Weaning of Moderately Preterm Infants from the Incubator to the Crib: A Randomized Clinical Trial.

OBJECTIVE: To assess whether length of hospital stay is decreased among moderately preterm infants weaned from incubator to crib at a lower vs higher weight. STUDY DESIGN: This trial was conducted in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants with gestational ages 29-33 weeks, birthweight <1600 g, and in an incubator were randomly assigned to a weaning weight of 1600 or 1800 g. Within 60 to 100 g of weaning weight, the incubator temperature was decreased by 1.0°C to 1.5°C every 24 hours until 28.0°C. The infants were weaned to the crib following stable temperature at 36.5°C to 37.4°C for 8 to 12 hours. Clothing and bedcoverings were standardized. The primary outcome was length of hospital stay from birth to discharge; secondary outcomes included length of stay and growth velocity from weaning to discharge. Adverse events were monitored. RESULTS: Of 1565 infants screened, 885 were eligible, and 366 enrolled-187 to the 1600-g and 179 to the 1800-g group. Maternal and neonatal characteristics did not differ among weight groups. Length of hospital stay was a median of 43 days in the lower and 41 days in the higher weight group (P = .12). Growth velocity from completion of weaning to discharge was higher in the lower weight group, 13.7 g/kg/day vs 12.8 g/kg/day (P = .005). Groups did not differ in adverse events. CONCLUSIONS: Among moderately preterm neonates, weaning from incubator to crib at a lower weight did not decrease length of stay, but was safe and was accompanied by higher weight gain after weaning. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02160002.

Survey of Neonatal Intensive Care Unit Nurses' Use of a Motion/Sound Infant Seat.

BACKGROUND: Perinatal substance exposure is an increasing concern in infants being cared for in neonatal intensive care units. Current recommendations support nonpharmacologic treatments for this population of infants. Multimodal (motion, sound) seats are often employed to soothe infants. PURPOSE: The purpose of this study was to survey neonatal intensive care unit nurses on their practices regarding the use of a motion/sound infant seat. METHODS: Sixty-six nurses (52% of 126 total nurses) completed the survey about their self-disclosed practices that included (1) reasons for use; (2) rationale for choice of settings of motion and sound; (3) duration of time infants spent in seat in one session; (4) perception of positive infant response; (5) who places infants in the seat; and (6) nursing instructions dispensed prior to use. RESULTS: Chief reasons for use were infant state, lack of persons to hold infants, and a diagnosis of neonatal abstinence syndrome. Rationale for choice of motion and sound settings included trial and error, prior settings, personal preferences/patterns, assumptions, and random selection. Nurse responses regarding the amount of time the infant was placed in the seat in a single session ranged from 10 to 360 minutes, with determining factors of infant cues, sleeping, feeding, and someone else to hold the infant. IMPLICATIONS FOR PRACTICE: As nonpharmacologic treatments evolve, nurses need guidelines for safe, effective interventions to care for infants. IMPLICATIONS FOR RESEARCH: Further research is necessary to ascertain the responses of withdrawing infants and to establish guidelines and education for use of the motion/sound infant seat.

Effectiveness of child restraints and booster legislation in Israel.

INTRODUCTION: 96 countries in the world have enacted child restraints and booster legislation (CRBL). Yet, findings regarding the effectiveness of CRBLs are mixed. The current study is the first to examine the association between Israel's CRBL, implemented in November 2004, and the traffic injury and fatality rates among children aged 0-9 years. We extend on previous studies by accounting for risk exposure and by comparing populations of children affected by the legislation to those who were not. METHODS: We used an interrupted time series design of kilometre driven-based traffic injury rates for children aged 0-4 years and children aged 5-9 years using childred aged 10-14 years as a comparison group. We estimated the effects of Israel's CRBL using monthly injury and fatality count data from the Israeli Central Bureau of Statistics. The sample includes all child vehicle occupants injured and killed in crashes in Israel between January 2003 and December 2011. RESULTS: Children aged 0-4 years experienced a 5.17% yearly reduction in traffic injury rate (incidence rate ratio (IRR): 0.94(95% CI 0.92 to 0.96); p=0.000), and the injury rate for children aged 5-9 years was associated with a 4.10% yearly reduction (IRR: 0.95(95% CI 0.93 to 0.98); p=0.001). The comprehensive CRBL implemented in Israel was associated with a 6.3% (95% CI -7.2% to5.5%; p=0.001) reduction in traffic injuries and fatalities for children aged 0-9 years. CONCLUSION: This is the first study comparing traffic injury rates per kilometre driven for motor vehicle-occupant children before and after the implementation of the CRBL in Israel.

Rear-Facing Car Safety Seat Use for Children 18 Months of Age: Prevalence and Determinants.

OBJECTIVE: To examine the prevalence and potential determinants of rear-facing car safety seat use among children approximately 18 months of age born at a university hospital. STUDY DESIGN: We administered a telephone survey to caregivers of children 17-19 months of age who were born between November 2013 and May 2014. The survey was designed to assess the prevalence of rear-facing car safety seat use and estimate the likelihood of rear-facing car safety seat use, compared with forward-facing car seat use, in reference to hypothesized determinants. aORs and 95% CIs were calculated using multivariable logistic regression. RESULTS: In total, 56% of potentially eligible caregivers (491/877) completed the survey; 62% of these reported rear-facing car safety seat use. Race, education, rurality, and household income were associated with rear-facing car safety seat use after controlling for potential confounders. Additionally, caregivers who reported having discussed car seats with their child's provider (aOR 1.7; 95% CI 1.1-2.6); receiving their child's primary care in pediatrics compared with family practice clinics (aOR 2.4; 95% CI 1.1-2.6); and being aware of the American Academy of Pediatrics rear-facing recommendation (aOR 2.8; 95% CI 1.8-4.1) were significantly more likely to report rear-facing car safety seat use. Conversely, caregivers who previously used a car seat with another child were less likely to have their child rear facing at 18 months of age (aOR 0.6; 95% CI 0.4-0.9). CONCLUSIONS: A large proportion of children were forward facing at 18 months of age. Future efforts focused on encouraging providers to discuss car seats during patient visits, increasing awareness of the American Academy of Pediatrics' rear-facing recommendation, and targeting high-risk populations may improve the prevalence of children who remain rear facing until 2 years of age.

Sudden unexpected infant deaths: sleep environment and circumstances.

OBJECTIVES: We sought to describe the characteristics and sleep circumstances of infants who die suddenly and unexpectedly and to examine similarities and differences in risk factors among infants whose deaths are classified as resulting from sudden infant death syndrome (SIDS), suffocation, or undetermined causes. METHODS: We used 2005 to 2008 data from 9 US states to assess 3136 sleep-related sudden unexpected infant deaths (SUIDs). RESULTS: Only 25% of infants were sleeping in a crib or on their back when found; 70% were on a surface not intended for infant sleep (e.g., adult bed). Importantly, 64% of infants were sharing a sleep surface, and almost half of these infants were sleeping with an adult. Infants whose deaths were classified as suffocation or undetermined cause were significantly more likely than were infants whose deaths were classified as SIDS to be found on a surface not intended for infant sleep and to be sharing that sleep surface. CONCLUSIONS: We identified modifiable sleep environment risk factors in a large proportion of the SUIDs assessed in this study. Our results make an important contribution to the mounting evidence that sleep environment hazards contribute to SUIDs.

Suffocation deaths associated with use of infant sleep positioners--United States, 1997-2011.

Unintentional suffocation is the leading cause of injury death among children aged <1 year in the United States, accounting for nearly 1,000 infant deaths annually. Since 1984, an estimated fourfold increase has been observed in accidental suffocation and strangulation in bed, with many of these deaths linked to unsafe sleep environments. Infant sleep positioners (ISPs) are devices intended to keep an infant in a specific position while sleeping, yet ISPs have been reported to have been present in the sleep environment in some cases of unintentional infant suffocation. Some specific ISPs have been cleared by the Food and Drug Administration (FDA) for the management of gastroesophageal reflux or plagiocephaly (asymmetry of the skull). However, many unapproved ISPs have been marketed to the general public with claims of preventing sudden infant death syndrome (SIDS), improving health, and enhancing sleep comfort. To characterize infant deaths associated with ISPs, FDA, the U.S. Consumer Product Safety Commission (CPSC), and CDC examined information reported to CPSC about 13 infant deaths in the past 13 years associated with the use of ISPs. In this case series, all infants but one were aged ≤3 months, and most were placed on their sides to sleep. Many were found prone (i.e., lying on their abdomens). Accompanying medical issues included prematurity and intercurrent respiratory illnesses. When providing guidance for parents of newborns, health-care providers need to emphasize the importance of placing infants to sleep on their backs in a safe sleep environment. This includes reminders about the American Academy of Pediatrics (AAP) recommendations against side sleep position, ISPs and pillows, comforters, and other soft bedding.

Cup introduction, drink type and vitamin supplementation in preterm babies at 11-25 months.

BACKGROUND: To avoid adverse effects of prolonged bottle use, the recommendations are that full-term babies are introduced to cups from 6 months and discouraged bottles from 12 months old. There are no recommendations for preterm babies. In the UK, the Department of Heath recommends the introduction of vitamin supplements, alongside the transition from formula to cow's milk. The present study aimed to determine age of cup introduction in a group of preterm babies, identify drinks offered from bottles versus cups and the types of cups used, and establish the prevalence and appropriateness of vitamin supplementation. METHODS: A validated postal questionnaire was sent to the parents of 369 babies born <34 weeks of gestation at Queen Charlottes Neonatal Unit; 104 sent in 2003 and 265 sent in 2004-2005. The questionnaire was sent when the babies were calculated to be between 12 and 18 months (all ages stated are uncorrected). A separate questionnaire was sent for each baby from multiple pregnancies. RESULTS: The questionnaire return rate was 46% (n = 169). Length of gestation (P < 0.001), hospital stay (P = 0.009), birth weight (P = 0.002) and maternal age (P < 0.001) were significantly greater and more mothers were of European origin (P = 0.036) for those babies for whom questionnaires were returned compared to nonresponders. Infant gender did not differ. Fifty-seven percent had been introduced to a cup before 12 months, distribution was: 58% (n = 53) of singletons, 54% (n = 37) of twins and 67% (n = 6) of triplets. This rose to 80% before 13 months. Thirteen percent (n = 22) had not started drinking from a cup and 17% (n = 29) only used cups at the time of the questionnaire. Cow's milk had been introduced to 69% (n = 117) of all babies and 32% (n = 54) were still on formula (10 on both and eight were on neither; hence, the figures do not sum to 100%). Cow's milk was drunk from bottles by 56% (n = 95) and formula by 31% (n = 52). A significantly greater proportion of twins and triplets were drinking cow's milk compared to singletons [80% (n = 62) versus 60% (n = 55) P = 0.005] and significantly fewer were drinking formula [22% (n = 17) versus 40% (n = 37) P = 0.012]. Water was the drink most commonly given from a cup (80%) (n = 135) followed by juice, which was given to 64% (n = 108). Juice drinks were given by bottle in 16% (n = 27). Fifty-two percent (n = 88) used a 'spill-proof' cup some of the time. Vitamins were given as recommended in 18% (n = 31), given even though not recommended in 12% (n = 20), not given but recommended in 49% (n = 83) and appropriately not given in 21% (n = 35). A greater percentage of twins and triplets, compared to singletons, were not commenced on vitamins, even though they were no longer drinking formula. CONCLUSIONS: The present study reports baseline data on cup introduction in preterm babies both from singleton and multiple births. The data suggest that education about appropriate bottle drinks, timing of cup introduction, suitable cups and the correct use of vitamin drops is required. However, because the profile of responders differed from nonresponders, these results may not be applicable to all preterm babies.

The influence of familiarity on life jacket donning performance: implications for participant selection.

Laboratories and test houses keep a "pool" of test subjects that volunteer to be participants in life jacket approval testing, which is believed to be an incorrect procedure. Fifty-six participants donned 8 child/infant life jackets onto 4 infant manikins in random order with time and accuracy of donning recorded. Average donning time for all 8 life jackets decreased significantly after the first donning experience. The findings show that the effect of familiarity occurs immediately after the first test, regardless of life jacket type, thus "contaminating" the subject and making them unsuitable for further tests. These observations are important for life jacket standards where the life jacket must be donned by a naïve participant. Currently, a poorly designed life jacket may receive a pass as a result of the learning effect as shown by participants with previous donning experiences.

What Is the Experience of Babywearing a NICU Graduate?

OBJECTIVE: To understand the experiences of caregivers using baby carriers to hold their infant after discharge from the NICU. DESIGN: The qualitative research design was transcendental phenomenology. SETTING/LOCAL PROBLEM: Caregiving of NICU graduates is associated with greater incidence of depression, anxiety, and posttraumatic stress disorder, which can impair caregivers' abilities to form secure attachments with their infants. In addition, lack of paid parental leave, especially among those of low socioeconomic status, can result in prolonged separations between infants and caregivers in the NICU, producing toxic stressors. PARTICIPANTS: Eight caregivers ages 21 to 41 years whose infants were discharged from the NICU of a regional referral academic medical center in Oklahoma City, Oklahoma. Homogenous convenience sampling was used by posting recruitment flyers in common areas of the NICU frequented by family members. INTERVENTION/MEASUREMENTS: Participants were educated before discharge on using baby carriers that held their infants in kangaroo position. They were asked to carry their infant in the carrier for 3 hours a day for the 2-month study period. RESULTS: Six total themes were identified; four were previously identified in kangaroo care and skin-to-skin care research: Decreased Stress and Anxiety, Calmness and Sleep, Attachment, and Parental Empowerment; two were independent to this study: Ease of Work and Self-Care. CONCLUSION: The themes identified indicate that babywearing has the potential to address harms-such as stress, fear, depression, anxiety, and posttraumatic stress disorder-that may be experienced by caregivers of infants discharged from the NICU. Babywearing can be used as an intervention to support caregivers and promote positive health outcomes after a NICU discharge.

Non-fatal and fatal crash injury risk for children in minivans compared with children in sport utility vehicles.

OBJECTIVE: To compare the fatal and non-fatal crash injury risk for children in minivans compared with midsize and large sport utility vehicles (SUVs). DESIGN: Three large population-based sources of US crash data were used--a nationwide cohort of sampled police-reported crashes (NASS-CDS) along with a census of fatal crashes (FARS), plus a large child crash surveillance system, Partners for Child Passenger Safety (PCPS)--collected in 16 states via insurance claim records and validated telephone survey. Each included: 2000-2006 data, occupants aged 0-15 years, traveling in minivan or (midsize/large) SUV, model year 1998-2007. Outcome of interest was parent/driver report of non-fatal injury (Abbreviated Injury Scale scores of 2 or higher) in PCPS and fatal injury in NASS-CDS/FARS. RESULTS: Compared with children riding in SUVs, those in minivans experienced a similar crude reduction in the relative risk of non-fatal injury (PCPS: unadjusted odds ratio (OR) = 0.55) and fatality (NASS-CDS/FARS cohort: unadjusted OR = 0.58). In PCPS, this reduction in injury risk changed little after adjustment for child, driver, and vehicle factors (adjusted OR = 0.56, 95% CI 0.38 to 0.82). Lower fatality risk in the NASS-CDS/FARS cohort was partially explained by the same factors (adjusted OR = 0.76, 95% CI 0.51 to 1.13). CONCLUSIONS: There may be important safety differences in vehicles during a crash that lead to fewer non-fatal injuries to child occupants of minivans compared with SUVs.

Screening for risky alcohol use among caregivers of pediatric trauma patients: a pilot study.

BACKGROUND: Injury is the leading cause of death for children and has been linked to caregiver drinking. Screening and brief intervention for risky drinking has been successful in adult trauma centers but has not been evaluated in caregivers of pediatric trauma patients. The purpose of this study was to investigate a pilot screening process for risky drinking caregivers, to determine rates of risky alcohol use, and to assess potential relationships between risky drinking and child safety behaviors. METHODS: Caregivers of pediatric trauma patients were screened by trained injury prevention educators. The screening assessed risky drinking, tobacco and illicit drug use, and child safety behaviors. Data were analyzed using descriptive analysis, frequency comparisons, and univariate logistic regression. RESULTS: Over 7 months, 295 caregivers were screened; 32.5% (n = 96) screened positive for risky alcohol use. For 173 injured children, one caregiver was screened, and for 61 children, two caregivers were screened. In the one-caregiver group, 29% (n = 50) screened positive for risky drinking. For the two-caregiver group, in 18% (n = 11) of the cases, both caregivers screened positive, whereas in 39% (n = 24) only one caregiver screened positive. Males were more likely to screen positive (p < 0.01). Relationships between reported child safety behaviors and risky drinking were of interest, but not statistically significant. CONCLUSIONS: The results of our study demonstrate that a substantial number of caregivers of pediatric trauma patients will self-report risky drinking behaviors, and therefore, an opportunity exists for these families to receive the benefits of screening and brief intervention programs in pediatric trauma care settings.

Baby walkers: a perspective from Turkey.

AIM: To determine in an urban population in Turkey, the frequency of baby walker (BW) use, beliefs and attitudes of mothers regarding BWs, frequency of BW-related injuries and whether families receive counselling from their paediatricians about BWs or not. METHODS: Children aged 2 months to 5 years who attended the well-child care clinics of Fatih University Hospital in Ankara comprised the sample. A semi-structured questionnaire was verbally administered. RESULTS: Of 495 children, 75.4% was found to use BW. Female gender [odds ratio (OR) = 1.82, 95% confidence interval (CI) =1.19-2.78) and lower maternal education (OR = 0.37, 95% CI = 1.18-0.74) were found to be associated with BW use. Frequencies of injuries associated with BWs were low (7.8%). Only 92 (18.6%) families received appropriate counselling by their paediatricians. CONCLUSION: The results of our study show that BW use is common in urban Turkey. Families are not informed about the lack of benefits and potential hazards of BWs and base reasons of using and not using on unique cultural beliefs rather than informed, evidence-based decisions. Paediatricians in Turkey and potentially other countries require information about the need for counselling families about the hazards associated with BW use.

Knowledge and attitude of Turkish parents regarding car safety seats for children.

BACKGROUND: One of the major causes of death among children younger than 15 years is vehicular injury. Car safety seats protect children in a crash if they are used correctly. The objective of this study was to assess the level of parental knowledge and their attitudes regarding car safety seats. METHODS: The survey was conducted in May and June 2007 at Bakirkoy Dr. Sadi Konuk Research-Training Hospital. Randomly selected parents were asked to complete an anonymous self-administered questionnaire after providing informed consent. Five hundred thirty-two Turkish parents were sampled. RESULTS: Twenty-eight percent of the parents did not know what a car safety seat was. While 20% of parents reported using a car safety seat, only 10% used them correctly. Car safety seat use was correlated with higher socioeconomic status. CONCLUSION: Increased education of parents regarding the proper use of child safety seats can protect children from potentially fatal injuries. Health care professionals are obligated to give information to parents regarding car safety seats and their proper use. This study should alert planners and policy makers regarding the need to implement educational prevention programs concerning car safety for children in Turkey.

Responses of the scaled pediatric human body model in the rear- and forward-facing child seats in simulated frontal motor vehicle crashes.

Objective: The study presents the first-ever endeavor at developing 18-, 24-, 30-, 36-, 42-, and 48-month-old pediatric finite element models from the 6-year-old PIPER human body model as a baseline and comparing their responses systematically in rear-facing and forward-facing simulations across similar boundary conditions.Methods: A 6-year-old PIPER model was scaled down to create anthropometric models of the 18-, 24-, 30-, 36-, 42-, and 48-month-old child using the PIPER scaling tool. The models were installed on a convertible car seat (rear-facing and forward-facing configurations) installed with a 3-point lap-shoulder belt in the rear outboard seat of a 2012 Toyota Camry vehicle model finite element model and setup for full-frontal crash simulation (24 G, 120 ms pulse).Results: The forward-facing models showed higher head resultant accelerations for 24-, 36-, 42-, and 48-month-old models (reduction for rear-facing seats ranging from 10% to 32%). For the 18- and 30-month-old models, the maximum head acceleration showed similar values (difference of less than 10%). Upper neck forces and moments were consistently lower for rear-facing models compared to forward-facing. The neck forces were reduced by 83%-90% and the neck moments were reduced by 63%-85% in the rear-facing models compared to their respective forward-facing configurations. The reduction in head injury criterion (HIC36) for rear-facing models ranged from 14% to 51%. The neck injury criterion (Nij) for all forward-facing models was 6 to 9 times the values of their rear-facing counterpart.Conclusions: The study shows the potential benefit of rear-facing orientation compared to forward-facing for children up to 4 years of age in a controlled environment.

Bassinet use and sudden unexpected death in infancy.

OBJECTIVE: To analyze risk factors in infants who die suddenly and unexpectedly in bassinets. STUDY DESIGN: A retrospective review of all deaths of infants involving bassinets reported to the Consumer Product Safety Commission (CPSC) between 1990 and 2004. RESULTS: For the 53 deaths analyzed, the mean age at death was 84 days. The cause of death was recorded as anoxia, asphyxiation, or suffocation in 85% and sudden infant death syndrome (SIDS) in 9.4%. In terms of position, 37% were placed prone for sleep, and 50% were prone when found dead. Additional items in the bassinet, including soft bedding, were noted in 74% of cases. Specific mechanical problems with the bassinets were noted in 17% of cases. CONCLUSIONS: The risk of sudden unexpected death in infants who sleep in bassinets can be reduced by following American Academy of Pediatrics guidelines, including positioning infants supine and avoiding soft bedding in bassinets. In addition, parents must ensure that the bassinet is mechanically sound and that no objects that can lead to suffocation are in or near the bassinet.

Police accident report forms: safety device coding and enacted laws.

Safety device coding on state police accident report (PAR) forms was compared with provisions in state traffic safety laws. PAR forms were obtained from all 50 states and the District of Columbia (states/DC). For seat belts, 22 states/DC had a primary seat belt enforcement law vs 50 with a PAR code. For car seats, all 51 states/DC had a law and a PAR code. For booster seats, 39 states/DC had a law vs nine with a PAR code. For motorcycle helmets, 21 states/DC had an all-age rider helmet law and another 26 a partial-age law vs 50 with a PAR code. For bicycle helmets, 21 states/DC had a partial-age rider helmet law vs 48 with a PAR code. Therefore gaps in the ability of states to fully record accident data reflective of existing state traffic safety laws are revealed. Revising the PAR forms in all states to include complete variables for safety devices should be an important priority, independent of the laws.

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

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

Evaluation of community-based programs to increase booster seat use.

This manuscript reports the results of an evaluation of two community-based booster seat promotion programs in Michigan; one program focused on a low-income community, while the other focused on a Hispanic community. Each community received funding to develop and implement a booster seat intervention program specific to their community. To determine the effectiveness of each program, direct observation surveys of booster seat use were conducted in each community, as well as in similarly composed comparison communities, before and after program implementation. A process evaluation documented activities and provided additional information for interpreting the results of the direct observation survey. Target age children (4-8 years) were observed traveling in cars, vans/minivans, sport-utility vehicles, and pickup trucks in each community. Baseline booster seat use was 19.0+/-5.3% and 9.7+/-2.5% for the low-income and Hispanic program communities, respectively. Post program results showed no significant change for the low-income program community, and a significant increase within the Hispanic program community. The process evaluation revealed challenges for each program and suggestions to overcome those challenges. Findings from the study can be useful to other communities interested in implementing programs to increase the use of booster seats.

Counseling about proper use of motor vehicle occupant restraints and avoidance of alcohol use while driving: U.S. Preventive Services Task Force recommendation statement.

DESCRIPTION: An assessment of the independent effectiveness of primary care interventions to increase the proper use of child safety seats, booster seats, and lap-and-shoulder belts to prevent motor vehicle occupant injuries (MVOIs) and to prevent alcohol-related MVOIs in adolescents and adults. METHODS: The U.S. Preventive Services Task Force reviewed evidence on the effectiveness of counseling in primary care about the proper use of child restraints in motor vehicles to prevent injury, as well as evidence on the impact of primary care counseling to prevent alcohol-related MVOIs in adolescents and adults. This included information gathered in the process of making their 1996 recommendation, as well as the accompanying systematic review of English-language articles published through 2005. RECOMMENDATION: Current evidence is insufficient to assess the incremental benefits, beyond the efficacy of legislation and community-based interventions, of counseling in the primary care setting to improve rates of proper use of motor vehicle occupant restraints. (I statement) Current evidence is insufficient to assess the balance of benefits and harms of routine counseling of all patients in the primary care setting to reduce driving while under the influence of alcohol or riding with drivers who are alcohol-impaired. (I statement).