Deciding when to cross in front of an autonomous vehicle: How child and adult pedestrians respond to eHMI timing and vehicle kinematics.

How autonomous vehicles (AVs) communicate their intentions to vulnerable road users (e.g., pedestrians) is a concern given the rapid growth and adoption of this technology. At present, little is known about how children respond to external Human Machine Interface (eHMI) signals from AVs. The current study examined how adults and children respond to the combination of explicit (eHMI signals) and implicit information (vehicle deceleration) to guide their road-crossing decisions. Children (8- to 12-year-olds) and adults made decisions about when to cross in front of a driverless car in an immersive virtual environment. The car sometimes stopped, either abruptly or gradually (manipulated within subjects), to allow participants to cross. When yielding, the car communicated its intent via a dome light that changed from red to green and varied in its timing onset (manipulated between subjects): early eHMI onset, late eHMI onset, or control (no eHMI). As expected, we found that both children and adults waited longer to enter the roadway when vehicles decelerated abruptly than gradually. However, adults responded to the early eHMI signal by crossing sooner when the cars decelerated either gradually or abruptly compared to the control condition. Children were heavily influenced by the late eHMI signal, crossing later when the eHMI signal appeared late and the vehicle decelerated either gradually or abruptly compared to the control condition. Unlike adults, children in the control condition behaved similarly to children in the early eHMI condition by crossing before the yielding vehicle came to a stop. Together, these findings suggest that early eHMI onset may lead to riskier behavior (initiating crossing well before a gradually decelerating vehicle comes to a stop), whereas late eHMI onset may lead to safer behavior (waiting for the eHMI signal to appear before initiating crossing). Without an eHMI signal, children show a concerning overreliance on gradual vehicle deceleration to judge yielding intent.

How do bicyclists respond to vehicles with adaptive headlamp systems? A nighttime study in an immersive virtual environment.

INTRODUCTION: The risk of motor vehicle-bicyclist crashes and fatalities is greater during nighttime than daytime lighting conditions, even though there are fewer cyclists on roadways at night. Vehicle Adaptive Headlamp Systems (AHS) aim to increase the visibility of bicyclists for drivers by directing a spotlight to illuminate bicyclists on or near the roadway. AHS technology also serves to alert bicyclists to the approaching vehicle by illuminating the road beneath the rider and by projecting a warning icon on the roadway. METHOD: Here, we examined how bicyclists respond to different AHS designs using a large screen, immersive virtual environment. Participants bicycled along a virtual road during nighttime lighting conditions and were overtaken by vehicles with and without an AHS system. The experiment included five treatment conditions with five different AHS designs. In each design a box of white light was projected beneath the rider; in four of the designs an icon was also projected on the road that varied in color (white or red) and position (to the left of the rider at midline or to the left of the front wheel). Participants in the control condition experienced only non-AHS vehicles. RESULTS: We found that riders in all AHS treatment conditions moved significantly farther away from overtaking vehicles with AHS systems, whereas riders in the control condition did not significantly move away from overtaking vehicles without AHS systems. PRACTICAL APPLICATIONS: The experiment demonstrates that AHS has potential to increase bicycling safety by influencing riders to steer away from overtaking vehicles.

Longitudinal and Concurrent Effortful Control as Predictors of Risky Bicycling in Adolescence: Moderating Effects of Age and Gender.

OBJECTIVE: Collisions between bicycles and motor vehicles are one of the leading risk factors for injury and death in childhood and adolescence. We examined longitudinal and concurrent effortful control (EC) as predictors of risky bicycling behavior in early- to mid-adolescence, with age and gender as moderators. We also examined whether EC was associated with parent-reported real-world bicycling behavior and all lifetime unintentional injuries. METHODS: Parent-reported EC measures were collected when children (N = 85) were 4 years old and when they were either 10 years (N = 42) or 15 years (N = 43) old. We assessed risky bicycling behavior by asking the adolescents to bicycle across roads with high-density traffic in an immersive virtual environment. Parents also reported on children's real-world bicycling behavior and lifetime unintentional injuries at the time of the bicycling session. RESULTS: We found that both longitudinal and concurrent EC predicted adolescents' gap choices, though these effects were moderated by age and gender. Lower parent-reported early EC in younger and older girls predicted a greater willingness to take tight gaps (3.5 s). Lower parent-reported concurrent EC in older boys predicted a greater willingness to take gaps of any size. Children lower in early EC started bicycling earlier and were rated as less cautious bicyclists as adolescents. Adolescents lower in concurrent EC were also rated as less cautious bicyclists and had experienced more lifetime unintentional injuries requiring medical attention. CONCLUSION: Early measures of child temperament may help to identify at-risk populations who may benefit from parent-based interventions.

Classic ketogenic diet versus further antiseizure medicine in infants with drug-resistant epilepsy (KIWE): a UK, multicentre, open-label, randomised clinical trial.

BACKGROUND: Many infancy-onset epilepsies have poor prognosis for seizure control and neurodevelopmental outcome. Ketogenic diets can improve seizures in children older than 2 years and adults who are unresponsive to antiseizure medicines. We aimed to establish the efficacy of a classic ketogenic diet at reducing seizure frequency compared with further antiseizure medicine in infants with drug-resistant epilepsy. METHODS: In this phase 4, open-label, multicentre, randomised clinical trial, infants aged 1-24 months with drug-resistant epilepsy (defined as four or more seizures per week and two or more previous antiseizure medications) were recruited from 19 hospitals in the UK. Following a 1-week or 2-week observation period, participants were randomly assigned using a computer-generated schedule, without stratification, to either a classic ketogenic diet or a further antiseizure medication for 8 weeks. Treatment allocation was masked from research nurses involved in patient care, but not from participants. The primary outcome was the median number of seizures per day, recorded during weeks 6-8. All analyses were by modified intention to treat, which included all participants with available data. Participants were followed for up to 12 months. All serious adverse events were recorded. The trial is registered with the European Union Drug Regulating Authorities Clinical Trials Database (2013-002195-40). The trial was terminated early before all participants had reached 12 months of follow-up because of slow recruitment and end of funding. FINDINGS: Between Jan 1, 2015, and Sept 30, 2021, 155 infants were assessed for eligibility, of whom 136 met inclusion criteria and were randomly assigned; 75 (55%) were male and 61 (45%) were female. 78 infants were assigned to a ketogenic diet and 58 to antiseizure medication, of whom 61 and 47, respectively, had available data and were included in the modifified intention-to-treat analysis at week 8. The median number of seizures per day during weeks 6-8, accounting for baseline rate and randomised group, was similar between the ketogenic diet group (5 [IQR 1-16]) and antiseizure medication group (3 [IQR 2-11]; IRR 1·33, 95% CI 0·84-2·11). A similar number of infants with at least one serious adverse event was reported in both groups (40 [51%] of 78 participants in the ketogenic diet group and 26 [45%] of 58 participants in the antiseizure medication group). The most common serious adverse events were seizures in both groups. Three infants died during the trial, all of whom were randomly assigned a ketogenic diet: one child (who also had dystonic cerebral palsy) was found not breathing at home; one child died suddenly and unexpectedly at home; and one child went into cardiac arrest during routine surgery under anaesthetic. The deaths were judged unrelated to treatment by local principal investigators and confirmed by the data safety monitoring committee. INTERPRETATION: In this phase 4 trial, a ketogenic diet did not differ in efficacy and tolerability to a further antiseizure medication, and it appears to be safe to use in infants with drug-resistant epilepsy. A ketogenic diet could be a treatment option in infants whose seizures continue despite previously trying two antiseizure medications. FUNDING: National Institute for Health and Care Research.

Rates and predictors of teen driver crash culpability.

BACKGROUND: Motor-vehicle crash risk is highest among teen drivers. Despite a wealth of research on the topic, there are still many contributors to these crashes that are not well understood. The current study sought to examine the contribution of graduated driver licensing (GDL) restrictions, sex, age, roadway circumstances, and citation history to teen drivers' crash culpability. METHOD: Crash system data from the Iowa Department of Transportation were linked with traffic-related charges from the Iowa Court Information System. Crashes involving teens aged 14 to 17 years between 2016 and 2019 were analyzed (N = 19,847). Culpability was determined using the driver contributing circumstances from the crash report. Moving and non-moving traffic citations issued prior to the date of each crash were considered. A multivariable logistic regression model was constructed to examine predictors of crash culpability. RESULTS: Teen drivers were determined to be culpable for more than two thirds of crashes (N = 13,604, 68.54%). Culpability was more prevalent among males, younger teens, in rural areas, in the presence of reported roadway contributing circumstances, during hours of restricted nighttime driving, and among teens with citation histories that included both moving and non-moving citations. Similarly, multivariable model results indicated that the likelihood of culpability was higher among males, in rural areas, and at each stage of GDL compared to teen drivers with unrestricted licenses. While drivers with a history of both moving and non-moving violations were more likely to be culpable, those with a history of only moving or only non-moving violations were less likely to be culpable compared to those with no violation history. CONCLUSION: Sex, crash location, and GDL stage were associated with teen driver crash culpability. A singular prior moving or non-moving violation may play a protective role in teen crash culpability.

Direct medical charges of all parties in teen-involved vehicle crashes by culpability.

BACKGROUND: Motor vehicle crashes among teen drivers often involve passengers in the teen's vehicle and occupants of other vehicles, and the full cost burden for all individuals is largely unknown. This analysis estimated direct hospitalisation and emergency department charges for teen-involved crashes by teen culpability, comparing charges for the teen driver, passengers and occupants of other vehicles. METHODS: Probabilistic linkage was performed to link the Iowa police crash reports with Iowa emergency department and Iowa hospital inpatient data. Teen drivers aged 14-17 involved in a crash from 2016 through 2020 were included. Teen culpability was determined through the crash report and examined by teen and crash characteristics. Direct medical charges were estimated from charges through linkage to the Iowa hospital inpatient and the Iowa emergency department databases. RESULTS: Among the 28 062 teen drivers involved in vehicle crashes in Iowa between 2016 and 2020, 62.1% were culpable and 37.9% were not culpable. For all parties involved, the inpatient charges were $20.5 million in culpable crashes and $7.2 million in non-culpable crashes. The emergency department charges were $18.7 million in teen culpable crashes and $6.8 million in teen non-culpable crashes. Of the $20.5 million total inpatient charges in which a teen driver was culpable, charges of $9.5 million (46.3%) were for the injured teen driver and $11.0 million (53.7%) for other involved parties. CONCLUSIONS: Culpable teen-involved crashes lead to higher proportions of injury and higher medical charges, with most of these charges covering other individuals in the crash.

How children judge affordances when walking and bicycling across virtual roads: Does mode of locomotion matter?

This investigation examined whether the mode of locomotion matters in how 8-, 10-, 12-, and 14-year-old children (N = 91) judge dynamic affordances in a complex perception-action task with significant safety risks. The primarily European American children in the sample came from the area of Iowa City, Iowa and were balanced for gender. The same children crossed a single lane of continuous traffic on foot and on bike (order counterbalanced) in identical immersive virtual environments. We found that although 8-year-olds chose significantly larger gaps when crossing on bike than on foot, these gaps were not large enough to compensate for their delay in entering the gap and their slowness in crossing the road. As a result, they ended up with less time to spare when exiting the roadway on bike than on foot. In contrast, 14-year-olds exhibited no difference in their gap choices on bike than on foot, nor did they exhibit a difference in their timing of entry into the gap. However, they crossed the road much more quickly on bike, resulting in significantly more time to spare when crossing on bike than on foot. The 10- and 12-year-olds' performance fit neatly between that of the 8- and 14-year-olds. We conclude that as children gained better control over the bike with age, they were better able to match their gap decisions with their crossing movements such that bicycling afforded even safer road-crossing than walking for 14-year-olds. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A comparison of daytime and nighttime pedestrian road-crossing behavior using an immersive virtual environment.

OBJECTIVE: Reduced visibility for both drivers and pedestrians is a key factor underlying the higher risk of vehicle-pedestrian collisions in dark conditions. This study investigated the extent to which pedestrians adjust for the higher risk of road crossing at night by comparing daytime and nighttime pedestrian road crossing using an immersive virtual environment. METHOD: Participants physically crossed a single lane of continuous traffic in an immersive pedestrian simulator. Participants were randomly assigned to either the daytime or the nighttime lighting condition. The primary measures were the size of the gap selected for crossing and the timing of crossing motions relative to the gap. RESULTS: The results showed that there were no significant differences in gap selection or movement timing in daytime vs. nighttime lighting conditions. However, there was a marginal increase in the time to spare after crossing the road when crossing in the dark, likely due to an accumulation of small differences in gap choices and movement timing. CONCLUSION: This study suggests that pedestrians do not adjust their road crossing to account for greater risk at night. As such, this study adds to our understanding of the potential risk factors for pedestrian injuries and fatalities in nighttime conditions.

How Do Child ADHD Symptoms and Oppositionality Impact Parent-Child Interactions When Crossing Virtual Roads?

OBJECTIVE: This study examined how parents and children interact when crossing virtual roads together. We examined (1) whether children's inattention/hyperactivity and oppositionality and children's failure to jointly perform the task interfered with parents' efforts to scaffold children's road-crossing skill and (2) whether experience with the joint road-crossing task impacted children's subsequent performance in a solo road-crossing task. METHODS: Fifty-five 8- to 10-year-old children with and without attention-deficit/hyperactivity disorder and their parents first jointly crossed a lane of traffic in an immersive pedestrian simulator. Children then completed the same road-crossing task alone. Parents completed questionnaires about children's symptoms of inattention/hyperactivity and oppositionality. RESULTS: Analyses of the joint road-crossing task showed that when parents and children crossed different gaps, parents suggested and opposed more gaps and were less likely to use a prospective gap communication strategy (i.e., communicating about a crossable gap prior to its arrival). Crossing different gaps was also associated with increased expressions of negative affect among parents and children and an increase in collisions among children. Children's level of parent-reported oppositionality also predicted an increase in child defiance and parental redirection of child behavior. Analyses of children's subsequent crossing performance indicated that parents' use of a prospective gap communication strategy during the joint road-crossing task predicted selection of larger gaps during the solo crossing task. CONCLUSIONS: Not crossing through the same gap and increased levels of child oppositionality interfered with the scaffolding process, potentially informing future parent-based intervention efforts for increasing children's road-crossing safety.

How do pedestrians respond to adaptive headlamp systems in vehicles? A road-crossing study in an immersive virtual environment.

Three-fourths of pedestrian fatalities in the U.S. occur in the dark (National Center for Statistics and Analysis, 2020). Adaptive Headlight Systems (AHS) offer the potential to address this problem by improving the visibility of pedestrians for drivers and alerting pedestrians to approaching vehicles. The goal of this study was to investigate how pedestrians respond to different types of AHS. We conducted a mixed factor experiment with 106 college-age adults using a large-screen pedestrian simulator. The task for participants was to cross a stream of continuous traffic without colliding with a vehicle. There were four AHS treatment conditions that differed in the color (white or red) and timing of an icon projected on the roadway in front the participant as an AHS vehicle approached. Participants in the treatment conditions encountered a mix of AHS and non-AHS vehicles. There was also a control condition in which participants encountered only non-AHS vehicles. We found that the color and the timing of the icon projected on the roadway influenced the size of the gaps crossed. Participants in the red icon with early onset condition chose the largest gaps for crossing. An unexpected outcome was that participants in the AHS treatment conditions chose larger gaps even when crossing in front of non-AHS vehicles, suggesting that experiences with AHS vehicles generalized to non-AHS vehicles. We conclude that AHS can have a significant, positive impact on pedestrian road-crossing safety.

Let's Cross the Next One: Parental Scaffolding of Prospective Control Over Movement.

This investigation examined parental scaffolding of children's prospective control over decisions and actions during a joint perception-action task. Parents and their 6-, 8-, 10-, and 12-year-old children (N = 128) repeatedly crossed a virtual roadway together. Guidance and control shifted from the parent to the child with increases in child age. Parents more often chose the gap that was crossed and prospectively communicated the gap choice with younger than older children. Greater use of an anticipatory gap selection strategy by parents predicted more precise timing of entry into the gap by children. This work suggests that social interaction may serve as an important experiential mechanism for the development of prospective control over decisions and actions in the perception-action domain.

Glut1 Deficiency Syndrome (Glut1DS): State of the art in 2020 and recommendations of the international Glut1DS study group.

Glut1 deficiency syndrome (Glut1DS) is a brain energy failure syndrome caused by impaired glucose transport across brain tissue barriers. Glucose diffusion across tissue barriers is facilitated by a family of proteins including glucose transporter type 1 (Glut1). Patients are treated effectively with ketogenic diet therapies (KDT) that provide a supplemental fuel, namely ketone bodies, for brain energy metabolism. The increasing complexity of Glut1DS, since its original description in 1991, now demands an international consensus statement regarding diagnosis and treatment. International experts (n = 23) developed a consensus statement utilizing their collective professional experience, responses to a standardized questionnaire, and serial discussions of wide-ranging issues related to Glut1DS. Key clinical features signaling the onset of Glut1DS are eye-head movement abnormalities, seizures, neurodevelopmental impairment, deceleration of head growth, and movement disorders. Diagnosis is confirmed by the presence of these clinical signs, hypoglycorrhachia documented by lumbar puncture, and genetic analysis showing pathogenic SLC2A1 variants. KDT represent standard choices with Glut1DS-specific recommendations regarding duration, composition, and management. Ongoing research has identified future interventions to restore Glut1 protein content and function. Clinical manifestations are influenced by patient age, genetic complexity, and novel therapeutic interventions. All clinical phenotypes will benefit from a better understanding of Glut1DS natural history throughout the life cycle and from improved guidelines facilitating early diagnosis and prompt treatment. Often, the presenting seizures are treated initially with antiseizure drugs before the cause of the epilepsy is ascertained and appropriate KDT are initiated. Initial drug treatment fails to treat the underlying metabolic disturbance during early brain development, contributing to the long-term disease burden. Impaired development of the brain microvasculature is one such complication of delayed Glut1DS treatment in the postnatal period. This international consensus statement should facilitate prompt diagnosis and guide best standard of care for Glut1DS throughout the life cycle.

Family Communication Patterns and Teen Driving Intervention Effectiveness.

Objectives: Teen drivers are at increased crash risk, largely due to lack of experience. Parents play a key role in influencing teen behaviors and attitudes around driving safety. Parent-involved interventions may improve teen driving safety but tend to be resource intensive and have limited scalability. In this study, we examined how family communication patterns (FCPs) impact teen risky driving and the effectiveness of a parent-focused teen driving intervention. Methods: Our data came from a large randomized controlled teen driving intervention trial. We randomized parent-teen dyads into one of 3 groups: parent communication intervention plus in-vehicle event recorder feedback; in-vehicle event recorder feedback only ; or control. The primary outcome variable was teen risky driving (self-reports and triggered events); the primary exposure variables were FCPs and intervention group. We used generalized linear models to calculate effect estimates. Results: Teens' baseline risky driving did not vary by family communication pattern. The impact of the parent-focused intervention was stronger in families with a laissez-faire FCP. The laissez-faire FCP focuses little on child conformity and downplays communication. Conclusions: These results provide a framework for targeting high-resource teen driving interventions (event recorder feedback and parent-communication training) to families with laissez-faire communication patterns to attain the greatest risk reductions.

Do mother-child conversations about safety differ in middle- and low-income families?

BACKGROUND: Children from low-income families experience a disproportionate number of unintentional injuries compared to their middle-income peers. Parents are well positioned to teach children about avoiding injury, yet little is known about parent-child safety conversations in low-income families. This study examined to what extent mother-child safety conversations differ between low- and middle-income families. METHODS: Mothers and their 8- to 10-year-old children from low- and middle-income families discussed and rated the safety of photos showing another child engaged in potentially dangerous activities. RESULTS: Dyads disagreed over safety ratings on a third of trials, and both middle- and low-income mothers were highly successful in resolving disagreements in their favor. Middle-income mothers justified their ratings by referring to almost twice as many dangerous features than outcomes, whereas low-income mothers generated roughly equal numbers of dangerous features and outcomes. Middle-income children did not differ in their references to dangerous features and outcomes, but low-income children focused heavily on dangerous outcomes relative to dangerous features. CONCLUSIONS: Describing how middle- and low-income families discuss safety is a first step in understanding whether similarities and differences contribute to how middle- and low-income children evaluate and navigate potentially dangerous situations.

How Does Crossing Roads with Friends Impact Risk Taking in Young Adolescents and Adults?

OBJECTIVE: The goal of this investigation was to examine how crossing roads with a friend versus alone affects gap decisions and movement timing in young adolescents and adults. METHODS: Ninety-six 12-year-olds and adults physically crossed a single lane of continuous traffic in an immersive pedestrian simulator. Participants completed 30 crossings either with a friend or alone. Participants were instructed to cross the road without being hit by a car, but friend pairs were not instructed to cross together. RESULTS: Pairs of adolescent friends exhibited riskier road-crossing behavior than pairs of adult friends. For gaps crossed together, adult pairs were more discriminating in their gap choices than adult solo crossers, crossing fewer of the smaller gaps and more of the larger gaps. This pattern did not hold for 12-year-old pairs compared to 12-year-old solo crossers. To compensate for their less discriminating gap choices, pairs of 12-year-olds adjusted their movement timing by entering and crossing the road more quickly. For gaps crossed separately, both adult and 12-year-old first crossers chose smaller gaps than second crossers. Unlike adults, 12-year-old first crossers were significantly less discriminating in their gap choices than 12-year-old second crossers. CONCLUSIONS: Compared to adults, young adolescents took riskier gaps in traffic when crossing virtual roads with a friend than when crossing alone. Given that young adolescents often cross roads together in everyday life, peer influences may pose a significant risk to road safety in early adolescence.

Harnessing Vehicle-to-Pedestrian (V2P) Communication Technology: Sending Traffic Warnings to Texting Pedestrians.

OBJECTIVE: We examined how sending mobile-device warnings to texting pedestrians when they initiate an unsafe road crossing influences their decisions and actions. BACKGROUND: Pedestrian texting has been identified as a key risk factor in pedestrian-vehicle collisions. Advances in sensing and communications technology offer the possibility of providing pedestrians with information about traffic conditions to assist them in safely crossing traffic-filled roadways. However, it is unclear how this information can be most effectively communicated to pedestrians. METHOD: We examined how texting and nontexting pedestrians crossed roads with continuous traffic in a large-screen, immersive pedestrian simulator using a between-subjects design with three conditions: texting, warning, and control. Texting participants in the warning condition received an alarm on their cell phone when they began to cross a dangerously small gap. RESULTS: The results demonstrate the detrimental influence of texting on pedestrians' gap selection, movement timing, and gaze behavior, and show the potential of warnings to improve decision making and safety. However, the results also reveal the limits of warning texting participants once they initiate a crossing and possible overreliance on technology that may lead to reduced situation awareness. CONCLUSION: Mobile devices and short-range communication technologies offer enormous potential to assist pedestrians, but further study is needed to better understand how to provide useful information in a timely manner. APPLICATION: The technology for communicating traffic information to pedestrians via mobile devices is on the horizon. Research on how such information influences all aspects of pedestrian behavior is critical to developing effective solutions.

Changes in perception-action tuning over long time scales: How children and adults perceive and act on dynamic affordances when crossing roads.

This investigation examined developmental change in how children perceive and act on dynamic affordances when crossing roads on foot. Six- to 14-year-olds and adults crossed roads with continuous cross-traffic in a large-screen, immersive pedestrian simulator. We observed change both in children's gap choices and in their ability to precisely synchronize their movement with the opening of a gap. Younger children were less discriminating than older children and adults, choosing fewer large gaps and more small gaps. Interestingly, 12-year-olds' gap choices were significantly more conservative than those of 6-, 8-, 10-, and 14-year-olds, and adults. Timing of entry behind the lead vehicle in the gap (a key measure of movement coordination) improved steadily with development, reaching adultlike levels by age 14. Coupled with their poorer timing of entry, 6-, 8-, and 10-year-olds' gap choices resulted in significantly less time to spare and more collisions than 14-year-olds and adults. Time to spare did not differ between 12-year-olds, 14-year-olds, and adults, indicating that 12-year-olds' more conservative gap choices compensated for their poorer timing of entry. The findings show that children's ability to perceive and act on dynamic affordances undergoes a prolonged period of development, and that older children appear to compensate for their poorer movement timing skills by adjusting their gap decisions to match their crossing actions. Implications for the development of perception-action tuning and road-crossing skills are discussed. (PsycINFO Database Record

Ketogenic diet in the treatment of epilepsy in children under the age of 2 years: study protocol for a randomised controlled trial.

BACKGROUND: The incidence of epilepsy is greatest in the first 2 years of life, an age group where there is generally a poor prognosis for both seizure control and neurodevelopmental outcome. Early control of seizures can be associated with better developmental outcome but many of the epilepsies presenting in infancy are poorly responsive to antiepileptic medication. The ketogenic diet (KD) is a high-fat, low-carbohydrate diet designed to mimic the effects of starvation on the body. Dietary fat is converted into ketones in the body and used as an energy source by the brain. The KD has been shown to be successful in controlling seizures in many observational studies, and in two randomised controlled trials (RCTs) in older children. However, little evidence is available in the very young. METHODS/DESIGN: An open-label RCT where eligible children (age 3 months to 2 years with epilepsy who have failed two antiepileptic drugs (AEDs)) undergo baseline assessment, including medical and seizure history. Participants then start an observation period (7 or 14 days) with documentation of seizure frequency. Randomisation will occur on day 8 or day 15 to receive the KD or a further AED; the allocated treatment will commence on day 15, with instruction and training. A second assessment (4 weeks after start of treatment) will include a clinical review and tolerability questionnaire (modified Hague Scale of Side Effects - for those allocated to the KD group). Assessments will be repeated at 8 weeks after the start of treatment including biochemical investigations, after which, according to patient response, KD (diet group) or AED (standard AED group) will then be continued or changed. Those in the AED group who have failed to achieve seizure control at the 8-week assessment will then be offered KD outside the context of the trial. Those in the KD arm who fail to achieve seizure control will be changed to standard clinical management. All patients will be followed up for 12 months from randomisation for retention, seizure outcome, quality of life and neurodevelopmental status. DISCUSSION: The slow rate of recruitment is an ongoing practical issue. There is a limitation to the number of eligible patients compared to what was predicted, mainly due to the nature of this patient group. After a substantial amendment to widen inclusion criteria and reduce the baseline period to 7 days for patients with a high seizure burden, the rate of recruitment steadily increased. A number of operational concerns regarding dietetic time were also highlighted impacting on the recruitment rate. However, the combination of a low dropout rate and the opening of further centres, the trial should successfully meet the final recruitment target. All nine centres are now recruiting and we hope to open further centres within the UK. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02205931 . Registered on 16 December 2013.

Ketogenic diet guidelines for infants with refractory epilepsy.

BACKGROUND: The ketogenic diet (KD) is an established, effective non-pharmacologic treatment for drug resistant childhood epilepsy. For a long time, the KD was not recommended for use in infancy (under the age of 2 years) because this is such a crucial period in development and the perceived high risk of nutritional inadequacies. Indeed, infants are a vulnerable population with specific nutritional requirements. But current research shows that the KD is highly effective and well tolerated in infants with epilepsy. Seizure freedom is often achieved and maintained in this specific patient group. There is a need for standardised protocols and management recommendations for clinical use. METHOD: In April 2015, a project group of 5 experts was established in order to create a consensus statement regarding the clinical management of the KD in infants. The manuscript was reviewed and amended by a larger group of 10 international experts in the KD field. Consensus was reached with regard to guidance on how the diet should be administered and in whom. RESULTS: The resulting recommendations include patient selection, pre-KD counseling and evaluation, specific nutritional requirements, preferred initiation, monitoring of adverse effects at initiation and follow-up, evaluation and KD discontinuation. CONCLUSION: This paper highlights recommendations based on best evidence, combined with expert opinions and gives directions for future research.

The role of Body Mass Index in child pedestrian injury risk.

The goal of the current investigation was to examine obesity as a potential risk factor for childhood pedestrian injury. A racially diverse sample of 7- and 8-year-old children completed a road-crossing task in a semi-immersive virtual environment and two pedestrian route selection tasks. Multiple linear regression analyses revealed that children with a higher Body Mass Index (BMI) waited less before crossing, had a smaller temporal buffer between themselves and oncoming traffic while crossing, and had more collisions with traffic. Girls were more cautious than boys when crossing the virtual roadway. Unlike the results from the virtual road-crossing task, BMI was not associated with risky route selection. Instead, race emerged as the strongest predictor, with African-American children selecting riskier routes for crossing. Together, these findings suggest overweight and obese children may be at increased risk for pedestrian injury. The discussion considers explanations for why obese children may exhibit riskier road-crossing behavior.