Racial differences in child safety restraint use in Tennessee.

OBJECTIVES: To evaluate the appropriate use of child safety restraints (CSR) in black and white children. DESIGN: Cross sectional, observational study of drivers of children age 0-10 years involving an on-site vehicle and CSR inspection and brief driver interview. RESULTS: Data were obtained on 244 white and 204 black children; results were stratified by race due to effect modification of race on driver restraint use and CSR use. Twenty four percent of black and 13% of white child passengers aged 4-10 years were completely unrestrained (p=0.003). Of the 168 black and 220 white child passengers aged 0-10 years who were restrained, 64% of black and 58% of white children had inappropriate restraint use. Appropriate CSR use was significantly lower in 4-8 year old passengers compared with appropriately restrained children aged <4 years and 9-10 years (p<0.0001 for both black and white child passengers). CONCLUSIONS: Black child passengers and all child passengers aged 4-8 years are at increased risk of being inappropriately restrained. Educational efforts should address specific barriers to booster seat use in these populations.     

High levels of incorrect use of car seat belts and child restraints in Fife--an important and under-recognised road safety issue.

OBJECTIVE: To pilot data collection instruments and to make a preliminary estimate of the level of incorrect use of car seat belts and child restraints in Fife, Scotland. DESIGN: Cross sectional survey of cars containing adults and children at a number of public sites across Fife in 1995 to assess use of car occupant restraints. Trained road safety officers assessed whether seat restraints were appropriate for the age of the passengers and whether restraints were used correctly. These assessments were based on standards published by the Child Accident Prevention Trust. PARTICIPANTS: The survey gathered data from 596 occupants in 180 cars: 327 adults and 269 children. Ten per cent of drivers who were approached refused to participate. Car occupant restraint was assessed in 180 drivers, 151 front seat passengers, and 265 rear seat passengers. MAIN RESULTS: Three hundred and sixty one occupants wore seat belts, 68 were restrained by a seat belt and booster cushion, 63 in toddler seats, 25 in two way seats, and 18 in rear facing infant carriers. Ninety seven per cent of drivers, 95% of front seat passengers, and 77% of rear seat passengers were restrained. However, in 98 (52%) vehicles at least one passenger was restrained by a device that was used incorrectly. Seven per cent of adults and 28% of children were secured incorrectly. The commonest errors were loose seat belts and restraint devices not adequately secured to the seat. Rates of incorrect use were highest in child seat restraints, reaching 60% with two way seats and 44% with rear facing infant seats. CONCLUSIONS: The incorrect use of car occupant restraints is an under-recognised problem, both by health professionals, and the general public. Incorrect use has been shown to reduce the effectiveness of restraints, can itself result in injury, and is likely to be an important factor in child passenger injuries. The correct use of car seat restraints merits greater attention in strategies aiming to reduce road traffic casualties. Areas of intervention that could be considered include raising public awareness of this problem, improving information and instruction given to those who purchase child restraints, and encouraging increased collaboration between manufacturers of cars and child restraints, in considering safety issues.     

Effect of booster seat laws on appropriate restraint use by children 4 to 7 years old involved in crashes

OBJECTIVE: To quantify the independent contribution of recently enacted booster seat laws on appropriate restraint use by child passengers in motor vehicles. DESIGN: Longitudinal study of children involved in crashes with data collected via insurance claims records and a validated telephone survey. SETTING: Sixteen states and Washington, DC, from December 1, 1998, through December 31, 2004. PARTICIPANTS: Probability sample of 5198 vehicles in crashes involving 6102 children aged 4 to 7 years, representing 78 159 vehicles and 91 752 children. MAIN EXPOSURES: Booster seat law provisions, child age, state, and secular trends. MAIN OUTCOME MEASURE: Reported appropriate restraint use for this age group, including forward-facing child safety seats, belt-positioning booster seats, and combination seats. RESULTS: Children aged 4 to 7 years in states with booster seat laws were 39% more likely to be reported as appropriately restrained than were children in other states (prevalence ratio [PR], 1.39; 95% confidence interval [CI], 1.14-1.70). Children aged 4 to 5 years were 23% more likely (PR,1.23; 95% CI, 0.80-1.42) and children 6 to 7 years twice as likely (PR, 2.09; 95% CI, 1.46-2.99) to be reported as appropriately restrained. For children aged 6 to 7 years, when compared with no law, laws through age 7 years were most effective (PR, 3.71; 95% CI, 2.49-5.42), followed by laws through age 4 or 5 years (PR, 1.43; 95% CI, 0.89-2.24). CONCLUSION: Given the higher current use of age-appropriate restraints among children 4 to 5 years compared with older children, future upgrades to child restraint laws should include children through at least age 7 years to maximize the number of children properly restrained for their age.     

Observed child restraint use in automobiles

Visual observations were made on restraint use in occupants of 5050 automobiles containing at least one passenger less than 10 years of age, and short interviews were conducted with the drivers. Ninety three per cent of passengers less than 10 years old were not restrained. Eighty nine per cent of passengers 10 or older and 78% of the drivers were not restrained. Sixteen per cent of child motor vehicle restraint devices observed were not used, and 73% of those in use were not used correctly. Use of such devices declined sharply after age one. Although child passengers were more likely to be restrained if the driver was restrained, more than 75% of the children were not restrained when the driver was, even if the driver was the child's parent.     

Are restrained children under 15 years of age in cars as effectively protected as adults?

AIM: To compare the injury distribution between children and adults, injured as restrained car passengers. METHODS: Population based study of data from a French road trauma registry in 1996-2002. Children under 15 years old were compared with adult casualties according to the distribution of serious injuries in three distinct body regions (head, chest, and abdomen) when they were restrained car passengers. A multivariate logistic regression was performed to quantify the risk of AIS2+ injury (Abbreviated Injury Scale of 2 or more). RESULTS: Among the 7568 casualties who were injured as restrained car passengers in car accidents, 1033 were less than 15 years old. Overall, 35.4% of children and 25.2% of adults were unrestrained. For children and adults, the risk of fatality was significantly reduced when they were restrained, but the percentages of children with Injury Severity Score (ISS) > or =16, were not significantly different between restrained and not restrained casualties. Compared to adults, restrained children aged 5-9 were 2.7 times (OR 2.74; 95% CI 1.17 to 6.43) as likely to sustain an AIS2+ abdominal injury, and tended to be more at risk of AIS2+ head injuries, but were less at risk of AIS2+ chest injuries. CONCLUSIONS: Children aged 5-9 years injured in road accidents as restrained car passengers were more likely to sustain an AIS2+ abdominal injury than adults. This emphasises the need to reinforce educational campaigns aimed not only at getting children into restraint systems, but also insisting on their correct use.     

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

OBJECTIVE: To estimate the association of passenger seating position with the risk of death for passengers in traffic crashes. Design, setting, PARTICIPANTS: Matched cohort analysis of data from the National Highway Traffic Safety Administration Fatality Analysis Reporting System regarding 56 644 passengers in 23 308 passenger cars, light trucks, vans, and sport utility vehicles that crashed during 1990-2001. MAIN OUTCOME MEASURE: The adjusted risk ratio (aRR) for death of a rear seat passenger compared with a front seat passenger within 30 days of a crash. RESULTS: The aRR for all passengers in the rear seat in a crash was 0.79 (95% CI 0.77 to 0.82). This estimate varied by age, restraint use, and the presence of a front passenger airbag (p<0.001). For restrained passengers in cars with a front passenger airbag, the aRR was 0.62 (95% CI 0.48 to 0.81) for children 0-12 years, 0.96 (95% CI 0.88 to 1.06) for passengers 13-29 years, 1.03 (95% CI 0.93 to 1.15) for passengers 30-59 years, and 1.06 (95% CI 0.90 to 1.26) for passengers 60 years or older. The rear seat was associated with more protection in cars without front airbags and more protection for unrestrained passengers compared with restrained passengers. CONCLUSIONS: Previous studies have reported that the rear seat was safer for persons of all ages; thus seating a young child in the rear has often meant that older children and adults had to assume an increased risk of death by sitting in the front. These results suggest that when front passenger airbags are present and passengers are restrained, putting adults in front and children in back enhances child safety without sacrificing adult safety.     

Exploring child car passenger safety practices in China: experience from a parental survey in Shanghai

Little is known about child passenger safety practice in China. This study aims to describe child passenger seating and restraint practice in Shanghai. Information on 970 children enrolled in five randomly selected kindergartens in the Songjiang and Pudong districts of Shanghai was collected from a parental survey during 2008-2009. The adjusted rate ratios for optimal (rear-seated alone) versus suboptimal seating position (including front-seated or sitting in adult laps) and restraint use versus non-use of restraints among child passengers were evaluated using multivariate binomial regression. Suboptimal seating position (16.9%) and non-use of restraints (60.8%) was common among child passengers. Younger age (≤4 years) and having parents who are licensed drivers decreased the likelihood of being rear-seated alone; whereas having a tertiary-educated mother increased the likelihood of a child being seated optimally. Compared with unlicensed parents, guardian parents who have a driver's licence were more likely to use restraints for their child passengers. This study suggests restraint non-use and suboptimal seating position are common for child passengers in the Songjiang and Pudong districts of Shanghai, and identifies risk factors influencing restraint use and seating position choice for child passengers. There is an urgent need to improve child passenger safety in China and these findings indicate potential targets for educational interventions in the absence of child restraint laws.     

Children's use of motor vehicle restraints: maternal psychological distress, maternal motor vehicle restraint practices, and sociodemographics.

OBJECTIVE: To determine the relative contribution of maternal psychological distress, maternal restraint use, and sociodemographic characteristics to the likelihood that a child would not be restrained in a motor vehicle. METHODS: We examined data on 6251 children aged 0-17 years from the 1998 National Health Interview Survey. The level of children's motor vehicle restraint use (low vs high) was examined by maternal psychological distress and motor vehicle restraint use. Multivariate regression analyses were used to model the odds of children's low use of motor vehicle restraints, controlling for potential confounders. RESULTS: According to maternal reports, more than 10% of children and nearly 13% of mothers reported low use of motor vehicle restraints. Multivariate analyses revealed that maternal use of restraints and psychological distress were both independently related to children's use of restraints, with maternal low use as the stronger correlate. Older children were more likely than younger children to be low users of motor vehicle restraints if the mother reported that she was a low user of restraints. Families with male children, black and Hispanic mothers, and 4 or more members reported lower use of restraints for their children. CONCLUSIONS: Children's low use of motor vehicle restraints was associated with low levels of maternal motor vehicle restraint use and maternal psychological distress. Moreover, maternal motor vehicle restraint practices become increasingly important as children age. Health care providers should consider maternal motor vehicle restraint use, maternal psychological distress, and child age in addition to sociodemographics when assessing children's motor vehicle safety.     

Serious injury is associated with suboptimal restraint use in child motor vehicle occupants

AIM: To investigate the relationship between restraint usage and injury outcome in child motor vehicle occupants aged 2-8 years. METHODS: Retrospective case review of all child occupants presenting at the Children's Hospital at Westmead between July 2002 and January 2005 subsequent to a motor vehicle crash. Injury severity was assessed in terms of the Abbreviated Injury Scale (AIS), by age and type of restraint. RESULTS: Data were collected for 152 child occupants aged 2 and 8 years. While nearly all children (94%) used some restraint, most (82%) used a suboptimal form of restraint. Injury severity between optimally restrained children and suboptimally restrained children differed significantly (Fisher's exact test, P<0.001), with suboptimally restrained children receiving a greater proportion of moderate to severe (AIS 2+) injuries. No optimally restrained child sustained an AIS 2+ injury. CONCLUSION: A total of 82% of child occupants aged 2-8 years involved in crashes were suboptimally restrained. All children who sustained serious injuries were suboptimally restrained. There is a need to encourage correct use of the most appropriate restraint for child motor vehicle occupants in order to reduce the number and severity of injuries in these road users.     

Why parents do not provide automobile restraints for their children

If children in cars were adequately restrained many deaths and injuries would be prevented. Currently in New Zealand only 17% of children 0–8 years are appropriately restrained. Questionnaires about child car restraints were completed by 3,288 mothers who had a child 0 to 8 years of age. Eighty-six per cent of the mothers drove at least twice a week while the child was with them. Overall, 52% claimed to always or usually use some form of approved child car restraint. The numbers varied with the age of the child. The reasons parents gave for not using a child car restraint could be place in 2 groups — those which could be changed through altering public attitudes (58%), and those which suggest a need for co-operation between government, car manufacturers and car seat manufacturers (42%). A significant association (P<0.001) was found between people who claimed to use restraints and those who favoured the compulsory use of restraints.     

Child seating position and restraint use in three states

OBJECTIVE: Because of risks from deploying airbags to children in front seats, extensive publicity has been aimed at getting them restrained and in rear seats. The objective of this study was to assess restraint use and seating positions among children in vehicles with and without airbags. METHOD: Surveys were conducted in cities in Michigan, North Carolina, and Texas 1998. Restraint use and seating position were noted for all children, as well as their estimated age, driver belt use, airbag presence, and vehicle license plate number. RESULTS: Fewer children were observed in the front seats of vehicles with passenger airbags (24%) than in vehicles without them (36%). Most of the children seated in front were ages 7-12 (44%-61%), followed by 3-6 year olds (29%-35%). Very few children ages 0-2 were seated in front (5%-12%). The overwhelming majority of children ages 0-2 were restrained. However, children ages 3-6 seated in the front were least likely to be restrained and most likely to be improperly restrained. Restraint use was higher when the driver was belted, but about 30% of 3-6 year olds were unrestrained even with a belted driver. CONCLUSIONS: Efforts should continue to educate parents about the importance of correct restraint use and rear seating for children, particularly once children move from child safety seats into adult belts. Efforts also should be made to enforce the seat belt laws that exist in every state.     

A sampling bias in identifying children in foster care using Medicaid data.

BACKGROUND: Prior research identified foster care children using Medicaid eligibility codes specific to foster care, but it is unknown whether these codes capture all foster care children. OBJECTIVES: To describe the sampling bias in relying on Medicaid eligibility codes to identify foster care children. METHODS: Using foster care administrative files linked to Medicaid data, we describe the proportion of children whose Medicaid eligibility was correctly encoded as foster child during a 1-year follow-up period following a new episode of foster care. Sampling bias is described by comparing claims in mental health, emergency department (ED), and other ambulatory settings among correctly and incorrectly classified foster care children. RESULTS: Twenty-eight percent of the 5683 sampled children were incorrectly classified in Medicaid eligibility files. In a multivariate logistic regression model, correct classification was associated with duration of foster care (>9 vs <2 months, odds ratio [OR] 7.67, 95% confidence interval [CI] 7.17-7.97), number of placements (>3 vs 1 placement, OR 4.20, 95% CI 3.14-5.64), and placement in a group home among adjudicated dependent children (OR 1.87, 95% CI 1.33-2.63). Compared with incorrectly classified children, correctly classified foster care children were 3 times more likely to use any services, 2 times more likely to visit the ED, 3 times more likely to make ambulatory visits, and 4 times more likely to use mental health care services (P < .001 for all comparisons). CONCLUSIONS: Identifying children in foster care using Medicaid eligibility files is prone to sampling bias that over-represents children in foster care who use more services.     

Use of restraint systems by preschool children in cars.

Many deaths and injuries would be prevented if children in cars were adequately restrained. Cars were stopped at random and the use of child car seats by 853 children aged between 6 months and 4 years was ascertained. One hundred and thirty-three (65%) of the children aged between 6 and 11 months were travelling in seat restraints. Thirty-five (30%) of the children aged between 3 and 4 years were similarly restrained. Thus there was a significant decline in the use of child car seats within the age range for which they are suitable. There are several possible explanations for this finding and it is suggested that not only should efforts be made to encourage parents to provide car restraints for their infants but that attention should be focused on the reasons for this decline in the use of seat restraints.     

Differences in pediatric preventive care counseling by provider type.

OBJECTIVE: Many children in the United States do not receive advice about health behaviors and injury prevention during routine preventive care visits. We investigated the role of provider type in the probability of receiving advice. METHODS: We analyzed children aged 3 to 17 in the Medical Expenditure Panel Data 2002 to 2003 surveys who had only 1 preventive clinic or office visit in the past year. We examined whether provider type affects whether the child is advised about healthy eating, physical activity, the harmful effects of smoking in the home, proper safety restraints in a car, and use of a helmet when riding a bicycle. RESULTS: Pediatricians were more likely to advise about healthy eating (63.6% vs 46.8% for other physicians and 41.1% for nonphysicians; P < .01). They were also more likely than nonphysicians to advise about exercise (40.1% vs 22.2%), the harmful effects of parental smoking (42.4% vs 21.4%), proper safety restraints in a car (39.9% vs 20.5%), and use of a bicycle helmet (45.7% vs 20.9%). Regardless of provider type, rates of advice were low. CONCLUSION: Many pediatric providers, particularly those not trained as pediatricians, are missing opportunities to advise about health behaviors and injury prevention.     

Effectiveness of child safety seats vs seat belts in reducing risk for death in children in passenger vehicle crashes

OBJECTIVE: To provide an estimate of benefit, if any, of child restraint systems over seat belts alone for children aged from 2 through 6 years. DESIGN: Cohort study. SETTING: A sample of children in US passenger vehicle crashes was obtained from the National Highway Transportation Safety Administration by combining cases involving a fatality from the US Department of Transportation Fatality Analysis Reporting System with a probability sample of cases without a fatality from the National Automotive Sampling System. PARTICIPANTS: Children in tow-away [corrected] crashes occurring between 1998 and 2003. MAIN EXPOSURE: Use of child restraint systems (rear-facing and forward-facing car seats, and shield and belt-positioning booster seats) vs seat belts. Potentially confounding variables included seating position, vehicle type, model year, driver and passenger ages, and driver survival status. MAIN OUTCOMES MEASURE: Death of child passengers from injuries incurred during the crash. RESULTS: Compared with seat belts, child restraints, when not seriously misused (eg, unattached restraint, child restraint system harness not used, 2 children restrained with 1 seat belt) were associated with a 28% reduction in risk for death (relative risk, 0.72; 95% confidence interval, 0.54-0.97) in children aged 2 through 6 years after adjusting for seating position, vehicle type, model year, driver and passenger ages, and driver survival status. When including cases of serious misuse, the effectiveness estimate was slightly lower (21%) (relative risk, 0.79; 95% confidence interval, 0.59-1.05). CONCLUSION: Based on these findings as well as previous epidemiological and biomechanical evidence for child restraint system effectiveness in reducing nonfatal injury risk, efforts should continue to promote use of child restraint systems through improved laws and with education and disbursement programs.     

Car safety seats for children: rear facing for best protection.

OBJECTIVE: To compare the injury risk between rear-facing (RFCS) and forward-facing (FFCS) car seats for children less than 2 years of age in the USA. METHODS: Data were extracted from a US National Highway Traffic Safety Administration vehicle crash database for the years 1988-2003. Children 0-23 months of age restrained in an RFCS or FFCS when riding in passenger cars, sport utility vehicles, or light trucks were included in the study. Logistic regression models and restraint effectiveness calculations were used to compare the risk of injury between children restrained in RFCSs and FFCSs. RESULTS: Children in FFCSs were significantly more likely to be seriously injured than children restrained in RFCSs in all crash types (OR=1.76, 95% CI 1.40 to 2.20). When considering frontal crashes alone, children in FFCSs were more likely to be seriously injured (OR=1.23), although this finding was not statistically significant (95% CI 0.95 to 1.59). In side crashes, however, children in FFCSs were much more likely to be injured (OR=5.53, 95% CI 3.74 to 8.18). When 1 year olds were analyzed separately, these children were also more likely to be seriously injured when restrained in FFCSs (OR=5.32, 95% CI 3.43 to 8.24). Effectiveness estimates for RFCSs (93%) were found to be 15% higher than those for FFCSs (78%). CONCLUSIONS: RFCSs are more effective than FFCSs in protecting restrained children aged 0-23 months. The same findings apply when 1 year olds are analyzed separately. Use of an RFCS, in accordance with restraint recommendations for child size and weight, is an excellent choice for optimum protection up to a child's second birthday.     

Seat belt use by children brought to an inner-city hospital.

OBJECTIVE: To characterize restraint use among children brought to an inner-city hospital by private car or taxicab. DESIGN: Cross-sectional survey and direct observation of a convenience sample. SETTING: Main entrance and clinic entrance of a large urban public hospital. PARTICIPANTS: Direct observation was made on 352 children brought by 257 vehicles. One hundred seventy-seven parents or caretakers responded to questionnaires for 240 children. INTERVENTION: None. MEASURES AND MAIN RESULTS: Of the 352 children who were directly observed, 256 (73%) arrived by taxicabs and 96 (27%) by private cars. Thirty-three of 352 (9%) children were observed to be appropriately restrained. Children brought by taxicabs were significantly less likely to be restrained than children brought by private cars (1% vs 31%, P < 0.001). Caretakers reported that seat belts were available in 46 of 54 (85%) private cars, compared to 38 of 88 (43%) taxicabs (P < 0.01). Twenty percent of caretakers who came by taxicabs did not check for seat belts. CONCLUSION: Taxicabs, which are exempt from the New York State's mandatory seat belt law, are a common mode of transportation for children in the inner city. While the overall use of child restraints in the study sample is low, it is particularly low for children in taxicabs. The low rate may be related to both the decreased availability of seat belts and the lack of the mandatory seat belt law for taxicabs. Strategies should be sought to improve child restraint availability in taxicabs and mandate seat belt use.     

Preventing motor vehicle injuries

Prevention of injuries to child passengers is a significant public health priority, as motor vehicle-related injuries remain a leading cause of death for children. Improvements in child restraint use have contributed to significant declines in child occupant mortality rates over the past 20 years. However, although overall restraint use has improved, many children are currently not optimally restrained for their age. Errors in installing and using child safety seats, as well as the premature graduation of children to vehicle safety belts, contribute to reducing the effectiveness of restraints for children. Further prevention of motor vehicle occupant injuries to children will require the combined approaches of engineering, education, and enforcement. This review presents current information regarding inappropriate restraint of children and highlights current engineering, education, and legislative efforts to improve child occupant protection.