CONCLUSION

While safer than the front seat for children, additional study is needed on the restraint systems and the potential for injury to pediatric rear occupants in an MVC. Our data suggest that pediatric age groups differ in injuries, risk factors, and MVC impacts. Recommendations for improved protection of child occupants and preferred seating positions are required.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Comparing least-squares and quantile regression approaches to analyzing median hospital charges

BACKGROUND

Emergency department (ED) and hospital charges obtained from administrative data sets are useful descriptors of injury severity and the burden to EDs and the health care system. However, charges are typically positively skewed due to costly procedures, long hospital stays, and complicated or prolonged treatment for few patients. The median is not affected by extreme observations and is useful in describing and comparing distributions of hospital charges. A least-squares analysis employing a log transformation is one approach for estimating median hospital charges, corresponding confidence intervals (CIs), and differences between groups; however, this method requires certain distributional properties. An alternate method is quantile regression, which allows estimation and inference related to the median without making distributional assumptions.

OBJECTIVES

The objective was to compare the log-transformation least-squares method to the quantile regression approach for estimating median hospital charges, differences in median charges between groups, and associated CIs.

METHODS

The authors performed simulations using repeated sampling of observed statewide ED and hospital charges and charges randomly generated from a hypothetical lognormal distribution. The median and 95% CI and the multiplicative difference between the median charges of two groups were estimated using both least-squares and quantile regression methods. Performance of the two methods was evaluated.

RESULTS

In contrast to least squares, quantile regression produced estimates that were unbiased and had smaller mean square errors in simulations of observed ED and hospital charges. Both methods performed well in simulations of hypothetical charges that met least-squares method assumptions. When the data did not follow the assumed distribution, least-squares estimates were often biased, and the associated CIs had lower than expected coverage as sample size increased.

CONCLUSIONS

Quantile regression analyses of hospital charges provide unbiased estimates even when lognormal and equal variance assumptions are violated. These methods may be particularly useful in describing and analyzing hospital charges from administrative data sets.

Childhood Crash Injury Patterns Associated with Restraint Misuse: Implications for Field Triage

Introduction:

Restraint misuse is a common problem leading to increased morbidity and mortality for children involved in motor vehicle crashes. The purpose of this project was to describe the injury patterns associated with restraint misuse in the pediatric population, with particular focus on clues to significant injury that can be identified by the prehospital provider that may impact subsequent triage decisions.

Methods:

This is a case series presentation that illustrates the injury patterns associated with various types of restraint misuse in infants (ages 0–1 years), toddlers (age 1–4 years), young children (ages 4–8 years), and pre-teens (ages 8–14 years). Cases were identified from the Crash Injury Research and Engineering Network (CIREN) database.

Results:

Six cases are presented that illustrate the injury patterns associated with misuse of rear-facing infant car seats (0–1 years), forward-facing child seats (1–4 years), booster seats (4–8 years), and shoulder belts (8–14 years). Prehospital assessment of appropriate restraint use is described.

Conclusions:

Restraint misuse in children is a common problem. Emergency medical services providers need to be aware of these issues when assessing children and determining appropriate triage to a trauma center. Ongoing educational efforts also are vital to inform parents regarding the risks of inappropriate restraint use and can encourage legislators to better define appropriate restraint use for older children.

Positive income shocks and accidental deaths among Cherokee Indians: a natural experiment

BACKGROUND

Several studies in low-income populations report the somewhat counterintuitive finding that positive income gains adversely affect adult health. The literature posits that receipt of a large portion of annual income increases, in the short term, risk-taking behaviour and/or the consumption of health-damaging goods. This work implies the hypothesis that persons with an unexpected gain in income will exhibit an elevated risk of accidental death-the fifth leading cause of death in the USA. We test this hypothesis directly by capitalizing on a natural experiment in which Cherokee Indians in rural North Carolina received discrete lump sum payments from a new casino.

METHODS

We applied Poisson regression to the monthly count of accidental deaths among Cherokee Indians over 204 months spanning 1990-2006. We controlled for temporal patterns in accidental deaths (e.g. seasonality and trend) as well as changes in population size.

RESULTS

As hypothesized, the risk of accidental death rises above expected levels during months of the large casino payments (relative risk = 2.62; 95% confidence interval = 1.54-4.47). Exploratory analyses of ethnographic interviews and behavioural surveys support that increased vehicular travel and consumption of health-damaging goods may account for the rise in accident proneness.

CONCLUSIONS

Although long-term income gains may improve health in this population, our findings indicate that acute responses to large income gains, in the short term, increase risk-taking and accident proneness. We encourage further investigation of natural experiments to identify causal economic antecedents of population health.

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.

Epidemiology of motor vehicle crashes in Utah

OBJECTIVES

This study describes the frequency and pattern of vehicle crashes and safety belt use in Utah; the proportion of vehicle crashes involving safety belt use, alcohol, and fatigue; and the influence these factors and others have on emergency room visits or hospital admissions and on the severity of the outcome.

METHODS

Data were obtained from the Utah Department of Transportation, Division of Traffic and Safety, from 1999 through 2005. Motor vehicle crash (MVC) data were linked to statewide hospital admission (inpatient) and emergency department (ED) records.

RESULTS

The trend in rates of crashes significantly decreased for both males and females, with rates of crashes involving alcohol decreasing for males but increasing for females and rates of crashes involving fatigue remaining constant for males and females over the study period. Drivers not wearing a safety belt or intoxicated or fatigued were significantly more likely to have contributed to the crash, visit the emergency room, be admitted to the hospital, and experience severe injury or death. Drivers in crashes who were intoxicated or fatigued were significantly less likely to be wearing a safety belt. When a safety belt was worn at the time of the crash, sitting in the front seat was safer than in the second or third seats, and sitting on the left side of the vehicle was safer than on the right side or in the middle. However, when a safety belt was not worn at the time of the crash, sitting in the front seat was more likely associated with injury or death than in the second or third seats or sitting in the middle seat.

CONCLUSION

Drivers in crashes who were intoxicated or fatigued were less likely to be wearing a safety belt and more likely to have contributed to the crash and experience serious injury or death. Severity of injury related to seat placement is moderated by safety belt use.

Parental awareness and perception for correct use of child occupant restraints in Korea

OBJECTIVE

To determine the rate of correct use of child occupant restraints (CORs) and to evaluate the parental awareness and perception associated with the use of CORs.

METHODS

A cross-sectional survey using self-report questionnaires was performed at 10 different hospitals. A total of 1573 parents and 2209 of their children 6 years of age or younger were studied.

RESULTS

The overall percentage of parents using CORs or adult seat belt was 57.7 percent. However, only 44.4 percent of those parents, which corresponds to 25.6 percent of all parents recruited, were correctly using the restraints for their children. The overall percentage of children using CORs or adult seat belt was 53 percent. However, the percentage of children correctly using the restraints was 14.3 percent for infants (<12 months of age), 42 percent for children one years old, 43.8 percent for children 2 years old, 28.7 percent for children 3 years old, 18.9 percent for children 4 years old, 13.9 percent for children 5 years old, and 10.5 percent for children 6 years old. The logistic regression analysis revealed that the mother's level of education, number of children in each household, child's age when parents started to use the CORs, and parental awareness about the fine for violation of car seat laws were the most influential variables associated with the correct use of CORs. The rates of correct use of CORs and parental preferences about CORs, respectively, differed by ages of their children. Most parents showed a negative perception of placing children in the front passenger seat. However, many parents were prematurely using adult seat belts for children without realizing the risk of injury.

CONCLUSION

More aggressive educational campaigns and increased enforcement of the car seat laws are needed to improve the awareness of parents on the efficacy of CORs.

Driver seat belt use indicates decreased risk for child passengers in a motor vehicle crash

STUDY OBJECTIVE

We examined the association between driver restraint use and child emergency department (ED) evaluation following a motor vehicle crash (MVC).

METHODS

This cohort study included child passengers aged 0-12 years riding with an adult driver aged 21 years or older involved in a MVC in Utah from 1999 to 2004. The 6 years of Utah MVC records were probabilistically linked to statewide Utah ED records. We estimated the relative risk of ED evaluation following a MVC for children riding with restrained versus unrestrained drivers. Generalized estimating equations were used to calculate relative risks adjusted for child, driver, and crash characteristics.

RESULTS

Six percent (6%) of children riding with restrained adult drivers were evaluated in the ED compared to twenty-two percent (22%) of children riding with unrestrained adult drivers following a MVC (relative risk 0.29, 95% confidence interval 0.26-0.32). After adjusting for child, vehicle, and crash characteristics, the relative risk of child ED evaluation associated with driver restraint remained significant (relative risk 0.82, 95% confidence interval 0.72-0.94). Driver restraint use was associated with child restraint use, less alcohol/drug involvement, and lower relative risk of severe collision types (head-on, rollover).

CONCLUSIONS

Driver seat belt use is associated with decreased risk of ED evaluation for child passengers in the event of a MVC.

Preventing Traffic Injuries: Strategies That Work

Motor vehicle crashes result in more than 40 000 deaths and 4.3 million nonfatal injuries annually. Many known effective strategies to address these preventable deaths and injuries are closely related to lifestyle factors. Clinicians can play a large part in supporting effective interventions in their practice, for example, by counseling patients about seat belt use. Clinicians can also have an impact in their community by supporting positive public policy change.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Short-term physical limitations in children following motor vehicle crashes

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

Rear seat occupant safety: kinematics and injury of PMHS restrained by a standard 3-point belt in frontal crashes

Very little experimental research has focused on the kinematics, dynamics, and injuries of rear-seated occupants. This study seeks to develop a baseline response for rear-seated post mortem human surrogates (PMHS) in frontal crashes. Three PMHS sled tests were performed in a sled buck designed to represent the interior rear-seat compartment of a contemporary mid-sized sedan. All occupants were positioned in the right-rear passenger seat and subjected to simulated frontal crashes with an impact speed of 48 km/h. The subjects were restrained by a standard, rear seat, 3-point seat belt. The response of each subject was evaluated in terms of whole-body kinematics, dynamics, and injury. All the PMHS experienced excessive forward translation of the pelvis resulting in a backward rotation of the torso at the time of maximum forward excursion. The three subjects experienced maximum normalized chest deflections of 30%, 45%, and 30%, respectively, and maximum 3 ms clip resultant chest accelerations of 50, 42, and 52 g, respectively. Additionally, each PMHS received at least 13 rib fractures (maximum of 29 fractures), and flexion-tension induced neck injuries initiating in the lower cervical spine (C4-T1). The neck trauma ranged from ligament damage (AIS 1) to complete cervical spine transection (AIS 5).

Metropolitan economic decline and infant mortality due to unintentional injury

Public health professionals assert that parents could prevent a substantial portion of infant mortality due to unintentional injury (IMUI) by creating a safe environment for the infant. Examples of safe parenting behaviors include attending to a bathing infant, properly securing a child safety seat in a motor vehicle, and removing soft pillows from a crib. The contraction of regional economies, an ambient phenomenon previously reported to affect salutary behaviors, may distract parents from these routine infant monitoring tasks. I test this distraction hypothesis that the monthly incidence of IMUI will vary inversely with the performance of the economy. I retrieve economic data from the Bureau of Labor Statistics and use data from the Birth Cohort File on 2,618,752 infants in all 26 metropolitan areas of California. Results support the hypothesis in that a 1% decline in employed persons coincides with an 8% increase of IMUI in that month. Findings remain robust to control for individual covariates that could confound observed associations. I discuss my findings in relation to the literature concerned with parental distraction, describe other mechanisms through which the economy may affect IMUI, and recommend further investigation.

Infant injuries from child restraint safety seat misuse at British Columbia Children's Hospital

BACKGROUND

Child restraint safety seats (CRS) are used to prevent injuries or deaths among child passengers involved in a motor vehicle crash. When used outside of a motor vehicle, CRS use could potentially place an infant at risk of injury. The objective of the current study was to describe the proportion of CRS misuse injuries among infants <12 months old and associated factors presenting to the British Columbia (BC) Children's Hospital Emergency Department over 5 years (1997-2002).

METHODS

The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) was the source for the emergency department injury surveillance data used in the present study. BC Children's Hospital is the participating CHIRPP site in British Columbia. A search of individual level patient records was conducted to capture all injuries from CRS misuse taking place during the study period using a predetermined code for 'child car seat-related injuries'. A retrospective analysis of 87 infants <12 months old, who presented at BC Children's Hospital for CRS-related injuries between January 1997 and December 2002 was performed in order to describe the epidemiologic and background factors related to injury occurrence.

RESULTS

Infants aged 0-4 months accounted for approximately 59.7% of cases (52/87). Among all infants, falls were a common mechanism of injury resulting from CRS misuse (98.8%, 86/87). Falls from elevated surfaces (e.g. chairs, tables, counters) were also common among infants presenting to the emergency departments and accounted for 43% of all falls (37/86).

CONCLUSIONS

Injury prevention efforts should be focused on reducing CRS outside the motor vehicle setting and preventing placement of the CRS at an elevated surface. Educating caregivers on the dangers of falls resulting from CRS misuse in a variety of care settings is also recommended.

Children at risk: predictors of car safety seat misuse in Ontario

When used correctly, child safety seats can reduce the risk of death and serious injury by 54% in toddlers and 71% in infants [National Highway Traffic Safety Administration (NHTSA), 2001. Traffic Safety Facts 2001. Children (DOT HS 809 471), U.S. Department of Transportation, Washington, DC]. The purpose of this study was to identify factors that predict correct use of car safety seats. The study was conducted in a large urban area in Southwestern Ontario and a small urban and rural area in Northern Ontario. Participants were 1263 caregivers who completed a self-report survey on their knowledge and use of car safety seats for their children (N=2199). Logistic regression analysis revealed that female caregivers, caregivers with higher levels of education, and caregivers who reported that finding information about the correct use of child safety seats was "difficult" were more likely to report correctly using car safety seats. The results also showed that children aged 7 months to 8 years old had substantially lower odds of being in the correct car safety seat compared to children aged 6 months or younger, or children aged 9 years or older. The high risk nature of misuse of child seats for infants and younger children may be an important cue to action for health professionals to develop comprehensive prevention strategies.

The effectiveness of a multimedia intervention on parents' knowledge and use of vehicle safety systems for children

Trauma due to road crashes is the leading cause of death and injury in Canadian children younger than 14 years, despite mandatory use of vehicle restraints since 1977. A multisite intervention study using a pretest-posttest design was conducted in four Ontario cities to test the effectiveness of an educational program on parents' knowledge of safety system use for children (0-12 years) 6 weeks following the educational intervention. The sample consisted of 418 families who reported on 732 children. Results indicated that knowledge increased significantly following the intervention. Use of professional sources of information was an important factor that is linked with increased parents' knowledge.

Rear seat safer: seating position, restraint use and injuries in children in traffic crashes in Victoria, Australia

Car crashes are a major cause of death and serious injury to children but most analyses of risk are based on US data. The Australian context is different in at least three ways: (1) the proportion of passenger-side airbags, a potential risk to children in front seats, is much lower; (2) unlike in the US, Australian airbags are designed to work with restrained passengers; (3) restraint use for children 0-12 years is high (>90%). Official data drawn from Victorian crash records (n=30,631) were used to calculate relative risks of death or serious injury for children (0-3 years, 4-7 years; 8-12 years) traveling in passenger cars during 1993-1998 and 1999-2004. Over 90% were reportedly wearing a restraint, and 20% were traveling in the front seat. For children under 4 years traveling in the front seat, the relative risk of death was twice as great as when traveling in the rear, and that of serious injury was 60% greater. The relative risk of death whilst traveling in the front seat was almost four times greater for children aged under 1 year. We suggest that serious consideration should be given to mandating rear seating for children, particularly those aged 4 and under.

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.

Seatbelts and the law: how well do we protect Australian children?

About a thousand Australian children are seriously injured in motor vehicle accidents each year, despite 92% using seatbelts or child restraints. Premature graduation of children to adult seatbelts, misuse of seatbelts and use of lap-only belts increase the risk of injury or death. In Australia, use of a child restraint or booster seat is not mandatory for children aged > 1 year, while other countries mandate their use for children up to 5-12 years old. Australian parents are confused about the safest restraint and seating position, particularly for children aged > 2 years. Australian child restraint legislation needs to be reviewed to increase the rate of optimal restraint use.

Injury admissions to pediatric intensive care are predictable and preventable: a call to action

Injuries are often preventable yet remain the most common cause of death in children ages 1 to 19 years in Canada. In this retrospective case series, the authors sought to determine the proportion of injury admissions to a tertiary multidisciplinary university hospital Pediatric intensive care unit (PICU) that were preventable by known measures. Patients were a consecutive sample of 104 children, aged 99 (mean [SD] 70; range, 1-215) months, who were admitted to PICU due to injury from July 1997 to June 1998. Charts were reviewed to determine morbidity (PICU days, ventilation days, and discharge to a rehabilitation hospital), mortality, and whether the injury occurred by a preventable mechanism (as recommended by the American Academy of Pediatrics). Out of 790 admissions, 104 (13.2%) were for injury-81% unintentional and 19% intentional. Unintentional injuries occurred by diverse mechanisms, and 65/84 (77%; 95% confidence interval, 67%-86%) were potentially preventable. Unintentional injuries were especially preventable in the younger age groups (P = .009): 71% (5/7) in those<1 year; 89% (31/35) in those 1 to 4 years; 89% (16/18) in those 5 to 9 years; and 54% (13/24) in those> or =10 years. Most intentional injuries were suicide attempts in adolescents, and 88% had multiple risk factors for suicide. Patients were in PICU for 2.9 (SD 4.5) days, ventilated in 73% for 2.8 (SD 4.4) days, had a mortality of 12.5% (95% confidence interval, 6.8%- 20.4%), and demonstrated common need for rehabilitation. Thus, injuries in children resulting in admission to the PICU are common and highly preventable events with significant morbidity and mortality. Novel strategies to improve the public's perception of the cost of childhood injury are needed.

Passenger seating position and the risk of passenger death in traffic crashes: a matched cohort study

OBJECTIVE

To estimate the association of passenger seating position with the risk of death for passengers in traffic crashes.

DESIGN, SETTING, PARTICIPANTS

Matched cohort analysis of data from the National Highway Traffic Safety Administration Fatality Analysis Reporting System regarding 56 644 passengers in 23 308 passenger cars, light trucks, vans, and sport utility vehicles that crashed during 1990-2001.

MAIN OUTCOME MEASURE

The adjusted risk ratio (aRR) for death of a rear seat passenger compared with a front seat passenger within 30 days of a crash.

RESULTS

The aRR for all passengers in the rear seat in a crash was 0.79 (95% CI 0.77 to 0.82). This estimate varied by age, restraint use, and the presence of a front passenger airbag (p<0.001). For restrained passengers in cars with a front passenger airbag, the aRR was 0.62 (95% CI 0.48 to 0.81) for children 0-12 years, 0.96 (95% CI 0.88 to 1.06) for passengers 13-29 years, 1.03 (95% CI 0.93 to 1.15) for passengers 30-59 years, and 1.06 (95% CI 0.90 to 1.26) for passengers 60 years or older. The rear seat was associated with more protection in cars without front airbags and more protection for unrestrained passengers compared with restrained passengers.

CONCLUSIONS

Previous studies have reported that the rear seat was safer for persons of all ages; thus seating a young child in the rear has often meant that older children and adults had to assume an increased risk of death by sitting in the front. These results suggest that when front passenger airbags are present and passengers are restrained, putting adults in front and children in back enhances child safety without sacrificing adult safety.

Trends in childhood injury mortality in Canada, 1979-2002

OBJECTIVE

To examine national trends in mortality rates for injuries among Canadian children younger than 15 years in 1979-2002.

METHODS

Data on injury deaths were obtained from the Canadian Vital Statistics system at Statistics Canada. Injuries were classified using the codes for external cause of injury and poisoning (E-codes) by intent and by mechanism. Mortality rates were age adjusted to the 1990 world standard population. Negative binomial regression was used to estimate the secular trends.

RESULTS

Annual mortality rates for total and unintentional injuries declined substantially (from 23.8 and 21.7 in 1979 to 7.2 and 5.8 in 2002, respectively), whereas suicide deaths among children aged 10-14 showed an increasing trend. All Canadian provinces and territories showed a decreasing trend in mortality rates of total injuries. Motor vehicle related injuries were the most common cause of injury deaths (accounted for an average of 36.4% of total injury deaths), followed by suffocation (14.3%), drowning (13.5%), and burning (11.1%); however, suffocation was the leading cause for infants. The number of potential years of life lost due to injury before age 75 decreased from 89 343 in 1979 to 27 948 in 2002 for children aged 0-14 years.

CONCLUSIONS

During the period 1979-2002, there were dramatic decreases in childhood mortality for total injuries and unintentional injuries as well as various degrees of reduction for all causes of injury except suffocation in children aged 10-14 years and drowning in infants. The reason for the reduction in injury mortality might be multifactoral.

Individual factors affecting the risk of death for rear-seated passengers in road crashes

We studied the effect of age, gender, use of restraint systems and seat position on the risk of death for rear-seated passengers of cars involved in road crashes. The data source was the Spanish register of traffic crashes with victims compiled by the Government's General Traffic Directorate. Data for crashes recorded from 1993 to 2002, inclusive, were studied. We used a matched cohort design to analyze all 5260 rear-seated passengers in vehicles occupied by two or three rear-seated passengers for accidents in which at least one of these passengers was killed. Conditional Poisson regression with death as the dependent variable was used. An increased risk of death was observed for females and children aged <3 years. For passengers aged 25 years and older, the risk increased with age. The use of restraint systems and central and right-side seats was associated with a lower risk. These results should be considered in research focused on passenger fragility and strategies to prevent injury and death.