Flaura Koplin Winston

Effects of Seating Position and Appropriate Restraint Use on the Risk of Injury to Children in Motor Vehicle Crashes

Background. Currently, many states are upgrading their child restraint laws to include provisions for the use of age-appropriate restraints through 6 to 8 years of age, with some also requiring rear seating for children, enabling the laws to be in closer alignment with best-practice recommendations. Objective. To evaluate the relationships of seating position and restraint status to the risk of injury among children in passenger vehicle crashes. Methods. This was a cross-sectional study of children <16 years of age who were involved in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 17980 children in 11506 crashes, representing 229106 children in 146613 crashes, was collected between December 1, 1998, and November 30, 2002. Parent reports were used to define restraint status, seating position, and occurrence of clinically significant injuries, with the use of a previously validated instrument. Results. Approximately 62% of the children used seat belts, 35% used child restraints, and 3% used no restraint. Nearly 4 of 5 children sat in the rear seat, with one half of all children being restrained appropriately for their age in the rear, although this varied according to the age of the child. Overall, 1.6% of children suffered serious injuries, 13.5% had minor injuries, and 84.9% did not have any injury. Unrestrained children in the front were at the highest risk of injury and appropriately restrained children in the rear were at the lowest risk, for all age groups. Inappropriately restrained children were at nearly twice the risk of injury, compared with appropriately restrained children (odds ratio [OR]: 1.8; 95% confidence interval [CI]: 1.4–2.3), whereas unrestrained children were at >3 times the risk (OR: 3.2; 95% CI: 2.5–4.1). The effect of seating row was smaller than the effect of restraint status; children in the front seat were at 40% greater risk of injury, compared with children in the rear seat (OR: 1.4; 95% CI: 1.2–1.7). Had all children in the study population been appropriately restrained in the rear seat, 1014 serious injuries (95% CI: 675–1353 injuries) would have been prevented (with the assumption that restraint effectiveness does not depend on a variety of other driver-related, child-related, crash-related, vehicle-related, and environmental factors). Conclusions. Age-appropriate restraint confers relatively more safety benefit than rear seating, but the 2 work synergistically to provide the best protection for children in crashes. These results support the current focus on age-appropriate restraint in recently upgraded state child restraint laws. However, it is important to note that considerable added benefit would be realized with additional requirements for rear seating.

Predicting Child Ptsd: The Relationship between Acute Stress Disorder and PTSD in Injured Children.

OBJECTIVE To examine the prevalence of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) in injured children and to evaluate the utility of ASD as a predictor of PTSD. METHOD Children hospitalized for injuries sustained in a traffic crash were enrolled in a prospective study. ASD was assessed in 243 children within 1 month after injury, and PTSD was assessed in 177 of these children 3 or more months after injury. The relationship between ASD and PTSD was examined via correlations between symptom severity scores and calculation of sensitivity, specificity, and positive and negative predictive values for categorical prediction of PTSD from ASD or subsets of ASD symptoms. RESULTS Eight percent of children met the symptom criteria for ASD and another 14% had subsyndromal ASD; 6% met the symptom criteria for PTSD and another 11% had subsyndromal PTSD. ASD and PTSD symptom severity were associated. Sensitivity was low for prediction of child PTSD from child ASD. Subsyndromal ASD was a more effective predictor of PTSD. CONCLUSIONS A substantial minority of injured children are affected by traumatic stress disorders. ASD in children may not be an optimal categorical predictor of PTSD. With increasing attention to early posttrauma services for children, empirically valid assessment/triage models deserve further study.

An evaluation of the effectiveness of forward facing child restraint systems

The objective of this study was to determine the effectiveness of forward facing child restraint systems (FFCRS) in preventing serious injury and hospitalization to children 12-47 months of age as compared with similar age children in seat belts. Data were obtained from a cross-sectional study of children aged 12-47 months in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. Effectiveness estimates were limited to those children between 12 and 47 months of age seated in the back row(s) of vehicles, restrained in FFCRS, regardless of misuse, or seat belts of all types and usage. Completed survey information was obtained on 1207 children, representing 12632 children in 11619 crashes between 1 December 1998 and 31 May 2002. Serious injuries occurred to 0.47% of all 12-47-month olds studied, including 1.72% of those in seat belts and 0.39% of those in child restraint systems. The risk of serious injury was 78% lower for children in FFCRS than in seat belts (odds ratio (OR) = 0.22, 95% confidence interval (CI) = 0.11-0.45, P = 0.001). The risk of hospitalization was 79% lower for children in FFCRS than in seat belts (OR = 0.21, 95% CI = 0.09-050, P = 0.001). There was no difference between the restraint types in preventing minor injuries. As compared with seat belts, CRS are very highly effective in preventing serious injuries and hospitalization, respectively. This effectiveness estimate is substantially higher than older estimates, demonstrating the benefits of current CRS designs. These results provide those educating parents and caregivers population-based data on the importance of child restraint use.

Prevalence of teen driver errors leading to serious motor vehicle crashes

OBJECTIVES Motor vehicle crashes are the leading cause of adolescent deaths. Programs and policies should target the most common and modifiable reasons for crashes. We estimated the frequency of critical reasons for crashes involving teen drivers, and examined in more depth specific teen driver errors. METHODS The National Highway Traffic Safety Administrations (NHTSA) National Motor Vehicle Crash Causation Survey collected data at the scene of a nationally representative sample of 5470 serious crashes between 7/05 and 12/07. NHTSA researchers assigned a single driver, vehicle, or environmental factor as the critical reason for the event immediately leading to each crash. We analyzed crashes involving 15-18 year old drivers. RESULTS 822 teen drivers were involved in 795 serious crashes, representing 335,667 teens in 325,291 crashes. Driver error was by far the most common reason for crashes (95.6%), as opposed to vehicle or environmental factors. Among crashes with a driver error, a teen made the error 79.3% of the time (75.8% of all teen-involved crashes). Recognition errors (e.g., inadequate surveillance, distraction) accounted for 46.3% of all teen errors, followed by decision errors (e.g., following too closely, too fast for conditions) (40.1%) and performance errors (e.g., loss of control) (8.0%). Inadequate surveillance, driving too fast for conditions, and distracted driving together accounted for almost half of all crashes. Aggressive driving behavior, drowsy driving, and physical impairments were less commonly cited as critical reasons. Males and females had similar proportions of broadly classified errors, although females were specifically more likely to make inadequate surveillance errors. CONCLUSIONS Our findings support prioritization of interventions targeting driver distraction and surveillance and hazard awareness training.

Partners for child passenger safety: a unique child-specific crash surveillance system

Insurance claims data were combined with telephone survey and on-site crash investigation data to create the first large scale, child-focused motor vehicle crash surveillance system in the US. Novel data management and transfer techniques were used to create a nearly real-time data collection system. In the first year of this on-going project, known as Partners for Child Passenger Safety, over 1200 children < or = 15 years of age per week were identified in crashes reported to State Farm Insurance Co. from 15 states and Washington, D.C. Partners for Child Passenger Safety is similar in its design and overall objectives to National Automotive Sampling System (NASS), the only other population-based crash surveillance system currently operating in the US.

Pediatric Providers’ Self-Reported Knowledge, Practices, and Attitudes About Concussion

OBJECTIVE: To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network. METHODS: A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried. RESULTS: There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval [CI]: 86%–95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 “not a barrier” to 5 “significant barrier” was used to assess providers’ barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%–23%), inadequate time to educate 15% (95% CI: 12%–24%), and not my role to educate 1% (95% CI: 0.4%–5%). Ninety-six percent (95% CI: 91%–98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%–100%) of providers without discharge instructions specific to concussion believed these resources would be helpful. CONCLUSIONS: Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and patient information could help enhance and standardize concussion management.

Optimal Restraint Reduces the Risk of Abdominal Injury in Children Involved in Motor Vehicle Crashes

Background:The American Academy of Pediatrics has established guidelines for optimal, age-appropriate child occupant restraint. While optimal restraint has been shown to reduce the risk of injuries overall, its effect on specific types of injuries, in particular abdominal injuries, has not been demonstrated. Methods:Cross-sectional study of children aged younger than 16 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 10,927 crashes involving 17,132 restrained children, representing 210,926 children in 136,734 crashes was collected between December 1, 1998 and May 31, 2002. Restraint use was categorized as optimal or suboptimal based on current American Academy of Pediatrics guidelines. The outcome of interest, abdominal injury, was defined as any reported injury to an intra-abdominal organ of Abbreviated Injury Scale ≥2 severity. Results:Among all restrained children, optimal was noted in 59% (n = 120,473) and suboptimal in 41% (n = 83,555). An associated abdominal organ injury was noted in 0.05% (n = 62) of the optimal restrained group and 0.17% (n = 140) of the suboptimal group. After adjusting for age and seating position (front vs. rear), optimally restrained children were more than 3 times less likely [odds ratio 3.51 (95% confidence interval, 1.87–6.60, P < 0.001)] as suboptimally restrained children to suffer an abdominal injury. Of note, there were no abdominal injuries reported among optimally restrained 4- to 8-year-olds. Conclusions:Optimally restrained children are at a significantly lower risk of abdominal injury than children suboptimally restrained for age. This disparity emphasizes the need for aggressive education efforts aimed not only at getting children into restraint systems, but also the importance of optimal, age-appropriate restraint.

EXPOSURE TO TRAFFIC AMONG URBAN CHILDREN INJURED AS PEDESTRIANS

Objectives: To explore the immediate pre-crash activities and the routine traffic exposure (street crossing and play) in a sample of urban children struck by automobiles. In particular, the traffic exposure of children who were struck while playing was compared with that of those struck while crossing streets. Design: Cross sectional survey. Setting: Urban pediatric emergency department. Patients: A total of 139 children ages 4–15 years evaluated for acute injuries resulting from pedestrian-motor vehicle collisions during a 14 month period. Main outcome measures: Sites of outdoor play, daily time in outdoor play, weekly number of street crossings, pre-crash circumstance (play v walking). Results: Altogether 39% of the children routinely used the street and 64% routinely used the sidewalks as play areas. The median number of street crossings per week per child was 27. There were no differences in exposures for the 29% who were hit while playing compared with the 71% who were hit while walking. Although 84% of the children walked to or from school at least one day per week, only 15% of the children were struck while on the school walking trip. The remainder were injured either while playing outdoors or while walking to other places. Conclusions: Urban children who are victims of pedestrian crashes have a high level of traffic exposure from a variety of circumstances related to their routine outdoor playing and street crossing activities. The distributions of traffic exposures were similar across the sample, indicating that the sample as a whole had high traffic exposure, regardless of the children’s activity preceding the crash. Future pedestrian injury programs should address the pervasive nature of children’s exposure to traffic during their routine outdoor activities.

Parent driver characteristics associated with sub-optimal restraint of child passengers.

Objectives. To identify parent driver demographic and socioeconomic characteristics associated with the use of sub-optimal restraints for child passengers under nine years. Methods. Cross-sectional study using in-depth, validated telephone interviews with parent drivers in a probability sample of 3,818 vehicle crashes involving 5,146 children. Sub-optimal restraint was defined as use of forward-facing child safety seats for infants under one or weighing under 20 lbs, and any seat-belt use for children under 9. Results. Sub-optimal restraint was more common among children under one and between four and eight years than among children aged one to three years (18%, 65%, and 5%, respectively). For children under nine, independent risk factors for sub-optimal restraint were: non-Hispanic black parent drivers (with non-Hispanic white parents as reference, adjusted relative risk, adjusted RR = 1.24, 95% CI: 1.09–1.41); less educated parents (with college graduate or above as reference: high school, adjusted RR = 1.27, 95% CI: 1.12–1.44; less than high school graduate, adjusted RR = 1.36, 95% CI: 1.13–1.63); and lower family income (with

Severe head injury caused by airbag deployment

50,000 or more as reference: <