Trends in booster seat use among young children in crashes

Risk factors and outcomes in pediatric blunt cardiac injuries

PURPOSE

Unlike adults, less is known of the etiology and risk factors for blunt cardiac injury (BCI) in children. Identifying risk factors for BCI in pediatric patients will allow for more specific screening practices following blunt trauma.

METHODS

A retrospective review was performed using the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019. All patients ≤ 16 years injured following blunt trauma were included. Demographics, mechanism, associated injuries, injury severity, and outcomes were collected. Univariate and multivariate regression was used to determine specific risk factors for BCI.

RESULTS

Of 266,045 pediatric patients included in the analysis, the incidence of BCI was less than 0.2%. The all-cause mortality seen in patients with BCI was 26%. Motor-vehicle collisions (MVCs) were the most common mechanism, although no association with seatbelt use was seen in adolescents (p = 0.158). The strongest independent risk factors for BCI were pulmonary contusions (OR 15.4, p < 0.001) and hemothorax (OR 8.9, p < 0.001).

CONCLUSIONS

Following trauma, the presence of pulmonary contusions or hemothorax should trigger additional screening investigations specific for BCI in pediatric patients.

Child restraint system use and its associated factors in Shenzhen

Child restraint system (CRS) is effective to protect child passenger safety in a motor vehicle crash. However, research on CRS is limited and the use rate of CRS is not high in China. We carried out a cross-sectional study to examine the use of CRS and its associated factors in Shenzhen. Via the method of cluster random sampling, parents who had at least one child aged 0 to 6 and owned a car from nine community health service centers and eight kindergartens were invited to complete the self-administered questionnaire during April and May 2014, including their knowledge of, attitude toward, and use behavior of CRS and socio-demographics. Multivariable logistic regression was used to explore the factors associated with CRS use. A total of 3768 parents participated in the survey, with a mean age of 33.94. Parents' knowledge and attitude regarding CRS were fair, with the mean score of 3.07 and 3.33 out of 6, respectively, and only 22.8% of them used CRS for their child passengers. Children aged below 3 years, drivers owing expensive cars and wearing seatbelts, and parents with higher knowledge and attitude scores had greater likelihoods to use CRS. Moreover, trip frequency and distance were also significantly associated with CRS use. The findings indicate that the use rate of CRS is low in Shenzhen and parents have fair levels of knowledge and attitude regarding CRS use. Comprehensive public education programs and legislative interventions are urgently required to increase the use of CRS and ensure child passenger safety in Shenzhen.

Child Passenger Safety

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death for children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats as long as possible; (2) forward-facing car safety seats from the time they outgrow rear-facing seats for most children through at least 4 years of age; (3) belt-positioning booster seats from the time they outgrow forward-facing seats for most children through at least 8 years of age; and (4) lap and shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health supervision visit.

Seat belt and child restraint use in a developing country metropolitan city

Seat belt and child restraint use is noted to be poor in developing countries such as Ghana. An unobstructive observational survey guided by the Theory of Planned Behaviour was therefore conducted to assess seat belt and child restraint use in the Cape Coast Metropolis, Ghana. The observational survey was carried out at the entrances of four nursery schools in medium and high class residential areas in the Metropolis to determine seat belt use by drivers and accompanied child being transported/dropped off in school. The results revealed that a total of 1922 vehicles comprising 826(43.0%) cars, 350(18.2%) SUV, 644(33.5%) taxis and 102(5.3%) mini buses with 3844 vehicle occupants comprising 1922 drivers and child apiece were successively observed. The majority of the drivers (53.1%) did not use the seat belt with 13.2% of the children been restrained. The gender of the driver has a relationship with the seat belt use. The vehicle type has a relationship with the child restraint use and the gender of the driver has a significant relationship with child restraint use. The enforcement of the Road Traffic Act 2004 and Road Traffic Regulation 2180 by the officials of Motor Transport and Traffic Department(MTTD) of the Ghana Police Service in collaboration with National Road Safety Commission (NRSC) can establish social norms that may have a greater potential to enhance seat belt and child restraint use in the Metropolis.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The influence of parental education and other socio-economic factors on child car seat use

INTRODUCTION

The behaviour of parents in ensuring car passenger safety for their children is associated with socio-economic (SE) status of the family; however, the influence of parental education has rarely been researched and the findings are contradictory. The aim of the study was to clarify whether parental education influences the use of a child car seat during short rides.

METHODS

A cross-sectional survey was carried out in outpatient clinics for children's healthcare across Slovenia. 904 parents of 3-year-old children participated in the study; the response rate was 95.9%. A self-administered questionnaire was used. A binary multiple logistic regression was applied to assess the association between parental unsafe behaviour as dependent variable, and education and other SE factors as independent variables.

RESULTS

14.6% of parents did not use a child car seat during short rides. Families where mother had low or college education had higher odds of the non-use of a child car seat than families where mother had a university education. Single-parent families and those who lived in areas with low or medium SE status also had higher odds of the non-use of a child car seat.

CONCLUSIONS

Low educational attainment influences parents' behaviour regarding the non-use of a child car seat. Low parental education is not the only risk factor since some highly educated parents also have high odds of unsafe behaviour. All parents should therefore be included in individually tailored safety counselling programmes. SE inequalities could be further reduced with provision of free child car seats for eligible families.

Child passenger safety laws in the United States, 1978-2010: policy diffusion in the absence of strong federal intervention

This article examines the diffusion of U.S. state child passenger safety laws, analyzing over-time changes and inter-state differences in all identifiable features of laws that plausibly influence crash-related morbidity and mortality. The observed trend shows many states' continuing efforts to update their laws to be consistent with latest motor vehicle safety recommendations, with each state modifying their laws on average 6 times over the 30-year period. However, there has been a considerable time lag in knowledge diffusion and policy adoption. Even though empirical evidence supporting the protective effect of child restraint devices was available in the early 1970s, laws requiring their use were not adopted by all 50 states until 1986. For laws requiring minors to be seated in rear seats, the first state law adoption did not occur until two decades after the evidence became publicly available. As of 2010, only 12 states explicitly required the use of booster seats, 9 for infant seats and 6 for toddler seats. There is also great variation among states in defining the child population to be covered by the laws, the vehicle operators subject to compliance, and the penalties resulting from non-compliance. Some states cover only up to 4-year-olds while others cover children up to age 17. As of 2010, states have as many as 14 exemptions, such as those for non-residents, non-parents, commercial vehicles, large vehicles, or vehicles without seatbelts. Factors such as the complexity of the state of the science, the changing nature of guidelines (from age to height/weight-related criteria), and the absence of coordinated federal actions are potential explanations for the observed patterns. The resulting uneven policy landscape among states suggests a strong need for improved communication among state legislators, public health researchers, advocates and concerned citizen groups to promote more efficient and effective policymaking.

Effectiveness of booster seats compared with no restraint or seat belt alone for crash injury prevention

OBJECTIVES

The objective was to evaluate the effectiveness of belt-positioning booster seats, compared with no restraint use and with seat belt use only, during motor vehicle crashes among U.S. children.

METHODS

This was a retrospective matched cohort study with data from the 1998 through 2009 National Automotive Sampling System (NASS) Crashworthiness Data System (CDS). The study sample consisted of children aged 0 to 10 years who were not seated in the front seat of the vehicle. We used Cox proportional hazards models to estimate the risk of overall, fatal, and regional body injury.

RESULTS

Children using seat belts in belt-positioning booster seats experienced less overall injury (Injury Severity Score [ISS] > 0, adjusted risk ratio [RR] = 0.73, 95% confidence interval [CI] = 0.55 to 0.96; Abbreviated Injury Scale [AIS] score of 2 or higher, adjusted RR = 0.30, 95% CI = 0.16 to 0.58; ISS > 8, adjusted RR = 0.19, 95% CI = 0.06 to 0.56), and less injury in most body regions except the neck (adjusted RR = 4.79, 95% CI = 1.43 to 16.00) than did children with no restraint use. Children using seat belts in belt-positioning booster seats had an equal risk of injury but higher risks of neck (adjusted RR = 1.86, 95% CI = 1.02 to 3.40) and thorax (adjusted RR = 2.86, 95% CI = 1.33 to 6.15) injury than did children restrained by seat belts only.

CONCLUSIONS

Children using belt-positioning booster seats appear to experience a higher risk of AIS > 0 injury to the neck and thorax than do children using seat belts only. Future research should examine whether the observed increase in neck and thorax injuries can be attributed to improper use of booster seats.

Promoting use of booster seats in rural areas through community sports programs

BACKGROUND

Booster seats reduce mortality and morbidity for young children in car crashes, but use is low, particularly in rural areas. This study targeted rural communities in 4 states using a community sports-based approach.

OBJECTIVE

The Strike Out Child Passenger Injury (Strike Out) intervention incorporated education about booster seat use in children ages 4-7 years within instructional baseball programs. We tested the effectiveness of Strike Out in increasing correct restraint use among participating children.

METHODS

Twenty communities with similar demographics from 4 states participated in a nonrandomized, controlled trial. Surveys of restraint use were conducted before and after baseball season. Intervention communities received tailored education and parents had direct consultation on booster seat use. Control communities received only brochures.

RESULTS

One thousand fourteen preintervention observation surveys for children ages 4-7 years (Intervention Group [I]: N = 511, Control [C]: N = 503) and 761 postintervention surveys (I: N = 409, C: N = 352) were obtained. For 3 of 4 states, the intervention resulted in increases in recommended child restraint use (Alabama +15.5%, Arkansas +16.1%, Illinois +11.0%). Communities in 1 state (Indiana) did not have a positive response (-9.2%). Overall, unadjusted restraint use increased 10.2% in intervention and 1.7% in control communities (P = .02). After adjustment for each state in the study, booster seat use was increased in intervention communities (Cochran-Mantel-Haenszel odds ratio 1.56, 95% confidence interval [1.16-2.10]).

CONCLUSIONS

A tailored intervention using baseball programs increased appropriate restraint use among targeted rural children overall and in 3 of 4 states studied. Such interventions hold promise for expansion into other sports and populations.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An exploratory study of parents' use and knowledge of car safety seats in Beijing, China

As the number of vehicles in China rapidly increases and there is no child safety seat law, the issue of road safety for children is a growing concern. The purpose of this study was to examine parents' use and knowledge of car safety seats in Beijing, China. Using a convenience sample of 843 parents, survey results showed that only 64.8% of parents used a safety restraint for their children; the remaining 35.2% of children, of which most were toddlers or school-aged children, travelled unrestrained in vehicles. Among parents who used a safety restraint, only 24.2% were using it correctly based on the child's age (for infants), weight and height. Common reasons for not using a safety seat included difficulty finding safety seats (56.6%), cost (26.1%), and a preference to hold the child (18.1%). Moreover, a large proportion of parents prematurely transitioned their child from a safety seat to seat belt. The results highlight the need to develop injury prevention interventions that communicate the benefits and encourage the use of child safety restraints in China.

Child passenger safety

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats for most infants up to 2 years of age; (2) forward-facing car safety seats for most children through 4 years of age; (3) belt-positioning booster seats for most children through 8 years of age; and (4) lap-and-shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health-supervision visit.

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

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

Identification and analysis of putative promoter motifs in Flavivirus genome

The genus Flavivirus comprises medically significant pathogenic virus; causing several infections in humans worldwide. Flavivirus genomes are 10-11 kb approximately and encode both structural and non structural region. The non structural region plays fundamental role in the stability, regulation and cell cycle of virus. The complete genomes of 26 Flavivirus were used for identification of promoter motifs through in silico approaches. The promoter sequences were encoded in merely 16 viruses and 10 viruses could not encode it. All these in silico identified promoter motifs was confirmed and verified with the known experimental data. This analysis suggests that presence of promoter may play a crucial role in the pattern of gene expression, regulation networks, cell specificity and development. It may also be useful for designing efficient expression vector and target specific delivery system in the gene therapy.

Determining the proportion of children too heavy for age-appropriate car seats in a practice-based research network

INTRODUCTION

more information is needed on how trends in childhood weight might influence legally compliant child safety seat (CSS) use.

OBJECTIVE

to determine the proportion of child passengers who cannot comply with one state's CSS law because of weight.

METHOD

6 practices in a practice-based research network provided data on patient demographics, heights, and weights. The authors calculated percentages of children above age-appropriate CSS weight cutoffs (20, 40, and 80 pounds, respectively) for the cohort below 6 years.

RESULTS

there were 717 participants below 6 years of age. Among all infants (<12 months), 16.4% weighed >20 pounds. Among children 12 months to <6 years old, 20% weighed >40 pounds. One weighed >80 pounds. There were no significant differences among racial groups. There was wide variation among practices, but differences did not achieve statistical significance.

CONCLUSION

many children in this diverse cohort were too heavy to be compliant with the state CSS law.

Injuries to belted older children in motor vehicle crashes

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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 lack of motor vehicle occupant restraint use in children arriving at school

BACKGROUND

Motor vehicle crashes are the leading cause of mortality for children aged 4-14 in the United States. Many children are driven daily to school, increasing their exposure to potential injury, especially if they are not appropriately restrained. Observing the level of motor vehicle occupant restraint (MVOR) use upon school arrival could lead to valuable information for the development of an injury prevention program targeted to this population. This study compares the rate of MVOR use upon arrival to elementary schools with that at regional intersections.

METHODS

One hundred thirty-five census tracts in the Denver, Colorado, area were identified and combined into 5 regions. Within each region, 1 controlled intersection and 1 elementary school were observed. Observations were conducted for 1 hour at each of these locations.

RESULTS

At intersections, 618 children in private vehicles were observed. MVOR use rate was 71.2% (440/618). At schools, 665 children in private vehicles were observed. MVOR use was 24.8% (165/665). Children arriving at school were less likely to be restrained than those observed at intersections (relative risk: 0.35, 95% CI: 0.30-0.40).

CONCLUSIONS

Children at elementary schools showed substantially lower MVOR use rates than those observed at controlled intersections. Further investigation is imperative to determine the reason behind the low use of MVOR in children being transported to school. Based on the reasons elicited, interventions emphasizing the importance of always using MVOR can be developed and tailored to meet the educational needs of parents transporting their children to school in private vehicles.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Child passenger restraint use and emergency department--reported injuries: a special study using the National Electronic Injury Surveillance System-All Injury Program, 2004

INTRODUCTION

In 2004, more than 180,000 child passengers aged <or=12 years sought care in U.S. hospital emergency departments (EDs) for injuries sustained in motor-vehicle crashes (MVCs).

METHOD

We expanded the National Electronic Injury Surveillance System-All Injury Program for 635 injured children aged <or=12 years treated at 15 hospital EDs in 2004 by collecting multiple injury diagnoses and interviewing parents about MVC circumstances.

RESULTS

Nine percent of the children were unrestrained and 36% were inappropriately restrained. Blacks and Hispanics were about six times more likely to be unrestrained than Non-Hispanic Whites (12% and 14%, respectively, vs. 2%). Seventy-seven percent of inappropriate restraint use occurred among children aged 4-8 years, who were prematurely placed in seatbelts. Eight percent of children required hospitalization; unrestrained children were three times more likely to be hospitalized than restrained children (21% vs. 7%).

CONCLUSION

Age-appropriate restraint use should be promoted for child passengers, particularly among Blacks, Hispanics, and children riding in trucks.

Alarming trends in the improper use of motor vehicle restraints in children: implications for public policy and the development of race-based strategies for improving compliance

PURPOSE

Little is known regarding the patterns of appropriate restraint use among minority children involved in motor vehicle collisions. The purpose of this study was to characterize patterns of restraint use among children hospitalized after motor vehicle collision and to examine the effects of race and socioeconomic status on compliance.

METHODS

All children admitted to our level I trauma center over a 10-year period were identified. Patterns of appropriate restraint use were compared between African American (AA) and white children. Compliance was also compared between children insured with Medicaid (as a surrogate for socioeconomic status) and those with private insurance coverage.

RESULTS

One thousand two hundred sixty-eight patients were included with an overall restraint use of 44.8% with only 20.3% restrained properly. Compared with white children, AAs were significantly less likely to be properly restrained (12.7% vs 22.2%, P < .001) or to be restrained by any means (28.8% vs 48.7%, P < .001). The greatest disparity between groups was observed in the use of car seats (16.0% vs 47.4%, P < .001). Medicaid patients were less likely to be restrained compared with those with commercial insurance (40.6% vs 48.3%, P = .022); however, race remained a significant predictor of noncompliance after controlling for the effect of insurance status.

CONCLUSIONS

These data demonstrate an alarming trend because nearly 80% of all children in our study were improperly restrained. Marked disparities in compliance were observed in the AA population even after controlling for insurance coverage. Future studies will need to further characterize the complex interplay between race and socioeconomic status with proper restraint use.

A risky treat: exploring parental perceptions of the barriers to seating their children in the rear seats of passenger vehicles

BACKGROUND

Sitting in the rear seat of a vehicle rather than in the front seat reduces children's risk of injury or death by > or =35% in the event of a crash. As road trauma is a leading cause of child morbidity and mortality in highly motorised nations, even in countries where restraint use is high, encouraging parents to place children in the rear seats of vehicles offers a low-cost avenue to improving children's overall health. However, little is known about the factors that affect parents' decisions about seating positions.

OBJECTIVE

To explore parental perceptions of barriers to placing their children in the rear seat of passenger vehicles whenever possible.

DESIGN AND SUBJECTS

Focus group discussions were held with urban parent-drivers to elicit their concerns about children's car safety and barriers to rear-seat use.

RESULTS

Most parents had a rule that children should sit in the rear seat. Parents said that they relaxed these rules for a variety of reasons including social pressure, perceptions of the trip as short and because children regard sitting in the front seat as a treat. Parenting style, child cooperativeness, social pressure and inability to justify the risk of injury were identified as barriers to rear-seat travel.

CONCLUSIONS

Effective interventions to increase the proportion of children travelling in the rear seat should address parents' experiences of pressure to relax seating rules and risk perception, as well as provide strategies that support sound parental safety decisions.

Using a Focus Group to Determine Car Seat Use Among Mothers of Children Aged 3 to 7 Years

PURPOSE

This study built on prior research and examined the beliefs, behaviors, barriers and motivating factors for use of child car seats with children aged 3 to 7 years.

STUDY DESIGN AND METHODS

Two focus groups of eight mothers each were conducted using a structured interview guide. One group consisted of African American and Latina women, the other of White women.

RESULTS

All of the mothers believed that properly restraining their children while riding in a car protected the children from injury. Most also reported that they have used car seats for their children. African American and Latina mothers, however, reported more inconsistent use of the seats, particularly with older children of this age group. They were also more likely to report greater resistance by their children to use car seats.

CLINICAL IMPLICATIONS

In this small study, there were ethnic disparities in differences in use of child car seats for children aged 3 to 7; this subject requires more research. In the meantime, public health programs on child car seats are needed and should take into account differing beliefs and behaviors of various cultural groups.

Odds of critical injuries in unrestrained pediatric victims of motor vehicle collision

OBJECTIVES

To compare morbidity and mortality between pediatric victims of motor vehicle collisions (MVC) who were unrestrained to those restrained and to describe compliance with child restraint usage in our population.

MATERIALS AND METHODS

A retrospective consecutive chart review study was performed on MVC victims 14 years old and younger who presented to our academic, level 1 trauma emergency department in 2003. Each patient's emergency department and hospital course was reviewed and data were collected. Odds ratios (ORs) were calculated for unrestrained children with respect to restrained children for fractures; intraabdominal injuries, intrathoracic injuries, intracranial injuries, admission, surgery, blood transfusion, intubation; and deaths. Hospital charges and length of hospital stay were compared between those unrestrained and restrained. Percentage of children unrestrained was determined.

RESULTS

Of 336 patients, 81 (24%) were unrestrained. Mean hospital stay for unrestrained children was longer, 1.94 days (95% confidence interval [CI] 0.75-3.12) versus 0.098 days (95% CI 0.02-0.21). Unrestrained victims had higher mean charges, 14,754 dollars (95% CI 7676 dollars-21,831 dollars) versus 1996 dollars (95% CI 1207 dollars-2786 dollars). Admissions (OR = 14.48, 95% CI 5.91-38.63), fractures (OR = 5.85, 95% CI 2.13-16.89), intraabdominal injuries (OR = 20.16, 95% CI 2.36-930.68), and intrathoracic injuries (OR = 13.09, 95% CI 1.26-647.05) were all more likely in unrestrained patients. No restrained child had intracranial injury, whereas 9/81 (11.11%) of unrestrained did. Odds were higher in unrestrained for surgery [OR = 13.09, 95% CI 3.30-74.33] and transfusion [OR = 27.61, 95% CI 3.56-229.85]. Ten out of 81 (12.35%) of unrestrained children required intubation versus none for restrained. The only 2 mortalities were unrestrained patients.

CONCLUSION

Critical injuries and cost of care are higher in unrestrained than restrained children. Improved compliance with child safety restraint in southern Arizona should decrease childhood morbidity and mortality from MVCs.

Improving pediatric prevention via the internet: a randomized, controlled trial

BACKGROUND

Innovations to improve the delivery of pediatric preventive care are needed.

METHODS

We enrolled children, 0 to 11 years of age, into a factorial, randomized, controlled trial of a tailored, evidence-based, Web site (MyHealthyChild) that provided information on prevention topics before a scheduled well-child visit. There were 2 components of the intervention, namely, parental Web content and provider notification. Parental Web content provided information to parents about prevention topics; provider notification communicated to physicians topics that were of interest to parents. We assigned 887 children randomly to 4 groups (usual care, content only, content and notification, or notification only). Outcomes were determined with telephone follow-up surveys conducted 2 to 4 weeks after the visit. Poisson regression analysis was used to determine the independent effects of each intervention on the number of topics discussed and the number of preventive practices implemented.

RESULTS

Parents in the notification/content group and in the notification-only group reported discussing more MyHealthyChild topics with their provider. Parents in the notification/content group and in the content-only group reported implementing more MyHealthyChild topic suggestions (such as use of a safety device).

CONCLUSIONS

A Web-based intervention can activate parents to discuss prevention topics with their child's provider. Delivery of tailored content can promote preventive practices.

An emergency department intervention to increase booster seat use for lower socioeconomic families

OBJECTIVES

To evaluate the effectiveness of booster seat education within an emergency department (ED) setting for families residing in lower socioeconomic neighborhoods.

METHODS

This was a prospective, randomized study of families with children aged 4 to 7 years and weighing 40 to 80 lb who presented to a pediatric ED without a booster seat and resided in lower socioeconomic communities. Subjects were randomly assigned to one of three groups: 1) received standard discharge instructions, 2) received five-minute booster seat training, and 3) received five-minute booster seat training and free booster seat with installation. Automobile restraint practices were obtained initially and by telephone at one month.

RESULTS

A total of 225 children were enrolled. Before randomization in the study, 79.6% of parents reported that their child was usually positioned in the car with a lap/shoulder belt and 13.3% with a lap belt alone. Some parents (16.4%) had never heard of a booster seat, and 44.9% believed a lap belt was sufficient restraint. A total of 147 parents (65.3%) were contacted for follow-up at one month. Only one parent (1.3%) in the control group and four parents (5.3%) in the education group purchased and used a booster seat after their ED visit, while 55 parents (98.2%) in the education and installation group reported using the booster seat; 42 (75.0%) of these parents reported using the seat 100% of the time.

CONCLUSIONS

Education in a pediatric ED did not convince parents to purchase and use booster seats; however, the combination of education with installation significantly increased booster seat use in this population.

Booster seat or seat belt? Motor vehicle injuries and child restraint laws in preschool and early school-age children

ISSUES AND PURPOSE

Despite numerous interventions to reduce motor vehicle injuries and deaths in children living in the United States, unintentional motor vehicle injuries continue to be the leading cause of death of U.S. children.

CONCLUSION

Even though child restraint laws have been enacted, many children 5 to 9 years of age continue to be injured in motor vehicle crashes. These injuries are related to the improper use of child restraints. Reasons for injuries in this age group were explored by a review of the current literature.

PRACTICE IMPLICATIONS

Nurses have a unique role in educating families about proper restraint and in contributing to the evidence base for practice.

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

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

Effectiveness of high back belt positioning booster seats in side impacts

OBJECTIVE

The objective of this study is to evaluate the potential of high back booster seats to provide effective protection to children in side impacts.

METHOD

This article presents a series of side impact sled tests at a velocity change of 30.5 km/h and a peak deceleration of 15.2 g, using the Hybrid III 6-year-old dummy in two styles of commonly used high-back booster seats: a conventional polystyrene booster seat and a convertible child restraint/booster seat. A series of tests were also performed using alternative anchorage systems in combination with the boosters. Simulated side impact tests were conducted at 90 degrees and 45 degrees.

RESULTS

The booster seats tested were found to be too short for the 6-year-old dummy and head contact with the side door occurred in all 90 degree tests, resulting in high HIC values. The greatest potential for achieving effective protection in side impact in this test series was observed when the convertible child restraint/booster was used in combination with a rigid anchorage system. Using this system, the body of the dummy was kept farther away from the door which resulted in a softer head impact with the side door.

CONCLUSIONS

Results from this work indicate that current booster seats offer poor torso containment and no head protection for children within the recommended age range. They also showed that the level of protection provided by belt positioning booster seats can be improved through the use of rigid anchorage systems. However, for this potential to be fully realized, belt positioning booster seats must offer better containment of the occupant during the impact.

The impact of a nationwide effort to reduce airbag-related deaths among children: an examination of fatality trends among younger and older age groups

INTRODUCTION

The purpose of this study was to examine the impact of a nationwide response to emerging airbag-related deaths among children. This response, implemented in 1996, focused on moving children to a rear seat and increasing proper restraint usage.

METHOD

Fatality trends from 1992 through 1996 and from 1996 through 2003 were examined for younger children (ages 0-3) and for older children (ages 4-12).

RESULTS

Prior to 1997, a steady reduction in unrestrained deaths (among younger children) was offset by increases in restrained deaths (among younger and older children), increases in rear-seat deaths (among younger children), and increases in front-seat deaths (among older children). After 1996, there were significant decreases in fatalities in both age groups, with larger and more immediate reductions among the younger children. The largest reductions were immediately after 1996, when younger-child deaths declined by 16%, and after 1999, when deaths among both age groups declined by about 16%.

CONCLUSIONS

The immediate reduction in front-seat deaths among younger children, particularly infants, appears to have been closely associated with the nationwide public information efforts implemented in 1996. Later reductions in front-seat and unrestrained deaths, among both younger and older children, were likely associated with the combination of legislative, enforcement, and public information programs, which increased after 1999.

IMPACT ON INDUSTRY

The findings suggest that a large expenditure of resources by public and private-sector organizations after 1996 resulted in the prevention of hundreds of deaths among young children. In addition, the results provide insights with regard to the categories of deaths most affected by such programs and issues that deserve additional attention.

Increases in booster seat use among children of low income families and variation with age

OBJECTIVES

To increase booster seat use among low income parents.

DESIGN/METHODS

A pre-test/post-test design conducted in nine daycare centers with post-test observations four to eight weeks after the intervention.

INTERVENTION

Parents who participated in an educational training received free seats, educational programs were provided to all daycare staff and children, and signs in parking lots informed parents about child restraints. At seven centers, new policies recommended compliance with state restraint laws. Parents at four centers randomly chosen from the seven received financial incentives if observed using booster seats.

MAIN OUTCOME MEASURE

The percent of children aged 4-8 riding in booster seats.

RESULTS

Pre-test observations of 185 4-8 year olds found 56% riding unrestrained and fewer than 3% riding in booster seats. After the intervention, observation of 146 children found the number riding in booster seats increased to 38% and the number observed without restraints decreased to 26%. Most booster seat use occurred with 4 and 5 year olds. No 7 or 8 year olds rode in booster seats. Changing center policies to recommend compliance with state restraint laws and an offer of financial incentives appeared to have no additional impact.

CONCLUSIONS

Booster seat usage among low income families can be increased dramatically, though use decreases with age. Providing free seats accompanied by training may be sufficient without the need for additional intervention.

Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices

PURPOSE

Despite the devastating consequences of cervical spine (C-spine) injury in children after motor vehicle collisions (MVC), the factors leading to the injury and the appropriateness of protective restraints remain undefined. The authors hypothesized that age-related anatomic factors contribute to inadequate restraints and therefore increase injury severity after MVC.

METHODS

Data on children (<18 years, 1997 to 2002) admitted to a level 1 pediatric trauma center were prospectively collected and retrospectively reviewed. Those with C-spine injuries caused by MVC were extracted and divided into 2 groups: young (0 to 8 years) and old (9 to 18 years). Statistical comparison was by Student's t test or Z-test, with P less than.05 accepted as significant.

RESULTS

Of 5,117 trauma admissions, 94 had C-spine injuries with a mean age of 11 +/- 5 years, 66% of which were boys. Among 1,124 patients who had sustained MVC there were 27 C-spine injuries (2.4% incidence), of which, 12 were less than 8 and 15 were older than 8 years. Restraint devices were utilized at least as frequently in younger children (young, 58% v. old, 43%; not significant). However, younger children had an increased incidence of permanent cord deficit (young, 57% v. old, 13%; P <.05) and closed head injury (young, 50% v. old, 7%; P <.05) even while wearing restraint devices, suggesting that restraint devices are inadequate or improperly used in younger patients. This is supported by the increased injury severity scores of the younger group (young, 37.7 +/- 8.5 v. old, 16.5 +/- 4.6; P <.05).

CONCLUSIONS

Younger children suffer more sever cervical spine injuries after motor vehicle collisions than their older counterparts, in part because of the inadequacy of currently existing restraint devices. Design modifications to current restraints, including the use of head straps, might improve outcome after MVC in younger patients.

Not all child safety seats are created equal: the potential dangers of shield booster seats

OBJECTIVE

Children are safest when traveling in a child safety seat appropriate for their age and size. Previous research indicates that children are often transitioned to shield booster seats (SBSs) before reaching the 40-lb weight limit for their forward-facing child safety seat (FFCSS). These children could have otherwise been restrained in a FFCSS as is currently recommended by the American Academy of Pediatrics and the National Highway Traffic Safety Administration. The objective of this study was to compare the injury patterns among children who were restrained in SBSs and FFCSSs. Children in FFCSSs were chosen as a comparison group because SBS are predominantly used to restrain children who are <40 lb and could have been restrained in an FFCSS, and SBSs are no longer certified for use in children who are >40 lb.

METHODS

This is a cohort study involving restrained crash victims who were admitted to a level 1 pediatric trauma center between 1991 and 2003. Patients were older than 1 year, weighed between 20 and 40 lb, and were restrained in an SBS (N = 16) or an FFCSS (N = 30). Injury Severity Score, Abbreviated Injury Scale, Glasgow coma score, intensive care admission, length of stay, and acute care charges served as outcomes of interest.

RESULTS

No significant differences regarding crash and occupant characteristics were found (mean Delta V, crash type, passenger compartment intrusion, driver restraint use). Odds of severe injury were greater for children in SBSs compared with children in FFCSSs as measured by Injury Severity Score >15 (odds ratio [OR]: 8.3; 95% confidence interval [CI]: 2.1-33.6), intensive care admission (OR: 5.5; 95% CI: 1.5-20.5), length of stay >2 days (OR: 6.3; 95% CI: 1.6-24.6), and Abbreviated Injury Scale > or = 3 (OR: 4.4; 95% CI: 1.2-16.1). Furthermore, SBS cases had greater odds of head (OR: 4.5; 95% CI: 1.2-17.3), chest (OR: 29.0; 95% CI: 3.1-267.3), and abdominal/pelvic injury (25% vs 0%).

CONCLUSION

This study provides information about the increased risk of injury associated with shield boosters when compared with FFCSSs. The challenge for pediatricians is not only to promote the use of child restraints but also to ensure that parents use the most appropriate restraint for their child's age and weight.

Too small for a seatbelt: predictors of booster seat use by child passengers

OBJECTIVES

Motor vehicle injury is the leading cause of injury death for children 4 to 8 years of age. Although booster seat use in this age group substantially reduces the risk of injury, most children are currently restrained by seatbelts designed for adults. The objective of this study was to measure booster seat use directly, determine factors predictive of proper child restraint, and assess parental reasons for booster use and nonuse.

METHODS

We conducted a cross-sectional, observational study in Seattle, Washington, Spokane, Washington, and Portland, Oregon, from February to April 2000. Drivers were surveyed in their vehicles after picking up children from schools and child care centers. Trained observers recorded child age, weight, and height and directly observed restraint use. Observed restraint use was compared with the recommended restraint method based on the child's weight and age. Data were analyzed using multivariate logistic regression, adjusted for clustering by car and site.

RESULTS

We observed 2880 children traveling in cars, 1539 of whom were eligible for booster seat use. Eighty-eight percent of drivers agreed to respond to our survey. Only 16.5% of children for whom a booster seat was recommended were properly restrained, compared with 80% of younger children for whom a child safety seat was recommended and 55% of children for whom an adult seatbelt was recommended. Relative to a 4-year-old booster-eligible child, a 6-year-old was only half as likely to use a booster seat (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.31-0.71) and an 8-year-old almost never used a booster seat (OR: 0.04; 95% CI: 0.01-0.19). Booster use was more common when the driver wore a seatbelt (OR: 3.1; 95% CI: 1.8-5.4). Parents whose children were using booster seat cited "safety" (61%) and "child comfort and visibility" (12%) as their primary concerns. When a child was not using a booster seat, parents most often believed that their child was "too big for a car seat" (56%), reported that the seat was in another vehicle (9%), or stated that they "had not heard" of booster seats (8%).

CONCLUSIONS

Many parents still incorrectly believe that children are safe in a seatbelt and have outgrown the need for a car seat. These results demonstrate the need for public education campaigns to educate parents about booster seat use.