Effectiveness of belt positioning booster seats: an updated assessment

Use of Child Safety Seat and its Determinants in Jeddah, Saudi Arabia: A Cross-sectional Study

Background

A child safety seat protects children from injury during motor vehicle accidents (MVAs). However, there is a lack of enforcement of regulation regarding its use in Saudi Arabia.

Objectives

This study aimed to determine the use of child safety seat and its determinants and barriers in Jeddah, Saudi Arabia.

Materials and Methods

This cross-sectional study was based on a structured face-to-face interview across Jeddah among families who drove in cars with children aged ≤5 years. The study used stratified multistage random sampling across the population of the governorate of Jeddah.

Results

A total of 675 parents were included, of which 311 (46.1%) reported having a child safety seat in their vehicle, and only 165 (24.4%) reported its regular use. Awareness levels among parents regarding child safety seat use and its benefits, parents' level of education, family size, family income, and the belief in the need for laws governing child safety seat were key determinants of child safety seat use. Poor awareness among parents regarding the utility of child safety seat in reducing child injuries, low education levels among parents, larger families with multiple children, poor affordability, low family income, and a clear lack of laws mandating the use of child safety seat were identified as key barriers.

Conclusions

The regular use of child safety seat for children aged ≤5 years is low in even one of the most urban populations of Saudi Arabia. This indicates the need for large-scale awareness drives and stricter implementation of laws enforcing the use of child safety seat in Saudi Arabia.

Surveillance methods and interventions implemented in American Indian and Alaska Native communities to increase child restraint device and seat belt use in motor vehicles: a systematic review

BACKGROUND

American Indian/Alaska Native (AI/AN) children are disproportionately affected by injuries and deaths related to motor vehicle crashes. We aimed to synthesise published evidence on surveillance methods and interventions implemented in AI/AN communities and analyse characteristics that make them successful in increasing child restraint devices and seat belt use.

METHODS

Studies were collected from the PubMed, Scopus, and TRID databases and the CDC Tribal Road Safety website, Community Guide, and Indian Health Service registers. Included studies collected primary data on AI/AN children (0-17) and reported morbidity/mortality outcomes related to child restraint devices or seat belt use. Studies with poor methodological quality, published before 2002, whose data were collected outside of the USA, or were non-English, were excluded. Checklists from the Joanna Briggs Institute were used to assess the risk of bias. In the synthesis of results, studies were grouped by whether a surveillance method or intervention was employed.

RESULTS

The final review included 9 studies covering 72 381 participants. Studies conducted surveillance methods, interventions involving law enforcement only and multipronged interventions. Multipronged approaches were most effective by using the distribution of child restraint devices combined with at least some of the following components: educational programmes, media campaigns, enactment/enforcement of child passenger restraint laws, incentive programmes and surveillance.

DISCUSSION

Although this review was limited by the number and quality of included studies, available resources suggest that we need multipronged, culturally tailored and sustainable interventions fostered by mutually beneficial and trusting partnerships. Continued investment in AI/AN road safety initiatives is necessary.

Safety/booster seats in pediatric motor vehicle crashes: Public health concern

INTRODUCTION

The American Academy of Pediatrics (AAP) guidelines recommend that children ≤12-years-old with height < 145 cm should use safety/booster seats. However, national adherence and clinical outcomes for eligible children involved in motor vehicle collisions (MVCs) are unknown. We hypothesized that children recommended to use safety/booster seats involved in MVCs have a lower rate of serious injuries if a safety/booster seat is used, compared to children without safety/booster seat.

METHODS

This retrospective cohort study queried the 2017-2019 Trauma Quality Improvement Program database for patients ≤12-years-old and <145 cm (recommendation for use of safety/booster seat per American Academy of Pediatrics) presenting after MVC. Serious injury was defined by abbreviated injury scale grade ≥3 for any body-region. High-risk MVC was defined by authors in conjunction with definitions provided by the Centers for Disease Control and Prevention and the American College of Surgeons Committee on Trauma.

RESULTS

From 8259 cases, 41% used a safety/booster seat. There was no difference in overall rate of serious traumatic injuries or mortality (both p > 0.05) between the safety/booster seat and no safety/booster seat groups. In a subset analysis of high-risk MVCs, the overall use of safety/booster seats was 56%. The rate of serious traumatic injury (53.6% vs. 62.1%, p = 0.017) and operative intervention (15.8% vs. 21.6%, p = 0.039) was lower in the safety/booster seat group compared to the no safety/booster seat group.

CONCLUSIONS

Despite AAP guidelines, less than half of recommended children in our study population presenting to a trauma center after MVC used safety/booster seats. Pediatric patients involved in a high-risk MVC suffered more serious injuries and were more likely to require surgical intervention without a safety/booster seat. A public health program to increase adherence to safety/booster seat use within this population appears warranted.

Injury Patterns, Imaging Usage, and Disparities Associated With Car Restraint Use in Children

BACKGROUND

Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC.

METHODS

A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint.

RESULTS

Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different.

DISCUSSION

African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.

Ease of Use ratings and real-world child restraint system errors from Safe Kids Illinois seat checks, 2015-2019

BACKGROUND

Child restraint systems (CRSs) significantly reduce risk of crash-related injury, however installation and use errors undermine their benefits. The National Highway Traffic Safety Administration (NHTSA) created the Ease of Use (EOU) rating system to help guide consumers and incentivize manufacturers to improve their products. The EOU rating system assigns one to five stars to four CRS features and overall. Our study assessed the relationship between EOU ratings and CRS installation and use errors documented in seat checks conducted by child passenger safety technicians (CPSTs).

METHODS

We performed a secondary analysis of data from Safe Kids Illinois seat check records from 2015 through 2019 and EOU ratings from 2008 to 2020. Five types of errors were documented by CPSTs. Study authors (JYL and MLM) used a tiered system to match seat check model numbers to EOU ratings. We calculated chi-square statistics and performed logistic regression analyses to assess for EOU as a predictor of relevant CRS errors (e.g., tether errors for forward-facing CRSs).

RESULTS

Our analyses included 2132 seat check observations, of which 217 (10.2%) were exact, 244 (10.5%) were probable, and 1671 (78.4%) were near matches via sorting and web search. Errors were most common for seat belts (70.7%) and least common for recline angle (36.9%). Star ratings for instructions, vehicle installation, and labels were associated with recline angle and seat belt errors. Star ratings for instructions, labels, and securing child were associated with harness errors. CRSs with 4-star and 5-star ratings had lower odds of errors for recline angle (Odds Ratio (OR) 0.62; 95% Confidence Interval (CI): 0.43, 0.89 and OR 0.31; 95% CI: 0.17, 0.56) lower anchors (OR 0.59; 95% CI 0.40, 0.89 and OR 0.38; 95% CI: 0.21, 0.68), and harness (OR 0.56; 95% CI: 0.40, 0.76 and OR 0.19; 95% CI: 0.10, 0.35) when compared with 1 and 2-star CRSs.

CONCLUSIONS

This study provides evidence in support of NHTSA's EOU ratings as predictors of some CRS installation and use errors among caregivers who obtain seat checks. A higher star rating may be helpful for caregivers when choosing a CRS that will yield lower installation errors.

Investigation of factors influencing submarining mitigation with child booster seats

OBJECTIVE

Automobile booster seats are intended to improve belt fit for children that are too large for a harness-style child restraint, but not yet big enough to fit properly in an adult seat belt. Our objective was to prospectively study the relationship between booster seat design and interaction with the seat belt (specifically, submarining risk) for a child occupant using computer simulation of automobile crash events.

METHODS

Frontal-impact simulations were performed with a 6-year-old child human body model. Simplified models of booster seats were developed using an automated process designed to capture key characteristics of booster geometry, stiffness, belt guide construction, and attachment to the vehicle seat. The child model was positioned in a range of postures from upright to slouched. Our main interest was submarining, where the child's pelvis slips under the lap belt and the belt loads into the abdomen (defined based on the motion of the lower lap belt edge relative to the ASIS).

RESULTS

Among the parameters studied, the factors that had the greatest effect on submarining risk were the booster's stiffness and the child's posture. Booster models of a low-stiffness construction (similar to an inflatable booster) nearly always resulted in submarining, regardless of the other design characteristics of the booster. A slouched posture also substantially increased the likelihood of submarining (even for high-stiffness boosters).

CONCLUSIONS

These results suggest that booster seats of a stiffer construction, and booster seats that promote an upright posture may provide a protective benefit compared to softer boosters and boosters that are more likely to result in slouching of the child.

Urban and Rural Child Deaths from Motor Vehicle Crashes: United States, 2015-2019

OBJECTIVE

The objective of the study was to examine child deaths in motor vehicle crashes by rurality, restraint use, and state child passenger restraint laws.

STUDY DESIGN

2015-2019 Fatality Analysis Reporting System data were analyzed to determine deaths and rates by passenger and crash characteristics. Optimal restraint use was defined using age and the type of the restraint according to child passenger safety recommendations.

RESULTS

Death rates per 100 000 population were highest for non-Hispanic Black (1.96; [1.84, 2.07]) and American Indian or Alaska Native children (2.67; [2.14, 3.20]) and lowest for Asian or Pacific Islander children (0.57; [0.47, 0.67]). Death rates increased with rurality with the lowest rate (0.88; [0.84, 0.92]) in the most urban counties and the highest rate (4.47; [3.88, 5.06]) in the most rural counties. Children who were not optimally restrained had higher deaths rates than optimally restrained children (0.84; [0.81, 0.87] vs 0.44; [0.42, 0.46], respectively). The death rate was higher in counties where states only required child passenger restraint use for passengers aged ≤6 years (1.64; [1.50, 1.78]) than that in those requiring child passenger restraint use for passengers aged ≤7 or ≤8 years (1.06; [1.01, 1.12]).

CONCLUSIONS

Proper restraint use and extending the ages covered by child passenger restraint laws reduce the risk for child crash deaths. Additionally, racial and geographic disparities in crash deaths were identified, especially among Black and Hispanic children in rural areas. Decision makers can consider extending the ages covered by child passenger restraint laws until at least age 9 to increase proper child restraint use and reduce crash injuries and deaths.

Belt fit for children in vehicle seats with and without belt-positioning boosters

OBJECTIVE

The purpose of the current study is to use 3D technology to measure in-vehicle belt fit both with and without booster seats across different vehicles among a large, diverse sample of children and to compare belt fit with and without a booster.

METHODS

Lap and shoulder belt fit were measured for 108 children ages 6-12 years sitting in the second-row, outboard seats of three vehicles from October 2017 to March 2018. Each child was measured with no booster, a backless booster, and a high-back (HB) booster in three different vehicles. Alternative high-back (HB HW) and backless boosters that could accommodate higher weights were used for children who were too large to fit in the standard boosters. Lap and torso belt scores were computed based on the belt location relative to skeletal landmarks.

RESULTS

Both lap and torso belt fit scores were significantly different across vehicles when using the vehicle belt alone (no booster). In all vehicles, lap belt fit improved when using boosters compared with no booster among children ages 6-12 years in rear seats-with one exception of the HB HW booster in the minivan. Torso belt fit improved when using boosters compared with no booster in the sedan, and torso belt fit improved in the minivan and SUV with the use of HB and HB HW boosters when compared with no booster.

CONCLUSIONS

Lap and torso belt fit for children ages 6-12 years in rear seats was substantially improved by using boosters. Parents and caregivers should continue to have their children use booster seats until vehicle seat belts fit properly which likely does not occur until children are 9-12 years old. Decision makers can consider strengthening child passenger restraint laws with booster seat provisions that require children who have outgrown car seats to use booster seats until at least age 9 to improve belt fit and reduce crash injuries and deaths.

Evaluation of parental education using biomechanical visualization to increase child restraint use in China

INTRODUCTION

Despite demonstrated effectiveness of child restraint system (CRS), its use in China is extremely low due to the lack of national legislation requiring the use of CRS, as well as lack of child passenger safety knowledge among caregivers. Implementing an effective intervention is urgently needed to promote the use of CRS. In this study, we primarily evaluated the effectiveness of biomechanical visualization delivered in the context of CRS education to promote CRS use.

METHODS

We conducted a cluster randomised controlled trial to test the effects of educational intervention programs on increased use of CRS. Participants included caregivers from 8 pre-schools located in two cities (i.e., Chaozhou and Shantou) in China. Following a baseline survey, 8 pre-schools were randomly assigned into 1 of 4 groups with 2 schools in each group: 1) CRS education-only, 2) CRS education with behavioral skill training, 3) CRS education with biomechanical visualization, and 4) control. The primary outcome was CRS use, and the secondary outcomes included scores of child passenger safety-related knowledge and CRS use-related attitudes. The effect of the intervention was assessed among caregivers at two time points: baseline preintervention and 6 months postintervention.

RESULTS

More than 70% caregivers had never used CRS at baseline. No statistically significant between-group differences CRS use were observed at baseline preintervention (34.2%, 25.4%, 29.6% and 21.9%, respectively, P = 0.18). However, compared to the control group, odds of CRS non-use was significantly lower in caregivers assigned to the CRS education with biomechanical visualization (adjusted odd ratio (AOR) = 0.11, 95% confidence interval (CI) = 0.07-0.17), CRS education with behavioral skill training (AOR = 0.15, 95%CI = 0.10-0.24) and CRS education-only (AOR = 0.26, 95%CI = 0.17-0.41) groups, respectively. Statistically significant differences were also observed in the secondary outcomes postintervention across groups. Specifically, the CRS education with biomechanical visualization and CRS education with behavioral skill training groups had higher mean knowledge change scores than the CRS education-only group (3.3 ± 1.5 vs. 2.9 ± 2.2, p = 0.035 and 3.2 ± 1.9 vs. 2.9 ± 2.2, p = 0.039, respectively). We also observed a significantly higher increase in the attitudes scores in the CRS education with biomechanical visualization group compared with the CRS education-only group (4.7 ± 2.1 vs. 3.5 ± 2.8,p = 0.026).

CONCLUSIONS

This study shows that both biomechanical visualization and behavioral skill training supplements to education improved understanding of CRS knowledge compared to education only, and all three strategies led to increased CRS use. Importantly, CRS education with biomechanical visualization was shown to be more effective than CRS education alone in improving caregiver's knowledge and attitudes. The use of biomechanical visualization may be an effective supplement to traditional education programs.

Association of venous thromboembolism following pediatric traumatic spinal injuries with injury severity and longer hospital stays

OBJECTIVE

Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs).

METHODS

The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014.

RESULTS

Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4-4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0-6.1), epidural hematoma (aOR 2.8, 95% CI 1.4-5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8-3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1-2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6-5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0-1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8-3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8-3.6).

CONCLUSIONS

VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.

Use of child safety seats and booster seats in the United States: A comparison of parent/caregiver-reported and observed use estimates

BACKGROUND

Motor-vehicles crashes are a leading cause of death among children. Age- and size-appropriate restraint use can prevent crash injuries and deaths among children. Strategies to increase child restraint use should be informed by reliable estimates of restraint use practices.

OBJECTIVE

Compare parent/caregiver-reported and observed child restraint use estimates from the FallStyles and Estilos surveys with the National Survey of the Use of Booster Seats (NSUBS).

METHODS

Estimates of child restraint use from two online, cross-sectional surveys-FallStyles, a survey of U.S. adults, and Estilos, a survey of U.S. Hispanic adults-were compared with observed data collected in NSUBS. Parents/caregivers of children aged ≤ 12 years were asked about the child's restraint use behaviors in FallStyles and Estilos, while restraint use was observed in NSUBS. Age-appropriate restraint use was defined as rear-facing child safety seat (CSS) use for children aged 0-4 years, forward-facing CSS use for children aged 2-7 years, booster seat use for children aged 5-12 years, and seat belt use for children aged 9-12 years. Age-appropriate restraint users are described by demographic characteristics and seat row, with weighted prevalence and corresponding 95% confidence intervals (CI) calculated.

RESULTS

Overall, child restraint use as reported by parents/caregivers was 90.8% (CI: 87.5-94.1) (FallStyles) and 89.4% (CI: 85.5-93.4) for observed use (NSUBS). Among Hispanic children, reported restraint use was 82.6% (CI: 73.9-91.3) (Estilos) and 84.4% (CI: 79.0-88.6) for observed use (NSUBS, Hispanic children only). For age-appropriate restraint use, estimates ranged from 74.3% (CI: 69.7-79.0) (FallStyles) to 59.7% (CI: 55.0-64.4) (NSUBS), and for Hispanic children, from 71.5% (CI: 62.1-81.0) (Estilos) to 57.2% (CI: 51.2-63.2) (NSUBS, Hispanic children only). Conclusion and Practical Application: Overall estimates of parent/caregiver-reported and observed child restraint use were similar. However, for age-appropriate restraint use, reported use was higher than observed use for most age groups.

Association between driver and child passenger restraint: Analysis of community-based observational survey data from 2005 to 2019

INTRODUCTION

Crash data suggest an association between driver seatbelt use and child passenger restraint. However, community-based restraint use is largely unknown. We examined the association between driver seatbelt use and child restraint using data from a state-wide observational study.

METHODS

Data from Iowa Child Passenger Restraint Survey, a representative state-wide survey of adult seat belt use and child passenger safety, were analyzed. A total of 44,996 child passengers age 0-17 years were observed from 2005 to 2019. Information about driver seatbelt use and child restraint was directly observed by surveyors and driver age was reported. Logistic regression was used to examine the association between driver seatbelt use and child restraint adjusting for vehicle type, community size, child seating position, child passenger age, and year.

RESULTS

Over the 15-year study period, 4,114 (9.1%) drivers were unbelted, 3,692 (8.2%) children were completely unrestrained, and another 1,601 (3.6%) children were improperly restrained (analyzed as unrestrained). About half of unbelted drivers had their child passengers unrestrained (51.8%), while nearly all belted drivers had their child passengers properly restrained (92.3%). Compared with belted drivers, unbelted drivers had an 11-fold increased odds of driving an unrestrained child passenger (OR = 11.19, 95%CI = 10.36, 12.09). The association between driver seatbelt use and child restraint was much stronger among teenage drivers. Unbelted teenage drivers were 33-fold more likely (OR = 33.34, 95%CI = 21.11, 52.64) to have an unrestrained child passenger.

CONCLUSION

These data suggest that efforts to increase driver seatbelt use may also have the added benefit of increasing child restraint use. Practical applications: Enforcement of child passenger laws and existing education programs for new drivers could be leveraged to increase awareness of the benefits of seatbelt use for both drivers themselves and their occupants. Interventions aimed at rural parents could emphasize the importance of child safety restraints.

Prevention of unintentional injuries in children under five years

We looked at existing recommendations for preventing unintentional injuries in children under five years of age, and we attempted to identify the main sources used as evidence for formulating these recommendations.

We conducted a literature search up to the 18th October 2019 by using key terms and manual search in selected sources. We summarized the recommendations and source of the evidence in tables for each of five areas of unintentional injuries: road traffic injuries, drowning, poisoning, thermal injuries, falls.

In 2008, the World Health Organization (WHO) published a comprehensive report with strategies for child injury prevention for the European region. More recently, the WHO published several guidance documents focused on one area such as drowning, usually with a global focus. The PrevInfad workgroup (Spanish Association of Primary Care Pediatrics) updated their document on road safety in April 2019, providing recommendations and a summary of the existing evidence. Preventive strategies for injuries in childhood are mainly based on surveillance data and the identification of risk factors. The key strategies for preventing unintentional injuries are a combination of environmental and behaviour modification, that can be achieved through engineering, enforcement and education. Consequently, for this kind of strategies, it is important to evaluate the effectiveness of both the intervention itself, and the way the intervention is advised to parents and caretakers so that there is good compliance of the recommendation.

The effectiveness of booster seat use in motor vehicle collisions

BACKGROUND

Alberta remains the only province in Canada without booster seat legislation. To date, analyses of booster seat effectiveness compared with seatbelt only use have demonstrated mixed findings using observational data.

METHODS

This study uses Alberta police collision report data for the years 2010-2016, inclusive. Using a case-control study design, children aged four to eight years, who were reported by police to be injured (cases), were compared with uninjured controls for restraint use (seatbelt, booster seat or no restraint). Logistic regression was used to estimate the relation between booster seat use and injury with adjusted odds ratios (aORs) and 95% confidence intervals (CI), stratified by collision types.

RESULTS

There were 12,922 children involved in collisions, of whom 570 were injured. Approximately 62% of all children included in the analysis were in a booster seat or safety seat at the time of collision. Crude analysis indicates higher odds of injury for seatbelt wearers compared with booster seat use (OR = 1.21; 95% CI: 1.02-1.44). Front-end vehicle-vehicle collisions, demonstrated higher odds of injury for seatbelt wearers relative to those in booster seats (aOR = 1.46; 95% CI: 1.03-2.07).

CONCLUSION

This analysis indicates a protective effect of booster seats that varies depending on the type of collision and impact location. These regionally-specific injury data may encourage and inform policy on the use of booster seats. Moreover, stratification by collision type may be necessary to inform analyses on booster seat effectiveness.

Unintentional injury deaths in children and youth, 2010-2019

BACKGROUND

Unintentional injuries are the leading cause of death for children and youth aged 1-19 in the United States. The purpose of this report is to describe how unintentional injury death rates among children and youth aged 0-19 years have changed during 2010-2019.

METHOD

CDC analyzed 2010-2019 data from the National Vital Statistics System (NVSS) to determine two-year average annual number and rate of unintentional injury deaths for children and youth aged 0-19 years by sex, age group, race/ethnicity, mechanism, county urbanization level, and state.

RESULTS

From 2010-2011 to 2018-2019, unintentional injury death rates decreased 11% overall-representing over 1,100 fewer annual deaths. However, rates increased among some groups-including an increase in deaths due to suffocation among infants (20%) and increases in motor-vehicle traffic deaths among Black children (9%) and poisoning deaths among Black (37%) and Hispanic (50%) children. In 2018-2019, rates were higher for males than females (11.3 vs. 6.6 per 100,000 population), children aged < 1 and 15-19 years (31.9 and 16.8 per 100,000) than other age groups, among American Indian or Alaska Native (AIAN) and Blacks than Whites (19.4 and 12.4 vs. 9.0 per 100,000), motor-vehicle traffic (MVT) than other causes of injury (4.0 per 100,000), and rates increased as rurality increased (6.8 most urban [large central metro] vs. 17.8 most rural [non-core/non-metro] per 100,000). From 2010-2011 to 2018-2019, 49 states plus DC had stable or decreasing unintentional injury death rates; death rates increased only in California (8%)-driven by poisoning deaths. Conclusion and Practical Application: While the overall injury death rates improved, certain subgroups and their caregivers can benefit from focused prevention strategies, including infants and Black, Hispanic, and AIAN children. Focusing effective strategies to reduce suffocation, MVT, and poisoning deaths among those at disproportionate risk could further reduce unintentional injury deaths among children and youth in the next decade.

Dynamic metrics to differentiate booster performance

OBJECTIVE

The purpose of this research was to explore candidate booster performance metrics that may have the potential to identify less effective booster systems, because current FMVSS No. 213 booster performance requirements can be met without a booster.

METHODS

To provide a more realistic test environment, dynamic testing was performed using a surrogate seat belt retractor on the most recent preliminary design update proposed for the FMVSS No. 213 seat assembly. Given that field data show that belt-positioning boosters are effective at reducing injury risk, potential testing measures were assessed relative to data collected for the no-booster condition. Eleven booster products were evaluated, as well as the no-booster condition, with 6 tests performed using the Hybrid III 10-year-old and 33 tests run with the Hybrid III 6-year-old.

RESULTS

Possible metrics associated with good anthropomorphic test device (ATD) kinematics (no submarining or rollout) were the difference between knee and head excursion, maximum torso angle, lumbar spine Moment Z, and lumbar spine Force Y.

CONCLUSIONS

When testing boosters under more realistic dynamic conditions, the proposed metrics would allow better discernment of less effective boosters, because they differentiate performance relative to the no-booster condition.

Modeling crashes involving children, finite mixture cumulative link mixed model

Despite the efforts in the literature review on the traffic safety of children, the majority of past studies mainly focused only on the child's seatbelt status, or its position while ignoring other underlying factors that might contribute to the severity of those crashes. Inclusion of ther factors is especially important for a mountainous state like Wyoming with one of the highest rates of children's traffic fatality in the country. Thus, this study is conducted to fill the gap by identifying important factors contributing to the severity of crashes involving children. Here child is defined as any passengers under 9 years old. A first step in identifying factors to the severity of crashes involving children is implementing a reliable statistical method that could account for heterogeneity across various observations. So, in this study, to account for the heterogeneity in the dataset, the standard cumulative link model (CLM) was extended to the random effect model, while instead of assigning the subjective attribute for random effect, an objective hierarchy through the finite mixture modeling (FMM) was used. The FMM was employed in the context of the CLM to prevent the loss of information due to disaggregation of the dataset into the homogeneous datasets. The comparison results highlighted that the random effect model by the objective hierarchy would result in a significant improvement in the model fit compared with the standard cumulative link model. The results highlighted factors such as safety equipment in use, type of collision, and various drivers' characteristics and actions such as belting condition, alcohol and drug involvement are some of the factors contributing to the severity of child crashes. As expected, the main findings of our results highlighted that various drivers' actions and behaviors are the main causes that children would undergo a higher severity level in crashes. An extensive discussion regarding the implications of the results and the implemented statistical method were given in the context of the manuscript.

Evaluation of LATCH vs. non-LATCH installations for boosters in frontal impacts

OBJECTIVES

The objective was to understand how the use or nonuse of the Lower Anchors and Tethers for Children (LATCH) system affects the performance of booster seats during frontal impacts.

METHODS

Sixteen frontal impact sled tests were conducted at 24.8 ± 0.3 g and 50.1 ± 0.2 kph. A production vehicle seat buck was attached to the sled. Four high-back boosters or combination seats in high-back booster mode and two backless booster models were tested. Each booster model was installed two different ways: using the LATCH system ("LATCH" installation) and without using the LATCH system ("non-LATCH" installation). All installations used a 3-point seat belt with retractor in emergency locking mode (ELR) to restrain a Hybrid III 6-year-old anthropomorphic test device (ATD). The retractor, belt webbing, buckle, vehicle seat cushion, and booster were replaced after each test. Some conditions were tested twice to establish repeatability. ATD and booster responses were compared between LATCH and non-LATCH tests.

RESULTS

Using LATCH reduced the forward movement of the booster itself by 32.3% to 71.5% compared to non-LATCH installations. Differences in most other metrics were small and often within the range of normal test-to-test variation. Forward movements of the ATD head and heel were similar between LATCH and non-LATCH tests (typically less than 10% difference). HIC36 values trended slightly higher for LATCH installations compared to non-LATCH installations (0.8% to 17.2%). Chest resultant accelerations were typically 7.3% to 21.2% higher for LATCH installations, except for one booster for which it was lower with LATCH. Chest deflections trended higher for LATCH installations compared to non-LATCH installations for the backless boosters (6.9% to 14.1%). For high-back boosters, chest deflection was similar between installation conditions (less than 5% difference). Shoulder belt loads showed the greatest reductions when LATCH installations included a top tether (12.9% to 20.8%). Instances of the ATD submarining under the lap belt were not observed in these tests.

CONCLUSIONS

Overall, the differences in kinematics and injury metrics were small between boosters installed using LATCH vs. non-LATCH.

Epidemiology of skeletal trauma and skull fractures in children younger than 1 year in Shenzhen: a retrospective study of 664 patients

Background

Unintentional injury is one of the top three causes of death for infants. However, the epidemiological studies of skeletal trauma and skull fractures in infants younger than 1 year were poorly understood in China. Therefore, our study aimed to examine accidental and emergency attendance in infants under 1 year. It also tried to determine the prevalence and severity of accident types in infants.

Methods

A retrospective analysis was performed on the demographic characteristics of infants younger than 1 year with skeletal trauma and skull fractures who visited the Shenzhen Children’s Hospital from January 1, 2016 to December 31, 2019. Age, gender, fracture site and type, mechanism of injury, length of visit, length of hospital stay, hospitalization cost, and treatment methods were analyzed.

Results

A total number of 675 fractures in 664 infants were included, the median age was 187days (IQR,90-273days), including 394 males and 270 females. The top three fracture sites were the skull (430 sites, 63.70 %), long bones of the limbs (168 sites, 24.89 %), and clavicle (53 sites, 7.85 %). The top three causes of injury were locomotion injuries (256 cases, 38.55 %), falls or trips from low height (from beds, tables, chairs, etc.) (130 cases, 19.58 %), and birth injuries (97 cases, 14.61 %). The greatest amount of fractures occurred in children 1–28 days of life (d) reached a top of 101 cases, followed by 331–365 days, accounting for 15.21 and 10.24 %, respectively. The number of fractures reached a trough of 29 cases in the 29-60d group (4.37 %). And increased again to 65 cases in the 151-180d group (9.79 %). The proportion remained relatively constant at 9 % in the 181-210d group (9.19 %) and 211-240d group (9.64 %). The interval between injury and visiting our hospital was ≤ 72 h in 554 cases.

Conclusions

Special attention should be given to the demographic characteristics of fractures in infants under 1 year of age, and appropriate outreach should be implemented. For example, health education should be provided to aid in the prevention especially for frequently occurring locomotion injuries, and prompt access to specialist medical care should be recommended for skull fractures, which are prone to delayed treatment. In addition, multidisciplinary collaboration should be implemented in trauma care, while also promoting the establishment of trauma centers in specialist children’s hospitals with a stronger capacity to treat pediatric trauma, and a regional system for pediatric trauma treatment.

Booster cushion design effects on child occupant kinematics and loading assessed using the PIPER 6-year-old HBM and the Q10 ATD in frontal impacts

OBJECTIVE

Our objective was to study the effect on child occupant kinematics and loading by differences in booster cushion designs and attachment in a frontal impact.

METHODS

Three different booster cushion designs were exposed to a frontal impact in vehicle rear seat interiors. The boosters were selected based on their difference in shape, stiffness, and guiding loop design. Tests were run varying the shoulder belt routing above or under the guiding loop, in addition to with or without attachment of the booster cushion to the vehicle ISOFIX anchorages. Eighteen simulations with the finite element PIPER 6-year-old human body model (HBM) were run investigating all combinations of parameters, in addition to 3 sled tests with a Q10 anthropomorphic test dummy (ATD).

RESULTS

Across 2 different child sizes, using an HBM and an ATD, respectively, consistent sensitivity to the booster design differences were seen. Boosters providing similar initial static belt fit can result in different occupant responses during a crash, due to the design of the boosters and their dynamic performance. Compression of the booster cushion resulted in a delayed pelvis restraint, influencing the upper body kinematics. The guiding loop design as well as the belt routing above or under the guide also influenced the upper body kinematics and shoulder belt interaction.

CONCLUSIONS

Early pelvis coupling to initiate torso pitch, and thereby an upper torso motion controlled by the shoulder belt, is the preferred occupant protection for booster-seated children. A stable mid-shoulder belt position centered over the chest initially is a prerequisite. Additionally, it was seen that the design of the guiding loops helps provide favorable interaction with the torso during the crash. The option to allow the shoulder belt to be placed above and under the guiding loops will accommodate a larger span of child sizes and adapt to more vehicle seat belt geometries. This study provides evidence that the design of the booster cushion plays an important role in creating an early pelvis coupling, as well as supporting favorable torso-shoulder belt interaction.

Pediatric occupant human body model kinematic and kinetic response variation to changes in seating posture in simulated frontal impacts - with and without automatic emergency braking

OBJECTIVE

The study quantifies the kinematics of children in booster child restraint systems (CRSs) in various naturalistic seating postures exposed to frontal impacts in a full-vehicle environment, with and without the application of pre-crash automatic emergency braking.

METHODS

The PIPER 6YO and 10YO pediatric human body models were positioned in CRSs. The 6YO was restrained on a lowback (LBB) and highback (HBB) booster, while the 10YO was positioned on an LBB and in a NoCRS condition. All simulations used the 3-point seatbelt. The child models were pre-positioned (gravity settled, seatbelt tensioned) in four naturalistic seating postures: leaning-forward, leaning-forward-inward, leaning-forward-outward, and a pre-submarining position, along with a baseline reference seating position. A 2012 Toyota Camry finite element (FE) model was used as the vehicle environment. A standard 3-point lap-shoulder belt system was modeled to restrain the child and CRS in the left-rear vehicle seat. Two vehicle impact cases were considered: with and without a pre-crash AEB. For with-AEB cases, a pre-crash phase was run to incorporate postural changes due to the application of AEB. All seating positions were ultimately subjected to a full-frontal rigid-barrier impact at 35 MPH. A total of 40 conditions were simulated in LS-DYNA.

RESULTS

Injury metrics varied widely for both occupants. Shoulder belt slippage was observed for the 6YO leaning-forward-inward on HBB. No head contact was observed for any simulated cases. Forward-leaning and forward-inward-leaning postures generally had greater head excursion across all seating postures. The lap belt rode over the pelvis for pre-submarining postures. Injury metrics for cases with pre-crash AEB were lower compared to their corresponding without-AEB cases. HIC15, head acceleration, upper neck tension force, and upper neck flexion moment were similar or lower for with-AEB scenarios.

CONCLUSIONS

Pre-crash AEB reduces the effect of the impact despite the same collision speed as cases without-AEB. This is primarily due to the limited travel distance of the occupant, thus, starting an earlier ride-down during the crash. Moreover, different initial seating postures lead to a wide range of injury exposures. Vehicle and child restraint design should incorporate these seating postures to ensure robust protection of the occupant in a crash.

Assessing an App-Based Child Restraint System Use Intervention in China: An RCT

INTRODUCTION

While child restraint systems are effective in protecting children from crash-related injuries and deaths, their use in China is extremely low. This study assessed the effectiveness of child restraint system education with and without behavioral skills training on improved use and explored participants' views regarding content and delivery of an onsite intervention and online (WeChat) boosters.

STUDY DESIGN

A randomized trial was conducted in 6 kindergartens from May 2017 to January 2018 in Shantou and Chaozhou, China. Selected kindergartens were randomly assigned to 3 groups: (1) control, (2) child restraint system education‒only, and (3) child restraint system education plus behavioral skills training. Analysis was conducted in May 2018.

SETTING/PARTICIPANTS

Participants were parents from the selected kindergartens.

INTERVENTION

Both intervention groups received child restraint system education that included one-time onsite education and biweekly online boosters for 3 months using an app to deliver education messages.

MAIN OUTCOME MEASURES

Survey questions included parent knowledge, attitude and behaviors of child restraint system use, and opinions related to the content and delivery of the onsite intervention and online boosters.

RESULTS

Child restraint system use in both intervention groups was higher than that of the control group post-intervention (27.3% and 31.7%, respectively). Compared with the control group, the intervention groups had a higher percentage of correct answers to all 9 items, except Item 7 measuring the parents' knowledge, attitude, and behaviors of child passenger safety after the intervention. Lower parent's level of education (OR=7.00, 95% CI=2.62, 18.70) and older child age (4 years: OR=3.92, 95% CI=1.08, 5.28; 5 years: OR=2.08, 95% CI=1.52, 5.31) were associated with lower rates of child restraint system use. Most parents (92.3%) preferred the online over the onsite intervention component.

CONCLUSIONS

An education intervention was effective in improving parents' knowledge, attitude, and practice of child restraint system use. A social media intervention booster (WeChat) may provide a new channel to help promote child passenger safety in China.

Prevalence of child passenger restraint use in Shantou, China from 2012 to 2017

BACKGROUND

Child passenger safety is an important public health problem in China. This study aimed to examine the prevalence of child passenger restraint use while riding in a car in the city of Shantou in China from 2012 to 2017.

METHODS

Three large-scale cross-sectional observational studies were conducted in 2012, 2015 and 2017, respectively. The observation sites included randomly selected hospitals, kindergartens, and primary and secondary schools. The outcome measures included the changes in percentages of seating position (e.g., front vs. rear), whether sitting on lap, and use of child restraint systems (CRS) or seat belts by year and by age group. Descriptive statistics, Chi-square tests and logistic regression were used to address the study aims.

RESULTS

A total of 9858 commuting children aged 17 and younger were observed in passenger cars in Shantou, China during the study. The proportion of children aged 0-5 sitting on adult's lap decreased from 26.6% in 2012 to 24.6% in 2017, while the proportion of CRS use among the children sitting in the rear row increased among children aged 0-5 (from 0.7% in 2012 to 14.2% in 2017) and children aged 6-11 (from 0.7% in 2012 to 2.4% in 2017). Comparing children aged 0-11 in 2012, children in the same ages were less likely to sit in the front row in 2015 (OR = 0.42, 95%CI = 0.37, 0.48) and in 2017 (OR = 0.27, 95%CI = 0.23, 0.31). Children aged 0-11 were more likely to sit in the rear row with CRS use in 2015 (OR = 8.50, 95%CI = 5.44, 13.28) and in 2017 (OR = 10.95, 95%CI = 7.02, 17.08) comparing with children in the same ages in 2012. As for children aged 12-17, they were more likely to use seat belt in 2017 (OR = 1.40, 95%CI = 1.06, 1.85) compared with those children in 2012.

CONCLUSIONS

While child passenger safety behaviors improved from 2012 to 2017 in Shantou, China, more efforts are needed to protect child passengers from injuries.

Affordability and Availability of Child Restraints in an Under-Served Population in South Africa

Background: Child road traffic injuries are a major global public health problem and the issue is particularly burdensome in middle-income countries such as South Africa where injury death rates are 41 per 100,000 for under 5′s and 24.5 per 100,000 for 5–14-year-old. Despite their known effectiveness in reducing injuries amongst children, the rates of use of child restraint systems (CRS) remains low in South Africa. Little is known about barriers to child restraint use especially in low- and middle-income countries. Methods: We carried out observation studies and parent/carer surveys in 7 suburbs of Cape Town over a three month period to assess usage rates and explore the knowledge and perceptions of parents towards child restraint legislation, ownership and cost; Results: Only 7.8% of child passengers were observed to be properly restrained in a CRS with driver seatbelt use and single child occupancy being associated with higher child restraint use. 92% of survey respondents claimed to have knowledge of current child restraint legislation, however, only 32% of those parents/carers were able to correctly identify the age requirements and penalty. Reasons given for not owning a child seat included high cost and the belief that seatbelts were a suitable alternative. Conclusions: These findings indicate the need for a tighter legislation with an increased fine paired with enhanced enforcement of both adult seatbelt and child restraint use. The provision of low-cost/subsidised CRS or borrowing schemes and targeted social marketing through online fora, well baby clinics, early learning centres would be beneficial in increasing ownership and use of CRS.

Child Posture and Belt Fit in a Range of Booster Configurations

Belt positioning boosters reduce injury risk for child occupants compared with seat belts alone. While boosters shorten the effective seat length (and thus reduce slouching), “boosting” the child relative to the vehicle interior components also achieves additional safety benefits. First, the increase of the lap belt angle usually improves belt fit across the pelvis and reduces the risk of the occupant slipping (“submarining”) under the belt. Second, the torso belt is re-centered over the bony landmarks of the shoulder for more effective/secure restraint. Third, the child’s head is relocated in a range better protected by side airbags. The objective of this research was to quantify differences in posture and belt fit across a range of booster designs that provide different levels of boosting. Posture and belt fit were measured in 25 child volunteers aged four to 12. Children were measured in three laboratory seating conditions selected to provide a range of cushion lengths and belt geometries. Six different boosters, as well as a no-booster condition, were evaluated. The low height boosters produced postures that were more slouched, with the hips further forward than in other more typical boosters. Lap belt fit in the low height boosters was not meaningfully different from the other boosters. Shoulder belt fit produced by the lowest height booster was similar to the no-booster condition. Belt positioning boosters that boost the child less than 70 mm produced postures similar to the no-booster condition. While lap belt guides on these products can produce a similar static lap belt fit, they may not provide adequate dynamic performance and do not achieve the other benefits that come with raising the child to a more advantageous location relative to interior components and belts.

Preventing injuries must be a priority to prevent disease in the twenty-first century

Injuries continue to be the leading cause of morbidity and mortality for children, adolescents, and young adults aged 1-24 years in industrialized countries in the twenty-first century. In this age group, injuries cause more fatalities than all other causes combined in the United States (U.S.). Importantly, many of these injuries are preventable. Annually in the U.S. there are >9 million emergency department visits for injuries and >16,000 deaths in children and adolescents aged 0-19 years. Among injury mechanisms, motor vehicle crashes, firearm suicide, and firearm homicide remain the leading mechanisms of injury-related death. More recently, poisoning has become a rapidly rising cause of both intentional and unintentional death in teenagers and young adults aged 15-24 years. For young children aged 1-5 years, water submersion injuries are the leading cause of death. Sports and home-related injuries are important mechanisms of nonfatal injuries. Preventing injuries, which potentially cause lifelong morbidity, as well as preventing injury deaths, must be a priority. A multi-pronged approach using legislation, advancing safety technology, improving the built environment, anticipatory guidance by clinical providers, and education of caregivers will be necessary to decrease and prevent injuries in the twenty-first century.

Systematic review of child restraint system interventions (2007-2018)

Objective: To systematically review and summarize articles evaluating the effectiveness of child restraint system (CRS) interventions targeting parents/caregivers' knowledge of, overall rates of and/or proper use of CRSs published in a recent time period.Methods: Using multiple databases, we identified peer-reviewed journal articles published between January 1, 2007 and December 31, 2018 using selected key search terms. Inclusion criteria were: (1) evaluation of an intervention/program for child passenger safety targeting a parent or caregiver of a child (2) quantitative data-based results (i.e., change in knowledge, behavior, or observed outcomes), (3) English-language, and (4) peer-reviewed journal publication. Through a systematic review process and peer consensus, n = 23 articles met inclusion criteria. References of these articles were reviewed for inclusion using the same process and n = 12 additional articles were identified.Results: A total of n = 35 articles met inclusion criteria. Of the n = 35 articles, n = 9 were randomized controlled trials (RCTs), n = 4 were cluster RCTs, n = 11 were nonrandomized trials, and n = 11 were pretest post-test studies. Types of interventions included face-to-face education (n = 26), web/video-based education (n = 8) or written educational materials (n = 1). Of the articles reviewed, n = 20 involved distribution of free or subsidized CRSs to some or all subjects. N = 20 articles involved trained CRS technicians and/or CRS installation check-points. In terms of outcomes measured, n = 3 articles assessed changes in knowledge of CRS use, n = 22 assessed changes in CRS behaviors (which includes self-report or observed behavior change), and n = 10 assessed changes in both CRS knowledge and behaviors. All articles (n = 3) that measured changes in knowledge as their only outcome demonstrated positive effects while articles measuring behavioral outcomes (self-report or observed) (n = 32) had mixed results.Conclusions: This review included a wide range of articles of heterogeneous methodologies, sample sizes, and outcomes measured. Although different approaches to CRS interventions were effective in increasing awareness and knowledge, the effects on CRS use behaviors - whether self-reported or observed - were mixed. Future research is needed to increase appropriate CRS use and reduce the burden of motor vehicle crash-related injuries among children.

Factors Affecting Child Injury Risk in Motor-Vehicle Crashes

Current recommendations for restraining child occupants are based on biomechanical testing and data from national and international field studies primarily conducted prior to 2011. We hypothesized that analysis to identify factors associated with pediatric injury in motor-vehicle crashes using a national database of more recent police-reported crashes in the United States involving children under age 13 where type of child restraint system (CRS) is recorded would support previous recommendations. Weighted data were extracted from the National Automotive Sampling System General Estimates System (NASS-GES) for crash years 2010 to 2015. Injury outcomes were grouped as CO (possible and no injury) or KAB (killed, incapacitating injury, nonincapacitating injury). Restraint was characterized as optimal, suboptimal, or unrestrained based on current best practice recommendations. Analysis used survey methods to identify factors associated with injury. Factors with significant effect on pediatric injury risk include restraint type, child age, driver injury, driver alcohol use, seating position, and crash direction. Compared to children using optimal restraint, unrestrained children have 4.9 (13-year-old) to 5.6 (< 1-year-old) times higher odds of injury, while suboptimally restrained children have 1.1 (13-year-old) to 1.9 (< 1-year-old) times higher odds of injury. As indicated by the differences in odds ratios, effects of restraint type attenuate with age. Results support current best practice recommendations to use each stage of child restraint (rear-facing CRS, forward-facing harnessed CRS, belt-positioning booster seat, lap and shoulder belt) as long as possible before switching to the next step.

Child passenger fatality: Child restraint system usage and contributing factors among the youngest passengers from 2011 to 2015

OBJECTIVE

Motor-vehicle crashes (MVC) remain a leading cause of preventable injury and death for children aged 0-3 in the United States. Despite advancement in legislation and public awareness there is continued evidence of inappropriate child restraint system (CRS) use among the youngest passengers. The current study focuses on appropriate CRS use from 2011 to 2015 using data from the Fatality Analysis Reporting System (FARS) for children aged 0-3.

METHODS

Child-, driver-, vehicle-, and trip-related characteristics were investigated within a sample of 648 children from 625 crashes over 5-years in which a child aged 0-3 was fatally injured while unrestrained or wearing an identified CRS type. Multivariable log-binomial regression was used to obtain relative risk.

RESULTS

Only 48% of the fatally injured children were appropriately restrained in a CRS. Premature transition to a booster seat and seat belt was evident. The largest proportion of rear-facing restraint use was reported in <1 year olds (40%), with less reported in 1 (11%) and 2 year olds (2%) and no usage in 3 year olds. Younger children were more likely to be in an appropriate CRS, while Black children, driver not restrained in a lap-shoulder belt configuration, and riding in a pickup truck were less likely to be restrained appropriately.

CONCLUSIONS

Evidence of inappropriate CRS use supports the use of more stringent legislation and parental interventions to communicate best practice recommendations and educate caregivers regarding appropriate child restraint methods. Practical applications: Public health campaigns focused on increasing appropriate restraint use in children are of great importance as optimally restrained children are less likely to sustain injuries, or require crash-related hospitalization compared to unrestrained children. Researchers and practitioners may find these surveillance findings essential when developing education and interventions targeting child-parent dyads at the greatest risk for a MVC-related fatality.

Characterization of the motion of booster-seated children during simulated in-vehicle precrash maneuvers

Objective: Precrash occupant motion may affect head and trunk position and restraint performance in a subsequent crash, particularly for young children. Others have studied seat belt-restrained adult drivers and adult and adolescent passengers in precrash maneuvers. For younger children, optimal restraint includes a belt-positioning booster seat, which in precrash maneuvers may contribute in unique ways to the overall body motion. Therefore, the objective of this study was to quantify booster-seated child occupant kinematic, kinetic, and muscle responses during precrash maneuvers and characterize booster movement with respect to the overall occupant kinematics.Methods: Vehicle maneuver tests were conducted with a recent model year sedan at the Transportation Research Center Inc. (TRC, Marysville, Ohio). Three precrash vehicle maneuvers were simulated: Automated and manual emergency braking (AEB and MEB) and oscillatory swerving or slalom (SLA). Each maneuver was repeated twice for each participant. Seven 6- to 8-year-old booster-seated children participated in the study and all subjects were seated in the right rear seat. Vehicle dynamics (i.e., motion, position, and orientation) were measured with an inertial and Global Positioning System navigation system (Oxford RT 3003). Kinematic data from human volunteers were collected with an 8-camera 3D motion capture system (Optitrack Prime 13 200 Hz, NaturalPoint, Inc.). Photoreflective markers were placed on participants' head and trunk. Electromyography (EMG; Trigno EMG Wireless Delsys, Inc., 2,000 Hz) sensors were placed on bilateral muscles predicted to be most likely involved in bracing behaviors.Results: Children demonstrated greater head and trunk velocity in MEB (head 123.7 ± 13.1 cm/s, trunk 77.6 ± 14.1 cm/s) compared to AEB (head 45.31 ± 11.5 cm/s, trunk 27.1 ± 5.5 cm/s; P < .001). Participants also showed greater head motion in MEB (18.9 ± 1.4 cm) vs. AEB (15.1 ± 4.8 cm) but the differences were not statistically significant (P < .1). Overall, the booster seats themselves did not move substantially (<3 cm) in the braking maneuvers. During the SLA, however, the booster seat moved laterally up to 5 cm in several subjects, contributing substantially to peak trunk (6.5-14.0 cm) and head (9.9-21.4 cm) excursion during the maneuver. Booster-seated children also exhibited a greater activation of biceps and deltoid muscles and abdominal and middle trapezii muscles than the sternocleidomastoids during these maneuvers.Conclusions: The quantification of booster seat motion and neuromuscular control and the relationship between kinematics and muscle activation in booster-seated children in precrash maneuvers provides important data on the transition between the precrash and crash phases for this young age group and may help identify opportunities for interventions that integrate active and passive safety.

Pilot Trial of an Emergency Department-based Intervention to Promote Child Passenger Safety Best Practices

BACKGROUND

Despite demonstrated effectiveness of child restraint systems (CRSs), use remains suboptimal. In this randomized pilot trial, we sought to determine the feasibility, acceptability, and potential efficacy of "Tiny Cargo, Big Deal" an ED-based intervention to promote guideline-concordant size-appropriate CRS use.

METHODS

Parents of children < 11 years old were recruited in two EDs and randomized in a 2 × 2 factorial design to four conditions: 1) generic information sheet, 2) tailored brochure mailed after the ED visit, 3) a single motivational interviewing-based counseling session in the ED, and 4) full intervention (counseling session plus tailored brochure). We assessed feasibility (recruitment, completion, follow-up rates) and acceptability (parent attitudes, uptake of information) in the ED, at 1 month and at 6 months. We obtained preliminary estimates of effect sizes of the intervention components on appropriate CRS use at 6-month follow-up.

RESULTS

Of the 514 parents assessed for eligibility, 456 met inclusion criteria and 347 consented to participate. Enrolled parents were mostly mothers (88.1%); 48.7% were 18 to 29 years old; 52.5% were non-Hispanic, white; and 65.2% reported size-appropriate CRS use. Completion rates were 97.7% for baseline survey, 81.6% for counseling, 51.9% for 1-month follow-up, and 59.3% for 6-month follow-up. In the ED, 70.5% rated thinking about child passenger safety in the ED as very helpful. At 1 month, 70.0% expressed positive attitudes toward the study. Of 132 parents who reported receiving study mailings, 78.9% reviewed the information. Parents randomized to the full intervention demonstrated an increase (+6.12 percentage points) and other groups a decrease (-1.69 to -9.3 percentage points) in the proportion of children reported to use a size-appropriate CRS at 6-month follow-up.

CONCLUSIONS

Suboptimal CRS use can be identified and intervened upon during a child's ED visit. A combined approach with ED-based counseling and mailed tailored brochures shows promise to improve size-appropriate CRS use.

Feasibility of providing child restraint devices after a motor vehicle crash in a pediatric emergency department

OBJECTIVE

Motor vehicle crashes (MVCs) cause disproportionate childhood morbidity and mortality. Ensuring that children are placed in appropriate child restraint devices (CRDs) would significantly reduce injuries and deaths as well as medical costs. The goal of the study is to evaluate the feasibility of providing child restraint devices after an MVC in a pediatric emergency department (PED).

METHODS

A guideline was developed to assess the need for CRDs for patients discharged from a PED after an MVC. Providers were educated on the use of the guideline. Caregivers were provided a brief educational intervention on legislation, proper installation, and best practices prior to distribution of a CRD. Quality assurance was conducted weekly to monitor for any missed opportunities.

RESULTS

From August 31, 2015, to August 31, 2016, 291 patients <7 years were evaluated in the PED of a level 1 trauma center following an MVC. Two hundred forty-seven children were correctly identified according to the guidelines (84.9%). Of these, 187 (75.7%) were identified as not requiring a replacement seat and 60 (24.3%) required a CRD replacement based on crash mechanisms and restraint use status and received a CRD replacement. Of the remaining 44 children, 38 (86.4%) whose crash mechanisms were severe enough or who were inappropriately restrained were not provided a CRD and thus missed; 6 (13.6%) received a replacement seat even though criteria were not met. Thus, PED providers correctly identified 61.2% (60/98) of children who required CRD replacement after an MVC.

CONCLUSION

Caring for children who present for evaluation after an MVC offers an opportunity for ED personnel to provide education to caregivers about the appropriate use of CRDs and state legislation. Establishing guidelines for the provision of a CRD for children who present to an ED following an MVC may help to improve the safety of children being transported in motor vehicles. Having a systematic process and adequate supply of CRDs readily available contributes to the success of children being discharged with the appropriate age- and weight-based CRD after being treated in an ED following an MVC.

Leading Causes of Fatal and Nonfatal Unintentional Injury for Children and Teens and the Role of Lifestyle Clinicians

About 1 in 5 child deaths is a result of unintentional injury. The leading causes of unintentional injury death vary by age. This report provides national fatal and nonfatal data for children and teens by age, sex, and race/ethnicity. Prevention strategies for the most common causes are highlighted. Opportunities for lifestyle clinicians to effectively guide their patients and their parents are discussed.

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.

Factors Associated With Child Restraint Use in Motor Vehicle Crashes

Motor vehicle crashes (MVCs) are a leading cause of death among children. Multivariable analyses of age-appropriate child restraint system (CRS) use in the "booster-aged" population are needed. The current study identified factors associated with age-appropriate CRS use in fatal MVCs for children 4 to 7 years old, using 2011 to 2015 data from the Fatality Analysis Reporting System. Of 929 MVC fatalities, 32% of fatally injured children were in an age-appropriate restraint. While age-appropriate CRS use was higher for 4-, 5-, and 6-year-olds relative to 7-year-olds (adjusted relative risk [aRR] = 2.57, 2.51, and 2.18, respectively; p < .01 for each comparison), black children (aRR = 0.62; p < .01) relative to white children, and drivers who had not used a lap-shoulder belt (aRR = 0.40; p < .01) relative to belted drivers were associated with lower levels of age-appropriate CRS use. Our findings underscore the continued importance of communicating best practice guidelines on CRSs to caregivers of young children.

The impact of booster seat use on child injury and mortality: Systematic review and meta-analysis of observational studies of booster seat effectiveness

OBJECTIVE

To determine through systematic review and meta-analysis of observational studies if booster seats, compared to seatbelts alone, reduce injury and mortality from motor vehicle collisions among child passengers four to eight years of age.

METHODS

A comprehensive search of several data sources (including Medline, Embase, and PsycINFO) was conducted from inception to December 2016, to retrieve relevant publications in any language and from any geographic region. Data extraction was completed by two independent reviewers, capturing: study details, population characteristics, exposure (booster seat compared to seat belt use), outcomes (injury and fatality), and all associations reported between the exposure and outcomes. Risk of bias assessment was completed by two reviewers using the QUIPS tool. Meta-analysis of sufficiently similar studies was conducted using random effects models.

RESULTS

Eleven observational studies were included in qualitative syntheses. The systematic review and meta-analysis found no association between booster seat use, compared to seatbelts, and reduced injury (4 studies, OR 1.03; 95% CI 0.53-1.99) or fatality (2 studies, OR 0.91; 95% CI 0.73-1.13).

CONCLUSIONS

Evidence on booster seat effectiveness to protect against injury and mortality in real-world conditions is limited. This review identified the need for high quality studies assessing the effects of different models of booster seats on children of varying ages and weights.

Factors Associated with Cell Phone Use While Driving: A Survey of Parents and Caregivers of Children Ages 4-10 Years

OBJECTIVES

To examine characteristics associated with cell phone use while driving by parents and caregivers of children ages 4-10 years.

STUDY DESIGN

National cross-sectional online survey with a convenience sample (March 2017-April 2017).

INCLUSION CRITERIA

Parent/caregiver of a child age 4-10 years in their home, age ≥18 years, read and spoke English, and drove child ≥6 times in previous 3 months. Adjusted logistic regression analyses were modeled for outcome measures of previous 3-month self-report cell phone use while driving with the child.

RESULTS

The analytic sample was n = 760. In the previous 3 months, 47% of parent/caregivers talked on a hand-held phone, 52.2% talked on a hands-free phone, 33.7% read texts, 26.7% sent texts, and 13.7% used social media while driving with their child in the vehicle. Compared with those who always used their typical child restraint system, participants who did not always use were more likely to talk on a hands-free phone (aOR 1.97, 95% CI 1.26-3.09), read a text (aOR 1.74, 95% CI 1.11-2.73), send a text (aOR 1.65, 95% CI 1.04-2.62), and use social media (aOR 2.92, 95% CI 1.73-4.94) while driving. Higher income, not wearing a seat belt (driver) on every trip, and driving under influence of alcohol also were associated with various types of cell phone use while driving.

CONCLUSIONS

Inconsistent child restraint system use, lack of seat belt use, and driving under the influence of alcohol are associated with parent/caregiver cell phone use while driving. Screening and education related to parental driving behaviors should include addressing multiple risk behaviors.

Situational Use of Child Restraint Systems and Carpooling Behaviors in Parents and Caregivers

Suboptimal compliance with child restraint system (CRS) recommendations can increase risk for injury or death in a motor vehicle crash. The purpose of this study was to examine scenarios associated with incomplete CRS use and non-use in children ages 4⁻10 years. We used a cross-sectional online survey with a convenience sample of parent/caregivers from the United States, age ≥18 years, with a child age 4⁻10 years in their home, who could read and spoke English, and drove child ≥6 times in previous three months. We used descriptive statistics and Mann-Whitney U to describe and compare the distribution of responses to situational use of CRSs among car seat users and booster seat users. We also used descriptive statistics and the Mann-Whitney U to describe and compare the distribution of responses to carpooling items among booster seat users and non-booster seat users. There were significant differences among those who reported most often using booster seats (n = 282) and car seats (n = 127) in situations involving rental cars, driving just around the corner, car too crowded to fit the CRS, not enough CRSs in the vehicle, the CRS is missing from the car, or the child is in someone else's car without a CRS (p < 0.05). Among those who reported most often using booster seats and who carpooled other children (n = 159), 71.7% (n = 114) always used a booster seat for their own child. When carpooling other children, booster seat users were significantly more likely to use booster seats for other children ages 4⁻10 than the non-booster seat users (p < 0.01). Continued education and programs surrounding CRS use is critical, particularly for children who should be in booster seats.

Severe Unintentional Injuries to Ohio Children: What We Should Be Addressing at Well-Child Visits

This was a retrospective study examining severe injuries to Ohio children in order to provide pediatricians with targeted injury talking points at well visits. We included children ≤14 years old from the Ohio Trauma Acute Care Registry with severe unintentional injuries from January 1, 2003, to December 31, 2012. There were 45 347 patients; 611 died, and the mean age was 6.8 years. Fractures/dislocations were common (46.6%), and many injuries occurred at home (49.1%). In children ≤2 years old, the leading causes of injury were falls and burns/fire; falls and motor vehicle collisions (MVCs) predominated above this age. Leading causes of death were MVCs, drowning, and suffocation. We concluded that national data may not always reflect state-specific injury patterns. In Ohio, though falls and MVCs were the most common mechanisms, fire and drowning also caused significant injury. Given limited time to discuss injury prevention, pediatricians should concentrate on statewide injuries.

The Effect of Booster Seat Use on Pediatric Injuries in Motor Vehicle Frontal Crashes

BACKGROUND

Motor vehicle crashes are a significant source of pediatric mortality and morbidity. Studies indicate that booster seats significantly improve seat belt fit for children who have not attained a height of 145 cm (4' 9"). This study examined injuries occurring in booster age children up to age 12, as the majority of children do not attain 145 cm until this age. The purpose of the study was to identify differences in injuries due to the type of restraint used, with attention to musculoskeletal injuries.

METHODS

Vehicle and occupant data were obtained from a publically available statistical sample of tow-away crashes. Frontal crashes over an 8-year period were examined. A data set of cases was created involving children ages 5 to 12 years who were unrestrained, restrained using the vehicle's lap and shoulder belt, and restrained using a booster seat with the vehicle's lap and shoulder seat belt. Injury severity, frequency, and patterns of distribution were compared.

RESULTS

Unrestrained children experienced moderate to severe injuries 3.8 to 19 times more frequently than children using restraints. There were more injuries to the head and face in unrestrained versus restrained children, but the head and face was the most frequently injured region for all groups. There were no serious cervical spine injuries reported for any group. Lower extremity fractures were not observed in booster seat users but occurred at similar rates in both unrestrained and seat belt restrained children. These fractures occurred in older children who were involved in more severe crashes.

CONCLUSIONS

Unrestrained children were more likely to experience moderate and severe injuries than restrained children. The data sample suggests that booster use may reduce the risk of extremity fracture, as there were no extremity fractures in children restrained with booster seats.

CLINICAL RELEVANCE

This work provides evidence for the efficacy of booster use for preventing orthopaedic injury in children. This evidence can be used to inform parents and establish recommendations for best practices in transporting children.

Preventive effects of car safety seat use on clinical outcomes in infants and young children with road traffic injuries: A 7-year observational study

INTRODUCTION

Road traffic injury (RTI) is one of the major mechanisms of injury leading to high disability and case-fatality in infants and children. Proper car safety seat use can reduce fatal outcomes in pediatric patients with RTI; however, the use rate is still low. This study aimed to measure the preventive effects of car safety seat use on clinical outcomes among infants and young children injured from RTI.

METHODS

A multicenter cross-sectional study was conducted using the Emergency Department-based Injury In-depth Surveillance (EDIIS) registry from 23 EDs between Jan 2010 and Dec 2016. All pediatric patients who were under 6 years of age and who sustained RTI in a vehicle with fewer than 10-seats were eligible. Primary and secondary endpoints were intracranial injury and mortality. We calculated the adjusted odds ratio (AOR) of the car safety seat for related outcomes adjusting for potential confounders.

RESULTS

Among 5545 eligible patients, 1452 (26.2%) patients were in car safety seats at the time of the crash (12.5% in 2010 to 33.9% in 2016, p-for-trend <0.01), and 104 (1.9%) patients had intracranial injuries. The patients using car safety seats were less likely to have intracranial injuries compared with the patients not using car safety seats (0.8% vs. 2.2%, AOR: 0.31 (0.17-0.57)). However, there was no significant difference in mortality between the two groups (0.4% vs. 0.6%, AOR: 0.50 (0.20-1.25)).

CONCLUSION

Use of the car safety seat has significant preventive effects on intracranial injury. Public health efforts to increase use of car safety seats for infants and young children are needed to reduce the burden of RTI.

Compatibility of booster seats and vehicles in the U.S. market

OBJECTIVE

The objective of this study was to analyze booster and rear vehicle seat dimensions to identify the most frequent compatibility problems.

METHODS

Measurements were collected from 40 high-back and backless boosters and 95 left rear and center rear row seating positions in 50 modern vehicles. Dimensions were compared for 3,800 booster/vehicle seat combinations. For validation and estimation of tolerance and correction factors, 72 booster installations were physically completed and compared with measurement-based compatibility predictions. Dimensions were also compared to the International Organization for Standardization (ISO) volumetric envelopes of forward-facing child restraints and boosters.

RESULTS

Seat belt buckles in outboard positions accommodated the width of boosters better than center positions (success rates of 85.4 and 34.7%, respectively). Adequate head restraint clearance occurred in 71.9 to 77.2% of combinations, depending on the booster's head support setting. Booster recline angles aligned properly with vehicle seat cushion angles in 71.5% of combinations. In cases of poor angle alignment, booster angles were more obtuse than the vehicle seat angles 97.7% of the time. Head restraint interference exacerbated angle alignment issues. Data indicate success rates above 90% for boosters being fully supported by the length of the seat cushion and for adequate height clearance with the vehicle roofline. Comparison to ISO envelopes indicates that most boosters on the U.S. market are taller and angled more obtusely than ISO target envelopes.

CONCLUSIONS

This study quantifies some of the common interferences between boosters and vehicles that may complicate booster usage. Data are useful for design and to prioritize specific problem areas.

Evaluation of give kids a boost: A school-based program to increase booster seat use among urban children in economically disadvantaged areas

OBJECTIVE

This study evaluated the effectiveness of a series of 1-year multifaceted school-based programs aimed at increasing booster seat use among urban children 4-7 years of age in economically disadvantaged areas.

METHODS

During 4 consecutive school years, 2011-2015, the Give Kids a Boost (GKB) program was implemented in a total of 8 schools with similar demographics in Dallas County. Observational surveys were conducted at project schools before project implementation (P₀), 1-4 weeks after the completion of project implementation (P₁), and 4-5 months later (P₂). Changes in booster seat use for the 3 time periods were compared for the 8 project and 14 comparison schools that received no intervention using a nonrandomized trial process. The intervention included (1) train-the-trainer sessions with teachers and parents; (2) presentations about booster seat safety; (3) tailored communication to parents; (4) distribution of fact sheets/resources; (5) walk-around education; and (6) booster seat inspections. The association between the GKB intervention and proper booster seat use was determined initially using univariate analysis. The association was also estimated using a generalized linear mixed model predicting a binomial outcome (booster seat use) for those aged 4 to 7 years, adjusted for child-level variables (age, sex, race/ethnicity) and car-level variables (vehicle type). The model incorporated the effects of clustering by site and by collection date to account for the possibility of repeated sampling.

RESULTS

In the 8 project schools, booster seat use for children 4-7 years of age increased an average of 20.9 percentage points between P₀ and P₁ (P₀ = 4.8%, P₁ = 25.7%; odds ratio [OR] = 6.9; 95% confidence interval [CI], 5.5, 8.7; P < .001) and remained at that level in the P₂ time period (P₂ = 25.7%; P < .001, for P₀ vs. P₂) in the univariate analysis. The 14 comparison schools had minimal change in booster seat use. The multivariable model showed that children at the project schools were significantly more likely to be properly restrained in a booster seat after the intervention (OR = 2.7; 95% CI, 2.2, 3.3) compared to the P₀ time period and compared to the comparison schools.

CONCLUSION

Despite study limitations, the GKB program was positively associated with an increase in proper booster seat use for children 4-7 years of age in school settings among diverse populations in economically disadvantaged areas. These increases persisted into the following school year in a majority of the project schools. The GKB model may be a replicable strategy to increase booster seat use among school-age children in similar urban settings.

Discordance between age- and size-based criteria of child passenger restraint appropriateness

OBJECTIVES

In this study, we sought to accomplish the following objectives: to (1) calculate the percentage of children considered appropriately restrained across 8 criteria of increasing restrictiveness; (2) examine agreement between age- and size-based appropriateness criteria; (3) assess for changes in the percentage of children considered appropriately restrained by the 8 criteria between 2011 (shortly after updates to U.S. guidelines) and 2015.

METHODS

Data from 2 cross-sectional surveys of 928 parents of children younger than 12 years old (n = 591 in 2011, n = 337 in 2015) were analyzed in 2017. Child age, weight, and height were measured at an emergency department visit and used to determine whether the parent-reported child passenger restraint was considered appropriate according to 8 criteria. Age-based criteria were derived from Michigan law and U.S.

GUIDELINES

Weight, height, and size-based criteria were derived from typical restraints available in the United States in 2007 and 2011. The percentage appropriate restraint use was calculated for each criterion. The kappa statistic was used to measure agreement between criteria. Change in appropriateness from 2011 to 2015 was assessed with chi-square statistics.

RESULTS

Percentage appropriate restraint use varied from a low of 19% for higher weight limits in 2011 to a high of 91% for Michigan law in 2015. Agreement between criteria was slight to moderate. The lowest kappa was for Michigan law and higher weight limits in 2011 (κ = 0.06) and highest for U.S. guidelines and lower weight limits in 2011 (κ = 0.60). Percentage appropriate restraint use was higher in 2015 than 2011 for the following criteria: U.S. guidelines (74 vs. 58%, P < .001), lower weight (57 vs. 47%, P = .005), higher weight (25 vs. 19%, P = .03), greater height (39 vs. 26%, P < .001), and greater size (42 vs. 30%, P = .001).

CONCLUSIONS

The percentage of children considered to be using an appropriate restraint varied substantially across criteria. Aligning the definition of appropriate restraint use with current U.S. guidelines would increase consistency in reporting results from studies of child passenger safety in the United States. Potential explanations for the increased percentage of children considered appropriately restrained between 2011 and 2015 include adoption of the updated U.S. guidelines and the use of child passenger restraints with higher weight and height limits.

Frontal and oblique crash tests of HIII 6-year-old child ATD using real-world, observed child passenger postures

OBJECTIVE

The aim of this study was to evaluate the consequences of frontal and oblique crashes when positioning a Hybrid III (HIII) 6-year-old child anthropometric test device (ATD) using observed child passenger postures from a naturalistic driving study (NDS).

METHODS

Five positions for booster-seated children aged 4-7 years were selected, including one reference position according to the FMVSS 213 ATD seating protocol and 4 based on real-world observed child passenger postures from an NDS including 2 user positions with forward tilting torso and 2 that combined both forward and lateral inboard tilting of the torso. Seventeen sled tests were conducted in a mid-sized vehicle body at 64 km/h (European New Car Assessment Programme [Euro NCAP] Offset Deformable Barrier [ODB] pulse), in full frontal and oblique (15°) crash directions. The rear-seated HIII 6-year-old child ATD was restrained on a high-back booster seat. In 10 tests, the booster seat was also attached with a top tether. In the oblique tests, the ATD was positioned on the far side. Three camera views and ATD responses (head, neck, and chest) were analyzed.

RESULTS

The shoulder belt slipped off the shoulder in all ATD positions in the oblique test configuration. In full frontal tests, the shoulder belt stayed on the shoulder in 3 out of 9 tests. Head acceleration and neck tension were decreased in the forward leaning positions; however, the total head excursion increased up to 210 mm compared to te reference position, due to belt slip-off and initial forward leaning position.

CONCLUSIONS

These results suggest that real-world child passenger postures may contribute to shoulder belt slip-off and increased head excursion, thus increasing the risk of head injury. Restraint system development needs to include a wider range of sitting postures that children may choose, in addition to the specified postures of ATDs in seating test protocols, to ensure robust performance across diverse use cases. In addition, these tests revealed that the child ATD is limited in its ability to mimic real-world child passenger postures. There is a need to develop child human body models that may offer greater flexibility for these types of crash evaluations.

Promoting booster seat use for young children: A school-based intervention pilot study

Purpose

Misuse and/or lack of booster seat use are often associated with high rates of injury and death among school-aged children. This pilot study examined the efficacy and the potential effectiveness of a booster seat intervention in the classroom.

Methods

Two elementary schools participated (randomly assigned as one intervention school and one control school). At the intervention school, a certified car seat specialist and a police officer held an interactive booster seat session. The height and age for each child were recorded. Children received a certificate indicating whether they met the requirements for booster seat use and a postcard with car seat restraint specifications. Children in the control school received a brochure on car seat safety. Pre- and post-intervention self-reports were collected and booster seat use was observed.

Results

Observational findings showed a decline in booster seat use at the control school and an increase in use at the intervention school. Self-reports of booster seat use indicated a decline at both schools; however, cell sizes were too small to permit statistical analyses.

Conclusion

Anecdotally researchers found the sessions were easy to conduct and were well received by the children and could be easily integrated into programming in schools. Classroom sessions may have the potential to positively influence booster seat use among 6- to 8-year-olds.

Child Passenger Safety in the Somali Communities of Columbus, Ohio

Children (particularly low-income minorities and refugees) are at high risk for serious injury or death from motor vehicle crashes. Interpreter-assisted data collection included key informant interviews, focus groups and face-to-face surveys with the Somali community of Columbus, Ohio about child passenger safety. Measurements included prevalence of child safety seats use, awareness and knowledge of and barriers to proper use in order to inform development, implementation, and initial evaluation of a culturally-appropriate intervention for Somali families. Somali parents regarded child passenger safety as an important topic, but many reported improper restraint behaviors of one or more children and/or did not have an adequate number of child safety seats. Few parents reported having child safety seats installed by a professional technician. Child passenger safety practices in the Somali communities of Columbus are a public health concern that should be addressed with culturally-appropriate interventions.

Seatbelt paths of the pregnant women sitting in the rear seat of a motor vehicle

PURPOSE

Seatbelt use during pregnancy is important to improve maternal and fetal survival after motor vehicle collisions. However, because the rear seatbelt of a motor vehicle tends to make contact with the neck, even if it is adequately used, some pregnant women sitting in the rear seat opt not to fasten the belt. The purpose of this study is to explore seatbelt-neck contact for pregnant women sitting in the rear seat of a motor vehicle.

METHODS

We carried out an anthropometric study. Japanese women who were ≥30 weeks pregnant (n = 12) sat in the left side of the rear seat of a typical mid-size passenger sedan and fastened the seatbelt. Seating posture was investigated by measuring the coordinates of the anthropometric data points of the pregnant women (head, shoulder, hip joint, and knee joint). The belt path was analyzed by measuring the clearance between the belt and the sternum or navel.

RESULTS

Among the 12 pregnant women at 33.9 week ± 3.3 week gestation, the shoulder belt deviated to the right side and subsequently contacted to the neck in four pregnant women (Contact group). The height of the Contact group was significantly shorter than that of Non-contact group (152.3 cm ± 3.0 cm vs. 159.0 cm ± 3.3 cm, p = 0.008). Regarding the relative position of the seatbelt to the subject's body, the distances from the top of the sternum to the center of the shoulder belt were significantly shorter in Contact group (3.9 cm ± 3.5 cm) than that in the Non-contact group (8.0 cm ± 1.6 cm, p = 0.03). However, no significant difference was found for the distance from the umbilicus to the center of the lap belt.

CONCLUSION

Our findings show that because of short height and late term of pregnancy with protrusion of the abdomen, the shoulder belt deviates to the right or left, avoiding the protruded uterus, and subsequently makes contact with the neck. Seatbelt systems for rear seats need to be developed to improve passenger safety, especially for pregnant women.

Standardized error severity score (ESS) ratings to quantify risk associated with child restraint system (CRS) and booster seat misuse

OBJECTIVE

Although numerous research studies have reported high levels of error and misuse of child restraint systems (CRS) and booster seats in experimental and real-world scenarios, conclusions are limited because they provide little information regarding which installation issues pose the highest risk and thus should be targeted for change. Beneficial to legislating bodies and researchers alike would be a standardized, globally relevant assessment of the potential injury risk associated with more common forms of CRS and booster seat misuse, which could be applied with observed error frequency-for example, in car seat clinics or during prototype user testing-to better identify and characterize the installation issues of greatest risk to safety.

METHODS

A group of 8 leading world experts in CRS and injury biomechanics, who were members of an international child safety project, estimated the potential injury severity associated with common forms of CRS and booster seat misuse. These injury risk error severity score (ESS) ratings were compiled and compared to scores from previous research that had used a similar procedure but with fewer respondents. To illustrate their application, and as part of a larger study examining CRS and booster seat labeling requirements, the new standardized ESS ratings were applied to objective installation performance data from 26 adult participants who installed a convertible (rear- vs. forward-facing) CRS and booster seat in a vehicle, and a child test dummy in the CRS and booster seat, using labels that only just met minimal regulatory requirements. The outcome measure, the risk priority number (RPN), represented the composite scores of injury risk and observed installation error frequency.

RESULTS

Variability within the sample of ESS ratings in the present study was smaller than that generated in previous studies, indicating better agreement among experts on what constituted injury risk. Application of the new standardized ESS ratings to installation performance data revealed several areas of misuse of the CRS/booster seat associated with high potential injury risk.

CONCLUSIONS

Collectively, findings indicate that standardized ESS ratings are useful for estimating injury risk potential associated with real-world CRS and booster seat installation errors.