Evaluating Child Passenger Restraint Use Education.

BACKGROUND: Despite recommendations and laws for child restraint use in motor vehicles, evidence of low restraint use remains, and there is a lack of evidence addressing the effectiveness of restraint use education. OBJECTIVE: This project aims to measure the impact of an education initiative on child passenger restraint use. METHODS: This pre- and postintervention study was conducted in six elementary schools in a Southwestern U.S. metropolitan area over 5 months from October 2022 to March 2023. Motor vehicle restraint use was collected from occupants arriving at elementary schools during the morning drop-off times. Participants were provided one-on-one education regarding child passenger safety guidelines and state laws. Comparison data were collected 1-3 weeks later at the same schools to evaluate the education provided. RESULTS: A total of 1,671 occupants in 612 vehicles were observed across six schools, with 343 adults and 553 children preintervention and 306 adults and 469 children postintervention. Overall restraint adherence in children improved postintervention from 42.3% to 56.1%, a 32.6% increase (p = < .001). In the primary age group of 4-8 years, restraint adherence improved postintervention from 34.8% to 54.2%, a 55.8% increase (p = <.001). CONCLUSIONS: The study results demonstrate that one-on-one education increases child passenger restraint use.

Frontal Crash Injury Metrics Are Below Mandated Limits for a Spica Casted Child Dummy in Currently Available Restraints.

BACKGROUND: There is a paucity of data defining safe transport protocols for children treated with hip spica casting. Although restraint devices for casted children are available, all federally mandated testing uses a noncasted anthropomorphic test device (ATD or crash dummy). The purpose of this study was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD to determine injury risk to the head, cervical spine, chest, and pelvis. METHODS: Using a 3-year-old ATD, dynamic crash sled tests simulating frontal crash were performed in accordance with government safety standards. The ATD was casted in a double-leg spica and the following restraint devices were tested: a seat designed for spica casted children, a restraint vest-harness, a traditional booster seat, and 2 traditional forward-facing car seats. RESULTS: Although the presence of the cast increased many of the injury metrics measured, all seats passed current federal guidelines for the head and chest. No single seat performed best in all metrics. The greatest magnitude of neck loading and second-highest head injury criterion values were observed for the booster seat. The vest-harness produced the highest head injury criterion and the chest compression exceeded proposed federal limits. CONCLUSIONS: The results suggest safe transport in commercially available seats is possible with the child properly restrained in a correctly fitting seat. However, parents should not assume a child restraint system is appropriate for use just based on fit as, for example, seats with harnesses outperformed an easy to fit booster seat. CLINICAL RELEVANCE: Each child and the position of the child's cast are unique and discharge planning involves consideration of safe transportation. Although this study suggests several seats used to transport spica casted children pass the federal head and chest injury prevention requirements, it is important to recognize that some children may still require emergency vehicle transport.

Evaluation of an After-Hours Child Passenger Safety Resource Guide.

Motor vehicle crashes are a leading cause of unintentional injury deaths for children in the United States. Child safety seats are effective in reducing the rate and severity of injury for children. Families seen in an emergency department (ED) outside of injury prevention (IP) operational hours may not have the same opportunity to obtain a child safety seat due to the unavailability of IP resources. This study evaluated the effectiveness of a resource guide that assists the ED staff to screen and provide the appropriate child safety seat. Two retrospective cohort analyses were conducted to assess the following: (1) patients seen in the ED who were eligible to be screened through the resource guide; and (2) patients who were screened and received a restraint system through the resource guide. Records for both cohorts were reviewed from May 1, 2015, to February 29, 2016. Descriptive statistics were used to describe each cohort. In Cohort 1, 10.6% of the 113 patients meeting criteria were screened for a restraint system. In Cohort 2, 20 patients received a restraint system through the resource guide and 90% of these received the appropriate restraint system for their age and weight. Our results demonstrate the need for an algorithm to increase consistency of the resource guide's utilization. Algorithm development to identify screening candidates, further refinement of the guide's restraint identification process, and staff training may improve this tool to ensure that all patients, despite the availability of IP staff, are screened for the appropriate child safety seat.

Quality of harness fit for normal and low birthweight infants observed among newborns in infant car seats.

INTRODUCTION: Child restraint fit is important for crash protection. For newborns, standards universally require a rear-facing restraint and some upper limit on size, but historically there has been no specification of a lower design limit and there is concern over whether low birthweight infants (LBW) are adequately restrained. The aim of this study was to determine the quality of harness fit for newborns of low and normal weight in a range of modern child restraints. METHODS: A convenience sample of infants (1.657-4.455 kg) were recruited from the postnatal ward and special care nursery <1 week from discharge. Infants (n=84) were assessed for harness fit in rear-facing-only restraints, convertible rear/forward restraints and a subset were assessed in a restraint specifically designed to accommodate LBW infants. Measures of harness fit were based on shoulder strap, crotch strap and buckle positioning. RESULTS: Less than 20% of infants achieved good harness fit, regardless of whether they were categorised as low (<2.5 kg) or normal weight. Rear-facing-only restraints were less likely to provide good fit than convertible restraints, in all measures of fit other than shoulder strap width. The proportions of infants achieving good fit were greater in the restraint designed for LBW infants than other restraint types. CONCLUSION: Poor accommodation continues to be a problem for LBW infants but is rectified in specifically designed restraints. Better specification of harness configuration for all rearward-facing restraints may be required to ensure adequate accommodation of normal birthweight infants.

Car Seat Safety: Typologies of Protective Health and Safety Behaviors for Mothers in West Virginia.

Objective Parenting practices differ for a variety of reasons, and three parenting behaviors may be directly influenced by research, policy, and overall parenting trends: car safety seats, vaccination, and breastfeeding. Mothers were categorized in terms of their rear-facing car safety seat utilization and its relationship to other parental health and safety behaviors. Methods A cross-sectional, online survey of mothers of children under 3 years of age (n = 124) was conducted. Items assessed mother's perceived risk and worry about being in an automobile accident, as well as duration of rear-facing car seat utilization. A cluster analysis based on these variables was performed to differentiate the sample into four distinct groups. Outcomes were knowledge of car safety seats, breastfeeding duration, and adherence to vaccination schedules. Results The sample was predominantly White, had an average age of 32 years, had breastfed, and had at least some college education. Two groups of interest had (Group 1) long duration of rear-facing use with low perceived risk and worry and (Group 2) short use with high perceived risk and worry. Fisher's Exact test indicated Group 1 had higher knowledge of airbag use with car seats (p = 0.035), lower intentions to use the recommended vaccinations schedule (p = 0.005), and were more likely to breastfeed (p = 0.044) for longer duration (p = 0.012). Conclusion Propensity for mothers' risk aversion may be the crucial element in both an appropriate duration of rear-facing car safety seat use and refusal of recommended vaccination schedule.

The Effects of Restraint Type on Pattern of Spine Injury in Children.

INTRODUCTION: While the use of vehicular restraints has reduced the morbidity and mortality of children involved in motor vehicle collisions (MVC), to our knowledge, no study has examined the relationship between restraint type and patterns of pediatric spinal injuries. The purpose of this study is to evaluate this association and review the spinal injuries sustained in children involved in MVC. METHODS: We completed an IRB-approved, retrospective chart review of all patients below 10 years of age presenting to a level 1 pediatric trauma hospital with spine injuries sustained in MVC from 2003 to 2011. We reviewed prehospital data, medical records, and radiographs to establish the restraint type and characterize the spinal injuries sustained. RESULTS: A total of 97 patients were identified with spinal trauma secondary to MVC with appropriate and documentation of restraint type. Results are reported regardless of whether the restraint employed was properly used per established guidelines. Car seat/booster seat (C/B) patients sustained significantly higher rates of cervical spine (62%) and ligamentous (62%) injuries than the 2-point (2P) (10%) and 3-point (3P) restraint (24%) groups (P<0.001). Two-point and 3P restraint use was associated with significantly higher rates of thoracolumbar injuries (67% and 62%, respectively) than the C/B (14%) and unrestrained (0%) groups (P<0.001). Two-point and 3P passengers also had a higher rate of flexion-distraction injuries (P<0.001). Patients in the unrestrained group sustained a significantly higher rate of cervical spine (80%) and ligamentous (40%) injuries than the 2P and 3P groups (P<0.001). No differences were found in the type or location of injury between the 2P and 3P groups. Significant differences in proper restraint use were identified between age groups with younger children demonstrating higher rates of proper restraint use (P<0.01). CONCLUSIONS: Two-point or 3P seatbelt use is associated with lower rates of cervical spine trauma but higher rates of thoracic and lumbar trauma, particularly flexion-distraction injuries, when compared with car or booster seats. Children in C/B and those who are unrestrained sustain high rates of cervical spine injury. LEVEL OF EVIDENCE: Level III-prognostic study.

Program fidelity measures associated with an effective child restraint program: Buckle-Up Safely.

OBJECTIVES: We sought to identify the program fidelity factors associated with successful implementation of the Buckle-Up Safely program, targeting correct use of age-appropriate child car restraints. METHODS: In 2010, we conducted a cluster randomized controlled trial of 830 families with children attending preschools and long day care centers in South West Sydney, New South Wales, Australia. Families received the Buckle-Up Safely program in the intervention arm of the study (13 services). Independent observers assessed the type of restraint and whether it was used correctly. RESULTS: This detailed process evaluation showed that the multifaceted program was implemented with high fidelity. Program protocols were adhered to and messaging was consistently delivered. Results from multilevel and logistic regression analyses show that age-appropriate restraint use was associated with attendance at a parent information session hosted at the center (adjusted odd ratio [AOR]=3.66; 95% confidence interval [CI]=1.61, 8.29) and adversely affected by the child being aged 2 to 3 years (AOR=0.14; 95% CI=0.07, 0.30) or being from a family with more than 2 children (AOR=0.34; 95% CI=0.17, 0.67). CONCLUSIONS: Findings highlight the importance of parents receiving hands-on education regarding the proper use of age-appropriate child restraints.

Are parents following the recommendations for keeping children younger than 2 years rear facing during motor vehicle travel?

PURPOSE: Between 2007 and 2012 there have been several recommendations that infants and toddlers ride in a car safety seat (CSS) rear facing until 2 years of age. This study reports the effect of these recommendations on the observed direction of travel for infants and toddlers transported in motor vehicles between 2007 and 2012. METHODS: This is an observational, cross-sectional survey of drivers transporting children collected at 25 convenience locations selected in Indiana during summer 2007 through 2012. Observations were conducted by Certified Child Passenger Safety Technicians. As drivers completed a written survey, the Certified Child Passenger Safety Technician recorded the vehicle seating location, type of restraint, CSS direction and use of the CSS harness or safety belt as appropriate, and demographic data. The infant and toddler's age and weight were collected. Data from 2007 through 2012 for ages birth through 23 months were compared in order to determine if recommendations impacted observed direction of travel. RESULTS: During the study period, the percent of infants and toddlers (birth through 23 months) observed rear facing in a motor vehicle varied from 44.2% (2007) to 59.1% (2012). For infants (birth through 11 months) observed rear facing, it was 85.1% (2009) to 91.6% (2012). The percent of toddlers (12 months through 23 months) observed rear facing ranged from 3.3% (2008) to 18.2% (2012). CONCLUSIONS: During the study period, the proportion of toddlers rear facing increased approximately 15% (p=0.03). Counselling by primary care providers should continue and be strengthened to increase parent and caregiver awareness of the latest child passenger safety recommendations.

Caregivers' confidence in performing child safety seat installations: what matters most?

BACKGROUND: Although effective when used correctly, child restraint systems (CRS) are commonly misused. Caregivers must make accurate judgements about the quality of their CRS installations, but there is little research on the psychological, technological, or contextual factors that might influence these judgements. METHODS: Seventy-five caregivers were observed installing a CRS into a vehicle and completed self-report surveys measuring risk appraisals, previous utilisation of CRS resources, task difficulty, and confidence that the CRS was installed correctly. RESULTS: Approximately 30% of caregivers installed the CRS inaccurately and insecurely, but reported that it was correctly installed. Predictors of confidence were ease of use (ß=0.47) and exposure to CRS resources (ß=-0.34). Installation errors and CRS security were unrelated to caregivers' confidence. CONCLUSIONS: An interdisciplinary approach is needed to understand factors influencing caregivers' judgements about their installations, optimise channels to connect caregivers to CRS resources, and to design safety technologies in light of these findings.

Impact of errors in age estimates on the classification of proper child occupant restraint use: an observational survey.

BACKGROUND: Proper classification of child occupant restraint use is dependent on the age of the child occupant. Observations of vehicle restraint use involve estimating child age. If estimates of age are incorrect, then a potential for misclassification of restraint use exists. OBJECTIVE: To compare estimated and confirmed child occupant age and calculate the impact of errors in age estimates on the proportion of children classified as properly restrained. METHODS: Observations of restraint use were completed for occupants 0-8 years of age at two health clinics. After initial observation, we approached the driver to confirm the child's age. Each child's restraint use was classified as either compliant or not compliant with state law, based on type of restraint used and based on the child's estimated and confirmed ages. RESULTS: Classification of age categories for child occupants (n=218) was correct in 86.3% of observations. For 48.6%, the confirmed and estimated age matched exactly, and for 98.1%, age matched within ±1 year. Overall, compliant restraint use based on estimated age was 39.4%, and based on confirmed age was 38.5%. In paired comparisons, restraint use based on estimated age versus confirmed age was concordant for more than 95% of children. CONCLUSIONS: The level of accuracy for age estimates was sufficient for making estimates of compliant restraint use. Errors in estimated age resulted in a less than 1 percentage point difference in overall proper restraint use calculations. The results suggest that such observations can be a reliable measure of proper child occupant restraint use.

A qualitative approach using the integrative model of behaviour change to identify intervention strategies to increase optimal child restraint practices among culturally and linguistically diverse families in New South Wales.

OBJECTIVES: To qualitatively explore barriers to optimal child restraint use using the integrative behaviour change model in culturally and linguistically diverse (CALD) communities in New South Wales (NSW), Australia. METHODS: A semi-structured discussion was used to conduct 11 language specific focus groups in Arabic, Assyrian, Cantonese, Mandarin, Vietnamese and Turkish. Translated transcriptions were analysed using the major concepts of the integrative behaviour change model. RESULTS: Restraint use intent among CALD community carers is related to perceived safety of their children and complying with the law. While most participants appreciated the safety benefits of correct and appropriate use, a minority did not. Child restraint legislation may positively influence social norms, and enforcement appears to increase parental self-efficacy. However, concerns over child comfort may negatively influence both norms and self-efficacy. There are clear deficits in knowledge that may act as barriers as well as confusion over best practice in safely transporting children. Large family size, vehicle size and cost appear to be real environmental constraints in CALD communities. CONCLUSION: Determinants of intent and deficits in knowledge in this diverse range of CALD communities in NSW Australia are similar to those reported in other qualitative studies regardless of the population studied. This indicates that key messages should be the same regardless of the target population. However, for CALD communities there is a specific need to ensure access to detailed information through appropriate delivery strategies and languages. Furthermore, practical constraints such as cost of restraints and family size may be particularly important in CALD communities.

Automobile safety in children: a review of North American evidence and recommendations.

In the United States, the rate of vehicle occupant deaths in children aged 1 to 3 years has decreased by over 50% in the past three decades. However, the Centers for Disease Control and Prevention report that motor vehicle crashes remain the leading cause of death in children aged 1 to 17 years. Parental compliance with child safety seats is poor, with up to 99% of children in certain age groups improperly restrained. Epidemiologic data support the proper use of automobile restraint systems to save lives. When appropriate restraint systems (based on age and weight) are used, a significant decrease occurs in the rates of mortality and serious injury. Legislation and public service campaigns can increase awareness regarding appropriate use of automobile restraint systems to decrease pediatric injury and fatality rates. Fluency and awareness, rather than cost, have been found to be the main reasons for improper use of automobile restraint systems; appropriately targeted education programs should continue to be developed. Physicians are optimally poised to educate patients and parents about automobile safety.

Promoting correct car seat use in parents of young children: challenges, recommendations, and implications for health communication.

Injuries involving motor vehicles continue to be the biggest threat to the safety of children. Although child safety seats (CSS) have been established as a central countermeasure in decreasing injury risk, the majority of parents do not use the correct car seat correctly. There are many challenges in promoting correct car seat use, which itself is a complex behavior. To advance this critical protective behavior, the public health community would benefit from clarifying CSS messaging, communicating clearly, and addressing the conflicting recommendations of product use. In this article, we present current challenges in promoting CSS use and draw on health communication and other fields to offer recommendations for future work in this area.

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

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

An observational survey of child car safety practices in private pre-primary and primary schools in two local government areas of Lagos State, Nigeria.

OBJECTIVE: To describe child car safety practices among children aged 0-8 years. Eight schools from two local government areas (LGAs) were selected by simple random sampling. Passenger cars were observed for child seating position and restraint use at each selected school as children were being dropped off in the morning. RESULTS: Observed child restraint use was very low, as was the rate of appropriate restraint for age (10.8% and 4.2%, respectively, in Eti-Osa, and 7.0% and 1.8% in Ikeja). Child restraint use decreased with increasing age group from 25% in those below 1 year, to 12% in those aged 1-3 years, and 7.4% in those aged 4-8 years. A large proportion of restrained passengers were inappropriately restrained in a seatbelt alone. Front seating among observed child passengers was not as high as in studies from similar environments (9.4% and 17.5% in Eti-Osa and Ikeja, respectively). Factors associated with child restraint use were number of child passengers in car, and whether or not the driver wore a seatbelt. Seating position of the child was significantly associated with the relationship of the driver to the child, and driver's gender. CONCLUSION: The level of child restraint use observed in this study is unacceptably low. The relatively low prevalence of front seating while riding in cars should however be further reduced. The study recommends the enactment of specific country legislation on the use of child restraints, accompanied by multifaceted intervention programmes to improve the availability and use of child car safety seats and booster seats.

Restraint of children with additional needs in motor vehicles: knowledge and challenges of paediatric occupational therapists in Victoria, Australia.

AIM: This research project aimed to understand the challenges faced by occupational therapists when making recommendations regarding the restraint of children with additional needs in motor vehicles in Victoria, Australia. METHODS: A cross-sectional survey design was used to explore current practice in relation to the prescription of motor vehicle restraints in Victoria, Australia. An electronic survey was sent to occupational therapists working with children aged from birth to 18 years in early intervention services, hospitals, schools, community services or private practice. RESULTS: Challenges faced by occupational therapists related to a lack of knowledge of relevant standards and legal requirements, issues seating children with behavioural difficulties, families' inability to purchase recommended equipment and constraints as a result of funding issues. CONCLUSION: Further work is required to develop appropriate resources which support occupational therapists to make car seating recommendations for children with additional needs which comply with Australian legal requirements and standards.

Seat belt misuse by a child transported in belt-positioning booster seat with deadly consequences.

Child passenger safety has been a major public health victory, but there is still work to be done. This case presentation is about a 5-year-old boy who placed the shoulder portion of the lap-shoulder seat belt behind his back who was recently killed in a motor vehicle crash. This article reviews what trauma nurses need to know about the latest improvements in child passenger safety practices. Also presented are important resources for trauma nurses to share with families to improve travel safety.

Factors predicting incorrect use of restraints by children travelling in cars: a cluster randomised observational study.

BACKGROUND: The benefits of correctly using size-appropriate restraints for children travelling in cars are well established, and considerable research has focused on the determinants of appropriate restraint choice. There are few studies of the factors associated with incorrect use. Objective To determine predictors of incorrect restraint use by child occupants and how these differ from inappropriate use. METHODS: A stratified multistage cluster sample of child occupants aged 0-10 years in New South Wales, Australia was used. Observation of restraint type and inspection of correctness of use was performed on arrival at schools, childcare centres, and child health clinics. An interview was conducted with the driver. Logistic regression was performed to estimate the effects of parental, family, and other characteristics on the likelihood of moderate or serious incorrect restraint use for restraint classes (rear/forward facing, booster, and seatbelt). RESULTS: Significant factors varied depending on age and restraint class. Older child restraint users (OR per year of age 0.27, 95% CI 0.07 to 0.98) and seatbelt users (OR per year of age 0.54, 95% CI 0.45 to 0.64) were less likely to be incorrectly using their restraints than younger users. Child restraint and booster users from non-English speaking families were more likely to be incorrectly using their restraints. Having more children in the car appeared to reduce incorrect use for booster (OR 0.18, 95% CI 0.06 to 0.57) and seatbelt users (OR 0.39, 95% CI 0.16 to 0.93). CONCLUSIONS: There is a need to reduce incorrect restraint use by both education and improved restraint design. Education aimed at reducing incorrect use may need to be targeted differently to appropriate use programmes, as the predictive factors differ.