| | Showing (motor vehicle) restraint: a primer for emergency physiciansAbstract In 2000, 1,668 child occupants under the age of 14 died in motor vehicle crashes and nearly 250,000 children were injured. When used correctly, child safety seats can dramatically reduce a child’s risk of death and serious injury in a motor vehicle crash. Emergency physicians have a unique opportunity to counsel parents and caregivers and provide recommendations on the appropriate restraint for their children as the majority of children in crashes who seek care are treated in emergency departments. The recommendations for child occupant protection are updated regularly. This paper will provide an overview of the current recommendations for restraining children in motor vehicles and identify sources for up to date information for physicians and families.
NEARLY HALF OF UNINTENTIONAL INJURY deaths to children are motor vehicle related. In fact, motor vehicle crashes are the leading cause of death in children between the ages of 1 and 14.1 In 2000, 1,668 child occupants under the age of 14 died in motor vehicle crashes and nearly 250,000 children were injured. More than half (56%) of children who were killed in crashes were unrestrained.2 The appropriate and correct use of child safety seats is essential and reduces a child’s risk of death in a crash by 71%.3 Between 1993 and 2000, an estimated 2,472 young lives were saved by child safety seat systems; 316 lives were saved in 2000 alone.2
A visit to the emergency department (ED) following a motor vehicle crash should be considered a teachable moment. A recent study demonstrated that the ED can be utilized to provide brief counseling to change injury-related risk behaviors.4 Patients may be particularly apt to change their behavior following a traumatic event such as a motor vehicle crash, and because many patients look to their physicians for guidance, emergency physicians should take advantage of this unique opportunity to educate parents about the proper child safety seat for their patients. This report describes a characteristic case of a young child inappropriately restrained for his age, and provides a review of the current literature on child occupant protection.
Exemplar case  A 4-year-old male (104 cm, 19 kg) was traveling in the center rear seat of a four-door sedan during daylight hours when the vehicle crossed over the centerline of a four-lane asphalt roadway and was struck on the front plane, slightly left of center, by a two-door coupe. The vehicle was driven by a restrained adult male. The child was restrained using the available lap belt, and his 2-year-old sibling (91 cm, 13 kg) was in the left rear seat in a forward facing child safety seat. The impact was serious, as judged by the Delta V, or change in velocity, of the vehicle (23.3 miles per hour). Delta V is a widely accepted measure of crash severity. The 4-year-old was transported via ambulance to a Level 1 Trauma Center. On initial examination, he was alert and oriented (Glasgow Coma score = 15), and was complaining of abdominal pain. A physical examination revealed a temperature of 98°F, pulse 100, respirations 20, and blood pressure of 92/60 mm Hg. Ecchymoses were present on his forehead and across the lower abdomen, and he was tender in the left upper quadrant of the abdomen. The remainder of his physical examination and trauma radiographs were normal, including a normal neurologic examination. A contrast-enhanced computed tomography (CT) scan was performed of the abdomen and pelvis, and revealed extensive thickening of the small bowel wall, a small amount of free fluid in the right paracolic gutter, and a small, grade 1 laceration of the left lobe of the liver. Initial laboratory findings included: hemoglobin of 11.9 G/dl, serum glutamate oxaloacetate transaminase of 52 mg/dl, serum glutamate pyruvate transaminase of 33 mg/dl, and amylase of 74 mg/dl. The remainder of his laboratory studies—including electrolytes, prothrombin time, and partial prothrombin time—were normal. A nasogastric tube was placed for gastric decompression, and the patient was admitted to the hospital for intravenous hydration and observation. Two hours later, the child continued to complain of abdominal pain and an exploratory laparotomy was performed. At laparotomy, a jejunal perforation was noted, and resection of 6 cm of the jejunum was performed. His postoperative course was unremarkable, and the child was discharged home after a six-day hospital stay. The adult male driver sustained a fracture to his left hip and contusions to his right and left forearm and was hospitalized for 6 days. The 2-year-old male sustained a contusion to his right shoulder and a small abrasion on his forehead above his right eye. He was discharged from the ED. Current child occupant protection recommendations Types of child safety seats Child safety seat design varies and is specific to a child’s age and size. Many parents ask which child safety seat is best for their child. The “best” child safety seat is one that is appropriate for the child’s size, fits the vehicle’s seats and seat belt systems, and is easy for the parents to use properly on every trip. The following discussion identifies various types of child safety seats and summarizes the current recommendations for infants and older children (Table 1). Restraining infants Most infants are safest in a motor vehicle when facing the rear of the vehicle (see section on car beds for information about premature infants). The majority of motor vehicle crashes are frontal impacts. In a frontal crash, the back of the rear-facing child safety seat supports the child’s head, neck, and back. The National Highway Traffic Safety Administration (NHTSA) and the American Academy of Pediatrics (AAP) recommend that children ride facing the rear of the vehicle until they reach both at least 1 year of age and 20 pounds (9 kg).5 This guideline was based on developmental considerations that put children at risk for spinal cord injury, including incomplete vertebral ossification and excessive ligamentous laxity. Currently, there are child safety seats available that can be used rear-facing until a child weighs between 30 and 35 pounds (13.5 kg). Parents should be encouraged to keep their children facing the rear of the vehicle for as long as possible while following the manufacturer’s instructions with their child safety seat. Rear-facing infants should ride semi-reclined according to the safety seat instruction manual but no more than a 45° angle from vertical to keep the child’s airway patent during a car ride. This is particularly important for newborn babies (see section on car beds for information about premature infants). Seating the newborn in a position that is too upright could cause the head to pitch forward and potentially obstruct the airway. Some parents have difficulty installing the child seat at this angle because most vehicle seats are tilted toward the rear of the vehicle, making the proper angle difficult to achieve. A tightly rolled towel or blanket placed under the foot end of the child safety seat at the bend of the vehicle seat may help parents achieve the correct angle.6 After six to eight months, most babies are able to sit facing the rear at a more upright angle, which is more protective in a crash and may help achieve a tight installation.7 Infant-only child safety seats Infant-only seats can be used for most children under 20 to 22 pounds (9-10 kg), depending on the manufacturer, and should be installed facing the rear of the vehicle (Fig 1). These seats are relatively small and light. Another advantage of this type of seat is that many infant-only seats come with a detachable base that can be installed in the vehicle. The infant carrier can then be removed with the child in it for easy transport. However, because these seats are only used for children less than 20 to 22 pounds, a child often outgrows this seat before he or she may be safely turned forward-facing, necessitating the use of a larger capacity rear-facing seat (see convertible child safety seats below). Convertible child safety seats Convertible child safety seats can be used both forward-facing and rear-facing and may be a more economical option because they can be used from birth up to 40 pounds (18 kg) (Fig 2). These seats are generally larger and heavier than infant-only seats. Convertible seats can be turned forward-facing when a child reaches at least 1 year of age and 20 pounds (9 kg). When the seat is turned forward-facing, a change is often required in the threading of the shoulder straps and the vehicle seat belt in order to safely secure the child safety seat. For children under 1 year and over 20 pounds, many convertible seats are approved for use rear-facing until the child reaches 30 to 35 pounds (13.5-15.75 kg).8 Although children may face forward at 1 year of age and 20 pounds, it is recommended to keep them rear-facing for as long as possible within the weight and height guidelines for the child safety seat. Car beds A baby born prematurely may need to use a car bed if he or she shows signs of apnea when sitting semi-reclined.9 The AAP recommends that infants born at less than 37 weeks gestation be observed in a semi-reclined position before hospital discharge to evaluate for apnea, bradycardia, and oxygen desaturation. If it is determined that the child cannot ride safely in a semi-reclined position, a side-facing car bed should be used to transport the child. Car beds allow these small infants to travel in a prone or supine position in the car.10 Some car beds can be converted to rear-facing infant-only seats for use when the child can safely sit semi-reclined. Restraining toddlers Although children over 1 year and 20 pounds can be placed forward-facing, they are still too small for the vehicle seat belt. By using a child safety seat, the child is effectively coupled to the vehicle. As a result, the child safety seat prevents ejection from the vehicle. In the event of a crash, a properly used child safety seat distributes the forces of the crash to the strongest parts of the skeleton (the hips, back, and shoulders), thereby reducing crash forces on any particular component of the child’s body. The child safety seat provides “ride down,” extending the time and distance for the child to move during a crash. Finally, child safety seats protect the child’s head, neck, and spinal cord by preventing contact with the inside of the vehicle or with other occupants.7 Children who have reached both 1 year of age and 20 pounds may be restrained in a forward-facing child safety seat in the back seat of the vehicle. As mentioned above, children may be kept rear-facing until they reach the maximum height and weight of the child safety seat according to the manufacturer’s instructions. All convertible and most forward-facing-only child safety seats are recommended for use until the child reaches 40 pounds. Some new products exist, and others may come to market which extend the size range for forward-facing child safety seats to 60 pounds (27 kg) or greater. The manufacturer’s instructions for a particular seat (contained in the instruction manual as well as printed on the seat itself) will display the upper weight limit for use. Using the child safety seat properly Once a parent has purchased the child safety seat, it must be used correctly for maximum protection. When installing a child safety seat, it is important that one consults both the vehicle manufacturer’s instructions as well as the manufacturer’s instructions for the child safety seat itself. To minimize possible injuries, the seat must be installed tightly in the vehicle, and the child must be secured tightly in the seat. Attaching the child safety seat to the vehicle With vehicle seat belts All child safety seats should be installed in the rear seat of the vehicle whenever possible. Child safety seats can be attached to the vehicle either through the vehicle seat belt or a new attachment system called Lower Anchorages and Tethers for Children (LATCH). If the vehicle seat belt is used, it should be routed through the belt path indicated on the child safety seat, and tightened so that the child safety seat does not move more than one inch toward the front of the car or from side to side when pulled at the belt path.11 Incompatibilities between the child safety seat and the vehicle seat often result in a loose installation. In addition, there are several different seat belt systems, latch plate mechanisms, and positions of seat belt anchors that contribute to the difficulty of achieving a tight fit. Many organizations have sought to tabulate combinations of child safety seats and vehicles that result in good compatibility, but the task has proved insurmountable because of the infinite pairings of child safety seat and vehicle type. Unfortunately, the only way to currently identify good compatibility is through trial and error by actually installing a particular seat in a particular vehicle. With LATCH systems A new system of installing child safety seats is found in some new vehicles and child safety seats. The LATCH system is designed to reduce the difficulty associated with installing child safety seats. This system uses dedicated attachment points in the vehicle rather than using the adult safety belt for child safety seat installation (Fig 3). All vehicles manufactured in September 2002 or later are required to have this anchoring system. For a rear-facing child safety seat, there are two points of attachment at the base of the child safety seat. These lower anchors buckle into the vehicle at two attachment points. For forward-facing child safety seats, a third attachment point is used for a tether strap (see below for description of tether straps). There is no need to use the adult seat belt with the child safety seat if the LATCH system is in use. Newer child safety seats are equipped to handle both the new LATCH system and the old attachment system using the adult safety belt.12 Another component of the LATCH system is a tether strap. A tether strap is a strap that is attached to the back of the child safety seat and is anchored to the rear shelf of the back seat of the vehicle, to the floor, to the back of the vehicle seat, or to the ceiling (check the vehicle’s owners manual for specifics). Many vehicles have tether anchor hardware already installed; others must be added by the consumer or the vehicle dealership. Tether straps help to reduce a child’s head excursion, or forward head movement, by securing the back of the child safety seat to the vehicle. This can, in turn, reduce head injury from contact with other structures in the vehicle. All new child safety seats are required to have tether straps as standard equipment, and many older child safety seats can be retrofitted with this option. Placing the child in the seat The harness The correct use of a child safety seat involves both tight installation of the seat in the vehicle and tight harness straps. Child safety seats come in three harness types: the t-shield, the tray shield, and the 5-point harness. While all three harness types meet the same federal motor vehicle safety standards, the 5-point harness typically fits children best, particularly infants. The 5-point harness can be adjusted snugly to the child’s body, better distributing the forces of a crash. It is usually more difficult to get a tight harness fit in a t-shield or tray shield child safety seat because the harness straps are not close to the body. In addition, for infants, the plastic shield often lies too close to the child’s face and neck. The purpose of the harness in any child safety seat is to keep the child restrained inside the seat. For a rear-facing child, the harness straps should be in harness slots that are at or below the child’s shoulders in order to keep the child from “ramping” upward in a frontal collision (see below for details regarding older children). For forward-facing seats, the harness should come out of the uppermost harness slots of the child safety seat, at or above the child’s shoulders. The harness is intended to keep the child low in the seat, and not allow the child’s body to slide forward and upward out of the seat. The harness straps should be very snug against the child’s body. If it is possible to pinch a fold (ie, excess slack) in the strap with one’s fingers, the strap is too loose.7 The chest clip A plastic clip, known as a chest clip or harness retainer clip, is required on many seats to keep the harness in place over the child’s shoulders. The harness should be threaded through the chest clip according to the manufacturer’s instructions and the top of the clip should be placed at armpit level. Frequently, parents do not tighten the harness sufficiently or properly place the chest clip on their child, which can lead to increased movement of the head and trunk in the event of a crash.13 This excessive movement can contribute to additional injuries, particularly head injuries, in a crash. Restraining the older child Children who have outgrown child safety seats (based on the upper weight limit) should be restrained in the rear seats of a vehicle in belt-positioning booster seats, using the lap and shoulder belts. There are two types of belt-positioning booster seats: the high back and the low back, or backless, models (Fig 5). Both are crash tested to meet the same federal motor vehicle safety standards and should be used according to the manufacturer’s recommendations. Booster seats raise the child up so that the lap and shoulder belts fit properly on the child. The lap belt should fit low across the child’s hips or upper thighs and the shoulder belt should cross the center of the child’s shoulder and chest. Children should use booster seats until they can safely use the adult safety belt. Most children do not fit properly in an adult lap and shoulder belt without a booster seat until they are at least 8 years of age. A NHTSA study showed that, in a select number of vehicles, the correct fit was achieved when the child was approximately 4’9” and 80 pounds.14 As this will vary with each child and each vehicle, the following test may be useful to determine if the adult safety belt fits a particular child appropriately.15 With the child sitting all the way against the auto seat back, check whether: (1) the child’s knees can bend comfortably at the edge of the auto seat; (2) the lap belt is as low as possible, touching the thighs; (3) the shoulder belt crosses the shoulder between the neck and the arm; and (4) the child can stay seated in this manner for the whole trip. The behavioral aspect of proper seat belt fit is important. There may be pre-school aged children who fit in an adult safety belt according to the above guidelines but are not mature enough to remain properly seated during the whole trip. For these children, other options need to be explored (Table 2). A second type of booster seat is a shield booster, which is installed in the vehicle with the lap portion of the adult seat belt (Fig 6). Shield boosters are no longer recommended for use by a child of any age by the AAP because they do not provide enough upper body restraint. Shield boosters have a padded shield, as opposed to a harness, to keep the child in place. Shield boosters are certified for use by children between 30 and 40 pounds (13.5-18 kg); however, children in this weight range are more safely restrained in a child safety seat with a harness. Some shield booster seats can be easily converted to low back belt-positioning booster seats by removing the shield according to the manufacturer’s instructions.8 Once children are no longer using child safety seats, more families are choosing extended cab pickup trucks as family vehicles. However, research has shown that the rear seat of an extended cab pickup truck presents unique hazards for children, including a small rear occupant compartment, side-facing jump seats, and the limitation of a lap-only safety belt.16 These vehicles are not optimal for transporting children. Children with special health care needs Children with special health care needs or behavioral problems may need to use special restraint systems for car travel. There are several resources available for parents of children with special needs.17 The AAP provides a “Car Seat Shopping Guide for Children With Special Needs,” that is available for parents and healthcare providers.18 Other resources can be found in Table 2. Injury patterns for children in motor vehicle crashes Fifteen percent of children involved in a motor vehicle crash are injured in some way19 and the risk of significant injury to children under the age of 16 riding in motor vehicles is 1.7%.20 When properly used, child safety seats are extremely effective in reducing fatal injury: 71% for infants and 54% for toddlers in passenger cars.3 In a study of children 2 to 5 years of age, children who were inappropriately restrained in seatbelts were 3.5 times more likely to be injured, particularly with a head injury, than children in a child safety seat or booster seat.21 An understanding of motor vehicle crash injury patterns in children provides clinicians with insight when treating these injuries and provides supporting information to be used in anticipatory guidance. Injury patterns to children in child safety seats A study of 25,774 children 12 through 47 months in age seated in forward-facing child safety seat systems (FFCRS), revealed that only 43 (0.17%) children in FFCRS experienced clinically significant injuries.22 Nearly all (96%) of the injuries were limited to the head, the spine, and the extremities. An in-depth review of these cases revealed that the head and brain injuries were attributed to looseness of the harness and attachment of the FFCRS to the vehicle. With these misuses, increased head excursion and acceleration led to the injuries sustained by these children. These included contact-induced injuries such as skull fractures and brain contusions as well as inertially-induced injuries such as subdural hematomas. Atlanto-occipital distraction in children in FFCRS has been identified previously in high severity crashes.23, 24, 25, 26, 27, 28 These authors described a mechanism where the entire skull-C1-C2 complex is lifted off the torso by separation of vertebrae, which have not yet formed a solid interlocking structure through ossification and geometric changes. The spinal cord is fatally damaged either by extreme stretching or complete transection. Injuries to the lower extremities have been identified as a common injury in children in FFCRS.22, 29 Because the lower extremities of a child in a FFCRS are free to move during a crash event, multiple injury mechanisms may exist. An in-depth review of children in FFCRS sustaining lower extremity fractures suggest that these injuries are caused by impact with the seat in front of the child occupant because of limited initial occupant space or space compromised by intrusion. Injury patterns to children using seat belts A recent study showed that 83% of children between the ages of 3 and 8 who should be using car seats or belt-positioning booster seats are being inappropriately graduated to the adult seat belt.30 Characteristic patterns of injury to children in automobile crashes resulting from lap and lap shoulder belts have been described for many years. These injuries are known as the “seat belt syndrome” and were first identified in 1956 as a constellation of injuries including hip and abdominal contusions (now commonly referred to as the seat belt sign), pelvic (ileal and pubis) fractures, lumbar spine injuries (including subluxations and compression fractures of the bodies of L2 to L4), and intra-abdominal injuries to both solid organs and hollow viscera.31 Two predominant factors have been hypothesized to explain belt-related abdominal visceral injuries: (1) the immaturity of the pediatric pelvis to properly anchor the lap portion of the belt, and (2) the tendency of children to scoot forward in the seat so that their knees break at the seat edge, allowing the lap belt to ride up over the anterior abdominal wall. From this position during rapid deceleration, the belt can cause mesenteric tears and bowel wall contusions because of direct compression between the belt and the spinal column.32 Intestinal perforations are likely caused by a sudden increase in intraluminal pressure, combined with compression of a short segment of bowel by the belt. Improper placement of the seat belt up over the abdominal wall leads to the lumbar spinal fractures known as Chance fractures.33 In this scenario, the fulcrum of crash forces lies at the juncture of the seat belt and abdominal wall. The entire spine is, therefore, posterior to the flexion axis, resulting in high-tension forces on the elements of the spine. This results in avulsion of bony and ligamentous structures of the spine which can occur at any point along the lumbar spine. Recently, head and face injuries were identified as additional consequences of the inappropriate use of seat belts by children for whom the seat belt does not fit properly. Based on a study of children between 2 and 5 years of age involved in crashes, those who were restrained in seat belts were more than four times more likely to sustain a significant head injury than those restrained in child safety seats or booster seats.21 A further study identified facial bone fractures as part of the constellation of injuries related to poor belt fit.34 The mechanism for these head and face injuries in children is related to poor torso restraint when a child is placed in a poorly-fitting shoulder belt. In the event of a crash, the child is more free to move forward and potentially contact structures in the vehicle, such as the back of the seat in front of them, or his/her knees because the shoulder belt cannot properly function to restrain them. Air bags and children Beginning in the mid-1990s, several reports of children being killed by deploying passenger airbags in relatively minor crashes focused attention on the unique needs of children in automotive safety. Airbags were designed to protect unbelted adult male occupants in a crash. Current estimates of the effectiveness of passenger airbags (PAB) suggest that they reduce adult occupant fatalities by 18% in frontal crashes and by 11% in all crashes.35 These same data suggest that PAB increase the risk of death for children under 10 years of age by 34%. For school-aged children, in the vast majority of cases, the mechanisms by which deploying PABs resulted in fatal injuries involved lack of restraint use and pre-impact braking resulting in children being improperly positioned in the deployment path of the PAB.36 For rear-facing infants, the PAB deploys and strikes the back of the infant seat with great force. The energy is transferred from the PAB through the back of the infant seat to the child’s head. Children in rear-facing child safety seats struck by deploying PABs have sustained severe brain injuries and skull fractures from this energy transfer to the brain. Because of this high risk, rear-facing infants should never ride in the front seat of a vehicle with an active PAB. Changes in PAB technology and substantial public education campaigns have resulted in a significant reduction in the number of children killed by PABs.37 However, recent data suggests that a large number of children, 1 out of every 8 children in crashes, continue to ride in the front seat of PAB-equipped vehicles. Among these children “at risk,” 8.5% were actually exposed to a deploying PAB.38 More than half of these children were < 13 years of age and, according to current recommendations, should have been seated in the rear seats.39 Results suggest that restrained children exposed to PABs are twice as likely to sustain moderate to severe injuries than a relevant comparison group of children. Exposure to PABs increases the risk of both minor injuries, including facial and chest abrasions, and more serious injuries, particularly upper extremity fractures. However, fatal PAB-associated injuries to restrained children remain extremely rare.38 In some vehicles where there is no back seat available, on/off switches have been installed for the PABs. On/off switches may also be installed if a child has a medical condition that requires constant monitoring and thus must sit in the front seat with the driver.40 It is important to remember to turn the PAB off when transporting a rear-facing child in the front seat of a vehicle; however, when an adult is riding in the front seat, the PAB should be turned on for maximum protection. If the vehicle does have a back seat with seat belts available, the child is safest riding in the back seat. Occasionally, the recommendation that all children under age 13 should always sit in the rear vehicle seats is not practical because of the number of child passengers and other circumstances. In this case, if an older child must sit in the front seat of a PAB-equipped vehicle, she should ride properly restrained according to her size and age and the vehicle seat should be placed in its rearmost position. This recommendation is applicable to the current fleet of PAB-equipped vehicles. With the advent of recent changes to the federal safety standards governing PABs, vehicle manufacturers are working to develop “smart” air bags that may prove to be safe for some child passengers. It is imperative that those who give advice related to PABs and children remain current as these new technologies are implemented. Some newer model year vehicles are equipped with side PABs in both the front and rear seats. These PABs can provide significant occupant protection to adult passengers in lateral crashes. NHTSA currently cautions that these side PABs may pose an injury risk to children who are lying down or leaning on the door.41 Side PABs vary among vehicles, and as a result, recommendations about children seated next to a side PAB will also vary. In addition, technology for these side PABs is changing rapidly and new designs may be more child-occupant friendly than older designs. Refer to the vehicle owner’s manual for specific instructions. Strategies to address restraint non-use In a recent study of motor vehicle crashes in the US, Edwards42 found that the rate of child restraint use was significantly related to driver restraint use. Children of restrained drivers were more than twice as likely to be restrained than children of unrestrained drivers.42 Parents cite many reasons for the non-use of child safety seats. The most frequently cited reason for non-use of child safety seats is that they are only going to be in the car a short time.44 Other reasons include: the child is uncomfortable, the child complains, and the safety seat is believed, by turn, to be unnecessary, expensive, or inconvenient.44, 45 It is important for children to be restrained both age- and weight-appropriately, and in addition, parents should lead by example and use safety belts when traveling in the car. Seat belt use is continuing to climb across the US, reaching 75% in 2002.43 At the same time, however, booster seat use, although increasing rapidly, is still very low. Data from the Partners for Child Passenger Safety study show that a mere 8% of children between the ages of 4 and 7 are appropriately restrained in a belt-positioning booster seat. A study of parents of booster seat-aged children showed that while knowledge of the benefits and purpose of booster seats is an important issue in promoting booster seat use, it is not the only issue. In particular, when compared to parents who use booster seats to restrain their child, parents who use seatbelts to restrain their children may perceive a lower risk of child-related injury in the event of a motor vehicle crash, may be less aware of child passenger safety issues, and may be less proactive in seeking child passenger safety information. In addition, “negotiability” is not an option among parents who used booster seats to restrain their children; however, it is an alternative among parents who use seat belts to restrain their children.46 Many parents look to the law to guide them in their choice of child restraint.46 All 50 states have primary child restraint laws requiring proper child restraint. Primary enforcement of child restraint laws allows police to stop and cite motorists simply for not having a child properly restrained in the car.43 The majority of these laws generally require the use of a child safety seat only up to about age 4, leaving a gap in child passenger safety laws, allowing young school age children to ride unprotected or inadequately protected in motor vehicles.46, 47 A movement to upgrade child restraint laws continues to be a focal point of many state injury prevention education and advocacy agencies. As of September 2002, 13 states have amended their statewide child restraint law to require older children to be restrained in a child restraint.48 Role of the emergency physician Parents look to physicians as a resource, and physicians therefore play a key role in education. In particular, emergency physicians counsel parents on many topics relating to injury prevention, safety, and health, and could influence these parents to properly restrain their children on every trip. Although education before a crash is the most important, the role of the emergency physician to assess and educate on appropriate restraint use shortly after the crash is crucial. The field of child passenger safety is constantly changing, and it is essential to have or be able to refer parents to up-to-date information. There are many resources available to get the most current information on child passenger safety (Table 2). With over 22,000 certified National Child Passenger Safety Technicians and Instructors, there are numerous opportunities for parents to access one-on-one education on appropriate child safety seat use and installation. Physicians can also spearhead an effort in their affiliated hospitals to ensure that children are discharged safely. Some hospitals have undertaken efforts to provide their patients or those in their community with child safety seats and booster seats at low or no cost. Part of this effort may also include demonstrating the proper seat for the child as well as the proper fit of the child safety seat in the caregiver’s vehicle. Depending on the resources of the institution, actual hands-on installation by a trained child passenger safety expert may not be feasible; however, efforts should be made to refer the family to local resources that can provide this service. The NHTSA49, 50 and the National Safe Kids Campaign51 can often suggest local experts and resources. At a bare minimum, discharge planning is a teachable moment and an opportunity for emergency physicians to reinforce messages about the importance of appropriate restraint of children. The simple message of “buckle up” is not enough. For optimal protection in a motor vehicle, a child must use an age- and weight-appropriate restraint correctly on every trip. Exemplar case reprise Consider the case presented at the beginning of this review. Rear seating and restraint were not enough to prevent serious injury. Inappropriate use of a lap belt by a young child led to a liver laceration and a jejunal perforation requiring surgery and a prolonged hospital stay. His 2-year-old sibling, appropriately restrained in a child safety seat, sustained only minor injuries. When advising parents and caregivers about restraining their child in a motor vehicle, the message should contain four important points: (1) that children should be restrained on every trip, even if it is a short one; (2) that children under the age of 13 should be seated in the back seat; (3) that children should be riding in the appropriate restraint for their size; and (4) that the restraint should be used correctly. Figure 5 Acknowledgements We thank the State Farm Insurance Companies for their support of the Partners for Child Passenger Safety. References 1.
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. a TraumaLink, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA b The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA  Address reprint requests to Kristy B. Arbogast, PhD, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, 3535 TraumaLink, 10th Floor, Philadelphia, PA 19104 USA
PII: S1522-8401(03)00017-X doi:10.1016/S1522-8401(03)00017-X © 2003 Elsevier Inc. All rights reserved. | |
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