Improving Child Passenger Safety Through Proper Restraint System Use.

Nurses could help close caregivers' knowledge gap.

Determination of potential dermal exposure rates of phosphorus flame retardants via the direct contact with a car seat using artificial skin.

Dermal exposure to phosphorus flame retardants (PFRs) has received much attention as a major alternative exposure route in recent years. However, the information regarding dermal exposure via direct contact with a product is limited. In addition, in the commonly used dermal permeability test, the target substance is dissolved in a solvent, which is unrealistic. In this study, a dermal permeability test of PFRs in three car seats was performed using artificial skin. The PFR concentrations in the car seats are 0.12 wt% tris(2-chloroethyl) phosphate (TCEP), 0.030-0.25 wt% tris(2-chloroisopropyl) phosphate (TCPP), 0.15 wt% triphenyl phosphate (TPhP), 0.89 wt% cresyl diphenyl phosphate (CsDPhP), 0.074 wt% tricresyl phosphate (TCsP), and 0.46-4.7 wt% diethylene glycol bis [di (2-chloroisopropyl) phosphate (DEG-BDCIPP). The mean skin permeation rates for a contact time of 24 h are 14 (TCEP), 5.4-160 (TCPP), 0.67 (CsDPhP), 0.38 (TPhP), and 3.3-58 ng cm-2 h-1 (DEG-BDCIPP). The concentrations of TCsP in receptor liquid were lower than the limit of quantification at the contact time of 24 h. The skin permeation rates were significantly affected by the type of car seat (e.g., fabric or non-fabric). The potential dermal TCPP exposure rate for an adult via direct contact with the car seat during the average daily contact time (1.3 h), which was the highest value assessed in this study, was estimated to be 16,000 ng kg-1 day-1, which is higher than that related to inhalation and dust ingestion reported as significant exposure route of PFRs in previous studies. These facts reveal that dermal exposure associated with direct contact with the product might be an important exposure pathway for PFRs.

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

BACKGROUND: American Indian/Alaska Native (AI/AN) children are disproportionately affected by injuries and deaths related to motor vehicle crashes. We aimed to synthesise published evidence on surveillance methods and interventions implemented in AI/AN communities and analyse characteristics that make them successful in increasing child restraint devices and seat belt use. METHODS: Studies were collected from the PubMed, Scopus, and TRID databases and the CDC Tribal Road Safety website, Community Guide, and Indian Health Service registers. Included studies collected primary data on AI/AN children (0-17) and reported morbidity/mortality outcomes related to child restraint devices or seat belt use. Studies with poor methodological quality, published before 2002, whose data were collected outside of the USA, or were non-English, were excluded. Checklists from the Joanna Briggs Institute were used to assess the risk of bias. In the synthesis of results, studies were grouped by whether a surveillance method or intervention was employed. RESULTS: The final review included 9 studies covering 72 381 participants. Studies conducted surveillance methods, interventions involving law enforcement only and multipronged interventions. Multipronged approaches were most effective by using the distribution of child restraint devices combined with at least some of the following components: educational programmes, media campaigns, enactment/enforcement of child passenger restraint laws, incentive programmes and surveillance. DISCUSSION: Although this review was limited by the number and quality of included studies, available resources suggest that we need multipronged, culturally tailored and sustainable interventions fostered by mutually beneficial and trusting partnerships. Continued investment in AI/AN road safety initiatives is necessary.

Improper Restraint Use in Fatal Pediatric Motor Vehicle Collisions.

PURPOSE: Motor vehicle collisions (MVC) are the second leading cause of death in children and adolescents, but appropriate restraint use remains inadequate. Our previous work shows that about half of pediatric MVC victims presenting to our trauma center were unrestrained. This study evaluates restraint use among children and adolescents who did not survive after MVC. We hypothesize that restraint use is even lower in this population than in pediatric MVC patients who reached our trauma center. METHODS: We reviewed the local Medical Examiner's public records for fatal MVCs involving decedents <19 years old from 2010 to 2021. When restraint use was not documented, local Fire Rescue public records were cross-referenced. Patients were excluded if restraint use was still unknown. Age, demographics, and restraint use were compared using standard statistical methods. RESULTS: Of 199 reviewed cases, 92 met selection criteria. Improper restraint use was documented in 72 patients (78%). Most decedents were White (72% versus 28% Black) and male (74%), with a median age of 17 years [15-18]. Improper restraint use was more common among Black (92% vs 73% White, p = 0.040) and male occupants (85% vs 58% female, p = 0.006). Improper restraint use was lower in the Hispanic population (73%) compared to non-Hispanic individuals (89%), but this difference was not statistically significant (p = 0.090). CONCLUSION: Most pediatric patients who die from MVCs in our county are improperly restrained. While male and Black patients are especially high-risk, the overall dismal rates of restraint use in our pediatric population present an opportunity to improve injury prevention measures. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

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

INTRODUCTION: The American Academy of Pediatrics (AAP) guidelines recommend that children ≤12-years-old with height < 145 cm should use safety/booster seats. However, national adherence and clinical outcomes for eligible children involved in motor vehicle collisions (MVCs) are unknown. We hypothesized that children recommended to use safety/booster seats involved in MVCs have a lower rate of serious injuries if a safety/booster seat is used, compared to children without safety/booster seat. METHODS: This retrospective cohort study queried the 2017-2019 Trauma Quality Improvement Program database for patients ≤12-years-old and <145 cm (recommendation for use of safety/booster seat per American Academy of Pediatrics) presenting after MVC. Serious injury was defined by abbreviated injury scale grade ≥3 for any body-region. High-risk MVC was defined by authors in conjunction with definitions provided by the Centers for Disease Control and Prevention and the American College of Surgeons Committee on Trauma. RESULTS: From 8259 cases, 41% used a safety/booster seat. There was no difference in overall rate of serious traumatic injuries or mortality (both p > 0.05) between the safety/booster seat and no safety/booster seat groups. In a subset analysis of high-risk MVCs, the overall use of safety/booster seats was 56%. The rate of serious traumatic injury (53.6% vs. 62.1%, p = 0.017) and operative intervention (15.8% vs. 21.6%, p = 0.039) was lower in the safety/booster seat group compared to the no safety/booster seat group. CONCLUSIONS: Despite AAP guidelines, less than half of recommended children in our study population presenting to a trauma center after MVC used safety/booster seats. Pediatric patients involved in a high-risk MVC suffered more serious injuries and were more likely to require surgical intervention without a safety/booster seat. A public health program to increase adherence to safety/booster seat use within this population appears warranted.

Child Safety Seat‒Use Behavior Among Parents of Newborns: A Trans-Theoretical Model‒Guided Intervention in Shantou, China, 2021.

We evaluated the effect of a trans-theoretical model-based intervention on child safety seat (CSS)‒use behaviors among parents of newborns in Shantou, China. Parents' knowledge, attitude, and self-efficacy scores on CSS use were significantly higher at one, three, and six months after the intervention compared with scores at baseline. Parents' stage of CSS use also advanced as the intervention progressed. The trans-theoretical model‒based intervention and evidence generated from this study may provide guidance for future individualized interventions to improve CSS use. (Am J Public Health. 2023;113(12):1271-1275. https://doi.org/10.2105/AJPH.2023.307415).

The effect of social media campaign on parental knowledge, attitudes and practices regarding the use of children car seats in the Gulf region.

BACKGROUND: Motor vehicle crashes (MVCs) are the leading cause of child deaths in the Gulf Cooperation Council. This study aimed to investigate the effect of a social media educational campaign on parents' knowledge of child safety seats. METHODS: We conducted a pre-post interventional study as an online educational module in Arabic and English. The module link was shared on social media and was accompanied by a pre-post survey that included questions about demographics, knowledge, and practices of car seat use. RESULTS: A total of 303 participants completed the campaign, with 23.8% fathers and 76.2% mothers answered the survey. The majority of participants were from Saudi Arabia (95.7%), while 4.3% were from other Gulf Cooperation Council (GCC) countries. Most parents agreed on the importance of organizing awareness campaigns and having a law to enforce the use of car seats. The pre-survey mean knowledge score was 11.64, which significantly increased to 13.1 in the post-survey (p < 0.001). CONCLUSIONS: The intervention of the educational campaign through social media resulted in a significant increase in parents' knowledge and awareness of the importance of using car seats correctly. This study highlights the potential effectiveness of social media campaigns in improving parents' knowledge and awareness of child safety seats.

Differences in participant characteristics and observed child restraint use between population-based and restraint fitting service samples.

OBJECTIVE: To compare characteristics and restraint use between a population-based and fitting service sample of child restraint users. METHOD: Characteristics of the two samples were compared using chi-squared tests. Differences in errors in restraint use observed in the two samples were modeled using logistic regression. RESULTS: There were significant differences in child age (p < 0.001), and restraint types (p < 0.001) between the two samples, with more younger children in the fitting service sample. Controlling for differences in restraint type, the odds that adult participants were female were 61% less in the fitting service sample than in the population-based sample (OR 0.39, 95%CI 0.21-0.71). The odds that adult participants perceived a large risk associated with restraint misuse (OR 3.62, 95%CI 1.33-9.84), had a household income in the highest bracket (OR 3.89, 95%CI 1.20-12.62) and were living in areas of highest socioeconomic advantage (OR 2.72, 95%CI 1.22-6.06) were approximately three times higher in the fitting service sample. Overall, more participants had errors in restraint use in the population-based sample (p = 0.021). However, after controlling for restraint type, securing errors were three times more likely (OR 3.34, 95%CI 1.12-10.2), and serious installation errors were almost twice as likely (OR 1.91, 95% CI 1.09-3.39) in the fitting service sample. CONCLUSIONS: While less resource intensive, convenience and/or fitting service samples may be less representative than population-based samples. Given the need for efficiency, methods that combine randomized population-based invitations to participate in restraint fitting check day events across geographically representative areas may be useful for ongoing surveillance of child restraint use.

Factors associated with booster seat use among Indigenous peoples in Canada.

OBJECTIVE: Booster seat use among the general population remains relatively low, despite their effectiveness in preventing injury among children when involved in motor vehicle collisions. Given the prevention of injuries that booster seats provide, understanding the factors that hinder or facilitate the use of these seats is critical, particularly in communities that are often overlooked when conducting general population studies. To date, no studies have examined the prevalence and predictors of booster seat use among Indigenous peoples in Canada. The purpose of this study was to examine the use of booster seat use among Indigenous peoples across Canada and the factors that impact their use. METHODS: Data were collected from a survey of participants from First Nations communities and organizations serving Indigenous peoples nationwide. Hypotheses arising from known predictors of booster seat use across the general population were tested using logistic regression models. RESULTS: The strongest predictor of booster seat use, even when all other study factors were accounted for, was the reduction of barriers related to the use of booster seats, such as a child's resistance to being placed or staying in the passive safety restraint or a parent, guardian, or other caregiver being unwilling to use or unsure of how to install/setup the booster seat. CONCLUSION: Most Indigenous participants consistently used booster seats to safely secure children being transported in vehicles. However, this compliance rate is well below that of the general population. Accessibility and affordability of child safety restraints and/or children's refusal to use booster seats, as well as having more than 1 child to secure, were identified as mitigating factors. Access to and the affordability of booster seats, coupled with clear and understandable information on how to use them, are critical components to compliance. Raising awareness among Indigenous peoples communities regarding the importance of using booster seats is imperative. To achieve this, Indigenous peoples must lead discussions to ensure that child safety strategies not only are based on research and best practices but are culturally connected and community driven. Through meaningful collaboration, vehicle-related injuries and mortality among Indigenous children can be significantly reduced.

Predictors of parents' use of child restraint systems: Evidence from China.

OBJECTIVE: Child restraint systems (CRS) can significantly lower the chance of child harm and death. Despite the benefit of CRS, their use in developing countries is low. Therefore, examining the factors that affect parents' use of CRS is essential. METHODS: In this study, the associations of demographic characteristics and the exogenous constructs in the health belief model (HBM) and the theory of planned behavior (TPB) with parents' CRS use were investigated with structural equation modeling. RESULTS: Demographic factors alone explained 23.1% of the variance in CRS use. The model's explanatory power increased greatly when exogenous constructs were incorporated from the HBM and TPB. Having a college degree, knowledge about CRS, perceived susceptibility, self-efficacy, and attitude significantly impacted parents' use of CRS. CONCLUSIONS: The use of CRS in China is still low. Much effort should be done to increase the use of CRS in China, including education, and publicity.

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

BACKGROUND: Child restraint systems (CRSs) significantly reduce risk of crash-related injury, however installation and use errors undermine their benefits. The National Highway Traffic Safety Administration (NHTSA) created the Ease of Use (EOU) rating system to help guide consumers and incentivize manufacturers to improve their products. The EOU rating system assigns one to five stars to four CRS features and overall. Our study assessed the relationship between EOU ratings and CRS installation and use errors documented in seat checks conducted by child passenger safety technicians (CPSTs). METHODS: We performed a secondary analysis of data from Safe Kids Illinois seat check records from 2015 through 2019 and EOU ratings from 2008 to 2020. Five types of errors were documented by CPSTs. Study authors (JYL and MLM) used a tiered system to match seat check model numbers to EOU ratings. We calculated chi-square statistics and performed logistic regression analyses to assess for EOU as a predictor of relevant CRS errors (e.g., tether errors for forward-facing CRSs). RESULTS: Our analyses included 2132 seat check observations, of which 217 (10.2%) were exact, 244 (10.5%) were probable, and 1671 (78.4%) were near matches via sorting and web search. Errors were most common for seat belts (70.7%) and least common for recline angle (36.9%). Star ratings for instructions, vehicle installation, and labels were associated with recline angle and seat belt errors. Star ratings for instructions, labels, and securing child were associated with harness errors. CRSs with 4-star and 5-star ratings had lower odds of errors for recline angle (Odds Ratio (OR) 0.62; 95% Confidence Interval (CI): 0.43, 0.89 and OR 0.31; 95% CI: 0.17, 0.56) lower anchors (OR 0.59; 95% CI 0.40, 0.89 and OR 0.38; 95% CI: 0.21, 0.68), and harness (OR 0.56; 95% CI: 0.40, 0.76 and OR 0.19; 95% CI: 0.10, 0.35) when compared with 1 and 2-star CRSs. CONCLUSIONS: This study provides evidence in support of NHTSA's EOU ratings as predictors of some CRS installation and use errors among caregivers who obtain seat checks. A higher star rating may be helpful for caregivers when choosing a CRS that will yield lower installation errors.

Child occupant safety in unconventional seating for vehicles with automated driving systems.

The objective of this study was to use computational models to study how unconventional seating positions and orientations in vehicles with Automated Driving System (ADS) may affect occupant response metrics of children with various restraint conditions. A literature review was first conducted to frame a simulation plan, including selections of surrogate ADS-equipped vehicles, potential seating arrangements, impact scenarios, anthropomorphic test device (ATD) models, and child restraint system (CRS) models that are relevant to the selected ATD models. Due to the lack of impact tests with child ATDs and CRS in farside, oblique, and rear impacts, 17 sled tests were conducted with CRS harness-restrained ATDs and vehicle belt-restrained ATDs in frontal, farside, oblique, and rear impact conditions. The sled tests were then used to validate a set of MADYMO (MAthematical DYnamic MOdels) v7.7 models. A total of 550 simulations were then conducted with four child ATDs and various CRS conditions across a range of conventional and unconventional seating locations and orientations under five impact directions. We did not find major safety concerns with ATDs restrained by harnessed CRSs based on the nature of ATD contacts. Compared with frontal and rear impacts, CRSs may rotate laterally in farside and oblique impacts, which could result in higher head and chest injury measures than frontal due to inertial loading to the CRS, and the larger lateral rotation of the CRS may lead to a contact between the CRS and vehicle interior. The major safety concern for vehicle belt-restrained ATDs (with and without booster) is that they have the potential to contact the seat next to them or the instrument panel behind them in a farside or oblique impact. Unconventional seating does not necessarily create additional safety concerns beyond what we know with the conventional seating. However, due to the orientation of the unconventional seats, the occupants on those seats may be involved in a higher percentage of oblique and rear-oblique impacts relative to their seating orientations than conventional seats, which may be considered in the future safety design process. This is the first study using different child ATDs and CRSs to investigate child occupant responses in a wide range of impact directions and seating orientations. Results from the sled tests and simulations provide a better understanding of child occupant responses in those crash conditions, but also identified several limitations of using frontal ATDs in other crash directions.

Frontal-oblique impact sled tests of a rearward-facing child restraint system with and without a support leg.

OBJECTIVE: To quantify the head and neck injury metrics of an anthropometric test device (ATD) in a rearward-facing child restraint system (CRS), with and without a support leg, in frontal-oblique impacts. METHODS: Sled tests using the Federal Motor Vehicle Safety Standards (FMVSS) 213 frontal crash pulse (48 km/h, 23 g) were performed with a simulated Consumer Reports test buck, which comprised a test bench that mimics the rear outboard vehicle seat of a sport utility vehicle (SUV). The test bench was rigidised to increase durability for repeated testing and the seat springs and cushion were replaced every five tests. A force plate was mounted to the floor of the test buck directly in front of the test bench to measure support leg peak reaction force. The test buck was rotated 30° and 60° relative to the longitudinal axis of the sled deck to represent frontal-oblique impacts. The door surrogate from the FMVSS 213a side impact test was rigidly attached to the sled deck adjacent to the test bench. The 18-month-old Q-Series (Q1.5) ATD was seated in a rearward-facing infant CRS, which was attached to the test bench with either rigid lower anchors or a three-point seatbelt. The rearward-facing infant CRS was tested with and without a support leg. Conductive foil was attached to the upper edge of the door panel and a strip of conductive foil was attached to the top of the ATD head so that a voltage signal quantified contact with the door panel. A new CRS was used for each test. A repeat test was performed for each condition for a total of 16 tests. DATA SOURCES: Resultant linear head acceleration 3 ms clip; head injury criterion 15 ms (HIC15); peak neck tensile force; peak neck flexion moment; potential difference between the ATD head and the door panel; support leg peak reaction force. RESULTS: The presence of a support leg significantly reduced head injury metrics (p < 0.001) and peak neck tensile force (p = 0.004) compared to tests without a support leg. Rigid lower anchors were associated with significant reductions in head injury metrics and peak neck flexion moment (p < 0.001) compared to tests that attached the CRS with the seatbelt. The 60° frontal-oblique tests had significantly elevated head injury metrics (p < 0.01) compared to the 30° frontal-oblique tests. No ATD head contact with the door was observed for 30° frontal-oblique tests. The ATD head contacted the door panel in the 60° frontal-oblique tests when the CRS was tested without the support leg. Average support leg peak reaction forces ranged from 2167 to 4160 N. The 30° frontal-oblique sled tests had significantly higher support leg peak reaction forces (p < 0.001) compared to the 60° frontal-oblique sled tests. CONCLUSIONS: The findings of the current study add to the growing body of evidence regarding the protective benefits of CRS models with a support leg and rigid lower anchors.

Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm.

OBJECTIVE: To study the association between discontinuing predischarge car seat tolerance screening (CSTS) with 30-day postdischarge adverse outcomes in infants born preterm. STUDY DESIGN: Retrospective cohort study involving all infants born preterm from 2010 through 2021 who survived to discharge to home in a 14-hospital integrated health care system. The exposure was discontinuation of CSTS. The primary outcome was a composite rate of death, 911 call-triggered transports, or readmissions associated with diagnostic codes of respiratory disorders, apnea, apparent life-threatening event, or brief resolved unexplained events within 30 days of discharge. Outcomes of infants born in the periods of CSTS and after discontinuation were compared. RESULTS: Twelve of 14 hospitals initially utilized CSTS and contributed patients to the CSTS period; 71.4% of neonatal intensive care unit (NICU) patients and 26.9% of non-NICU infants were screened. All hospitals participated in the discontinuation period; 0.1% was screened. Rates of the unadjusted primary outcome were 1.02% in infants in the CSTS period (n = 21 122) and 1.06% after discontinuation (n = 20 142) (P = .76). The aOR (95% CI) was 0.95 (0.75, 1.19). Statistically insignificant differences between periods were observed in components of the primary outcome, gestational age strata, NICU admission status groups, and other secondary analyses. CONCLUSIONS: Discontinuation of CSTS in a large integrated health care network was not associated with a change in 30-day postdischarge adverse outcomes. CSTS's value as a standard predischarge assessment deserves further evaluation.

Standardizing Child Passenger Safety Screening in the Emergency Department: A Quality Improvement Study.

BACKGROUND: Motor vehicle collisions remain a leading cause of death and injury in children in the United States. Our Level I trauma center found that 53% of children ages 1-19 years are improperly restrained or unrestrained. Our center employs a Pediatric Injury Prevention Coalition with nationally certified child passenger safety technicians who are active in the community yet remain underutilized in the clinical setting. OBJECTIVE: The purpose of the quality improvement project was to standardize child passenger safety screening in the emergency department to increase referrals to a Pediatric Injury Prevention Coalition. METHODS: This quality improvement project utilized a pre-/postdesign of data collected before and after implementing the child passenger safety bundle. Using the Plan-Do-Study-Act model, organizational change processes were identified, and quality improvement interventions implemented from March to May 2022. RESULTS: The total number of families referred was 199, representing 230 children, which was 3.8% of the eligible population. A significant relationship was found between child passenger safety screening and referral to the Pediatric Injury Prevention Coalition in 2019 and 2021, χ2 (1, n = 230) = 239.98, p < .001, and χ2 (1, n = 230) = 240.78, p < .001, respectively. Forty-one percent of the referred families established contact with the Pediatric Injury Prevention Coalition. CONCLUSION: Standardizing child passenger safety screening in the emergency department increased referrals to a Pediatric Injury Prevention Coalition and resulted in improved child safety seat distribution and child passenger safety education.

Sociodemographic disparities in child restraint selection and variation in child passenger safety information sources.

PURPOSE: Marginalized and otherwise vulnerable groups remain at higher risk than their counterparts for not having all of their children appropriately restrained during vehicle trips. Little is known about potential sources of these disparities, however a commonly theorized factor has been where caregivers find or obtain information (i.e., their information sources). The objective of this study was to: (1) characterize caregivers' actual and preferred sources of information related to child passenger safety information, overall and within sociodemographic groups; and (2) determine if, and if so how, sources impact appropriate child restraint use (i.e., child/seat fit). METHODS: We conducted an online, cross-sectional survey of US caregivers. Caregivers answered questions about themselves, their child(ren), their child(ren)'s restraint use during trips, and their information sources to learn which seat their child should be using. We used Fisher's exact and Pearson chi-square tests to compare used and preferred sources of information across caregiver demographics (age, education, race/ethnicity), as well as to determine whether information sources were associated with caregivers' appropriate child restraint use. RESULTS: A total of 1,302 caregivers from 36 states with 2,092 children completed the survey. The majority (91%) of children were appropriately restrained. More caregivers from marginalized and otherwise vulnerable groups had children inappropriately restrained when compared with their counterparts. We identified multiple differences in both used and preferred information sources by caregivers' age, race/ethnicity, and education level. In addition, we found a trend that caregivers from populations with higher rates of inappropriate use seemingly used fewer information sources. Ultimately, information sources were not associated with appropriate restraint use; however, within vulnerable populations, almost all caregivers had all of their children appropriately restrained if they had used a Child Passenger Safety Technician (CPST)/Inspection Station or their Pediatrician. CONCLUSION: Our findings reiterate calls for more tailored interventions and efforts to combat widening disparities in child restraint use and crash outcomes and suggest one promising method may be providing more access to child passenger safety experts. Future studies must untangle the likely complex relationship between information sources and appropriate/accurate child restraint use.

The effect of reclined seatback angles on the motion of booster-seated children during lateral-oblique low-acceleration impacts.

Belt-positioning boosters (BPB) may prevent submarining in novel seating configurations such as seats with reclined seatbacks. However, several knowledge gaps in the motion of reclined child occupants remain as previous reclined child studies only examined responses of a child anthropomorphic test device (ATD) and the PIPER finite element (FE) model in frontal impacts. The aim of this study is to investigate the effect of reclined seatback angles and two types of BPBs on the motion of child volunteer occupants in low-acceleration far-side lateral-oblique impacts. Six healthy children (3 males, 3 females, 6-8 years, seated height: 66±3.2 cm, weight: 25.2±3.2 kg) were seated on two types of low-back BPB (standard and lightweight) on a vehicle seat and restrained by a 3-point simulated-integrated seatbelt on a low-acceleration sled. The sled exposed the participants to a low-speed lateral-oblique (80° from frontal) pulse (2 g). Three seatback recline angles (25°, 45°, 60° from vertical) with two BPB (standard and lightweight) were tested. A 10-camera 3D-motion-capture system (Natural Point Inc.) was used to capture peak lateral head and trunk displacements and forward knee-head distance. Three seat-belt load cells (Denton ATD Inc) captured peak seatbelt loads. Electromyography (EMG, Delsys Inc) recorded muscle activation. Repeated Measure 2-way ANOVAs were performed to evaluate the effect of seatback recline angle and BPB on kinematics. Tukey's post-hoc test for pairwise comparisons was used. P-level was set to 0.05. Peak lateral head and trunk displacement decreased with the increasing seatback recline angle (p < 0.005, p < 0.001, respectively). Lateral peak head displacement was greater in the 25° compared to the 60° condition (p < 0.002) and in the 45° condition compared to the 60° condition (p < 0.04). Lateral peak trunk displacement was greater in the 25° condition than the 45° condition (p < 0.009) and the 60° condition (p < 0.001), and in the 45° condition than the 60° condition (p < 0.03). Overall peak lateral head and trunk displacements and knee-head forward distance were slightly greater in the standard than the lightweight BPB (p < 0.04), however these differences between BPBs were small (∼10 mm). Shoulder belt peak load decreased as the reclined seatback angle increased (p < 0.03): the shoulder belt peak load was statistically greater in the 25° condition than the 60° condition (p < 0.02). Muscle activation from the neck, upper trunk, and lower legs showed great activation. Neck muscles activation increased with the increase in seatback recline angle. Thighs, upper arms, and abdominal muscles showed small activation and no effect of conditions. Child volunteers showed decreased displacement suggesting that reclined seatbacks placed the booster-seated children in a more favorable position within the shoulder belt in a low-acceleration lateral-oblique impact, compared to nominal seatback angles. BPB type seemed to minimally influence the children's motion: the small differences found may have been due to the slight difference in heights between the two BPBs. Future research with more severe pulses is needed to better understand reclined children's motion in far-side lateral-oblique impacts.

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

BACKGROUND: Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC. METHODS: A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint. RESULTS: Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different. DISCUSSION: African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.