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All-terrain vehicles (ATVs) represent a serious and ongoing public health and safety concern for children and adolescents. Survey studies indicate that high proportions of youth ride ATVs in both rural and nonrural populations. The significant human and economic costs of pediatric ATV-related deaths and injuries result from a number of major risk factors that are highly common in pediatric ATV crashes: operating adult-size vehicles, riding with or as passengers, lack of protective equipment, and riding on public roads. Other less well-studied but potentially significant risk factors are speed, riding at night, alcohol use among older teenagers, and lack of training and supervision. Although potentially safer than adult ATVs, youth models present a number of safety concerns that have not been addressed with rigorous study. The most common ATV crash mechanism is a noncollision event—for example, a rollover. Common injury mechanisms include ejection from the vehicle, resulting in extremity and head injuries, and being pinned or crushed by the vehicle with resulting multiorgan trauma and/or compression asphyxia. Traumatic brain injury and multisystem trauma are the 2 most common causes of death and disabling injury. Taken together, a large multidecade body of evidence is the basis for the American Academy of Pediatrics policy statement recommendation that no child younger than 16 years of age ride on an ATV. Because children continue to be allowed to ride these vehicles, however, efforts to prevent pediatric ATV-related deaths and injuries require multipronged strategies, including education of both youth and parents, safety-based engineering, and enforcement of evidence-based safety laws.

OBJECTIVES Although it has been established that smoke alarms have more difficulty awakening children from sleep than adults, no attempt has been previously made to characterize how smoke alarm responsiveness changes with age during childhood. The objective of this study is to evaluate the age-dependent responsiveness to various smoke alarm signals among children 5 to 12 years old. METHODS The effect of age on children’s response to 4 types of smoke alarms (human voice, hybrid voice-tone, low-frequency tone, and high-frequency tone) was evaluated using combined data from 3 previous studies. RESULTS There were 540 subjects (median age 9 years; 51.7% male). The proportion of children who awakened demonstrated a statistically significant (P < .001) increase of 3.1% to 7.6% for each additional year of age between 5 and 12 years old for the 4 alarm types. Similarly, child age showed a statistically significant (P < .001) effect on the proportion who escaped for each of the 4 alarm types. The proportion of subjects who awakened or escaped did not differ significantly by sex for any of the alarm types. Median time-to-awaken and median time-to-escape decreased with increase in child age for all alarm types. CONCLUSIONS This study demonstrates the substantial influence of child age on the effectiveness of audible smoke alarms during childhood. Among 12-year-olds, only 56.3% escaped within 1 minute (and 67.6% within 2 minutes) to a high-frequency tone. However, a hybrid voice-low-frequency tone alarm is >96% effective at awakening and prompting escape within 1 minute among children 9 years and older.

Participation in youth soccer in the United States continues to increase steadily, with a greater percentage of preadolescent participants than perhaps any other youth sport. Despite the wide-ranging health benefits of participation in organized sports, injuries occur and represent a threat to the health and performance of young athletes. Youth soccer has a greater reported injury rate than many other contact sports, and recent studies suggest that injury rates are increasing. Large increases in the incidence of concussions in youth soccer have been reported, and anterior cruciate ligament injuries remain a significant problem in this sport, particularly among female athletes. Considerable new research has identified a number of modifiable risk factors for lower-extremity injuries and concussion, and several prevention programs have been identified to reduce the risk of injury. Rule enforcement and fair play also serve an important role in reducing the risk of injury among youth soccer participants. This report provides an updated review of the relevant literature as well as recommendations to promote the safe participation of children and adolescents in soccer.

OBJECTIVES: Living in substandard housing may be one factor that increases the risk of fire and burn injuries in low-income urban environments. The purposes of this study are to (1) describe the frequency and characteristics of substandard housing in urban homes with young children and (2) explore the hypothesis that better housing quality is associated with a greater likelihood of having working smoke alarms and safe hot water temperatures. METHODS: A total 246 caregivers of children ages 0 to 7 years were recruited from a pediatric emergency department and a well-child clinic. In-home observations were completed by using 46 items from the Housing and Urban Development’s Housing Quality Standards. RESULTS: Virtually all homes (99%) failed the housing quality measure. Items with the highest failure rates were those related to heating and cooling; walls, ceilings, and floors; and sanitation and safety domains. One working smoke alarm was observed in 82% of the homes, 42% had 1 on every level, and 62% had safe hot water temperatures. For every increase of 1 item in the number of housing quality items passed, the odds of having any working smoke alarm increased by 10%, the odds of having 1 on every level by 18%, and the odds of having safe hot water temperatures by 8%. CONCLUSIONS: Many children may be at heightened risk for fire and scald burns by virtue of their home environment. Stronger collaboration between housing, health care, and injury prevention professionals is urgently needed to maximize opportunities to improve home safety.

Toilet-seat contact dermatitis is a common condition around the world and is reemerging in the United States. It can be easily recognized and treated. However, few practitioners consider this diagnosis, which results in a delay in treatment and often exacerbation of the skin eruption. In the past, exposure to wooden toilet seats and associated varnish, lacquers, and paints led to the development of an allergic contact dermatitis on the buttocks and posterior thighs. In recent years, most public facilities have changed to plastic seats, resulting in a change in the clinical presentation of toilet-seat dermatitis. We present 5 cases of toilet-seat dermatitis in children from the United States and India and review the history, presentation, and clinical course of the disease. Our findings suggest that toilet-seat dermatitis is more common than previously recognized and should be considered in any child with a dermatitis that involves the buttocks and posterior thighs.

OBJECTIVE. The goals were to describe the epidemiologic features of pediatric skating-related injuries sustained from 1993 to 2003 and to compare ice skating–related injuries with roller skating–and in-line skating–related injuries. METHODS. An analysis of pediatric skating-related injury data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission was performed. RESULTS. An estimated 1 235 467 pediatric skating participants presented to hospital emergency departments with injuries between 1993 and 2003. These children had a mean age of 10.9 years (SD: 3.2 years; range: 1–18 years), and 50.0% were male. The most common mechanism of injury was a fall (83.1%). Ice skaters sustained a greater proportion of head injuries (13.3%), compared with roller skaters (4.4%) and in-line skaters (5.0%). Ice skaters also experienced a greater proportion of concussions (4.3%), compared with roller skaters (0.6%) and in-line skaters (0.8%). The proportion of facial injuries among ice skaters was greater than the proportions among roller skaters and in-line skaters. The majority of roller skating–and in-line skating–related injuries were upper-extremity fractures (53.9% and 59.7%, respectively). Children ≤6 years of age experienced a greater proportion of head and facial injuries than did older children in each skating activity. CONCLUSIONS. The epidemiologic features of pediatric ice skating–related injuries differ from those of roller skating–and in-line skating–related injuries. Children should wear helmets during all recreational skating activities, especially ice skating, because of the risk of serious head injuries. Wrist guards should be worn to protect against the common upper-extremity fractures sustained during skating.

Objective. Safe storage of firearms has been recommended as a means of preventing gun-related pediatric injuries, yet few interventions have led to significant improvements in storage practices. This study examined a multifaceted community education campaign to promote safe handgun storage and the campaign's impact on firearm locking and loading practices in households with children.Methods. Beginning in 1997, a safe-storage campaign consisting of television and radio announcements, educational materials, billboards, and discount coupons for lock boxes was conducted in King County, Washington. The campaign evaluation used a quasi-experimental design and compared the intervention site with 9 control counties outside Washington State and west of the Mississippi River. Cross-sectional, random-digit-dial telephone surveys of handgun-owning households with children were conducted in all study counties both before the intervention in 1996 (n = 302) and again in 2001 (n = 255). The main analyses assessed whether greater improvements in household firearm-storage practices occurred between 1996 and 2001 in the intervention, compared with the control, counties. Primary outcomes were based on up to 3 handguns per household and included (1) all stored with trigger locks, lock boxes, or gun safes (formal locking devices), (2) all stored in lock boxes or gun safes, (3) any stored loaded, (4) any stored loaded without a formal locking device, and (5) any stored loaded and not in a lock box or gun safe. Data were also collected on up to 1 long gun per household; long-gun outcomes included (1) stored with a trigger lock or gun safe and (2) stored loaded.Results. Overall, handguns and long guns were generally more likely to be stored locked and less likely to be loaded in 2001 compared with 1996, with these trends seeming to be more consistent in the intervention county. Even so, more than one quarter of households with children and handguns in 2001 failed to store all of their handguns with a formal locking device, and up to 8% continued to possess at least 1 loaded handgun that was not stored with a formal device. The majority of households that stored their handguns with formal devices used lock boxes or gun safes. Storage of handguns in lock boxes or gun safes became more common in both the intervention (adjusted odds ratio [aOR]: 1.71; 95% confidence interval [CI]: 1.03–2.84) and control households (aOR: 1.66; 95% CI: 1.01–2.72) between 1996 and 2001. None of the other measured changes reached statistical significance, such as storing any household handgun loaded (aOR: 0.71; 95% CI: 0.35–1.42 [intervention]; aOR: 1.08; 95% CI: 0.58–2.00 [control]) or keeping any household handgun loaded and not stored in a lock box or gun safe (aOR: 0.59; 95% CI: 0.22–1.55 [intervention]; aOR: 0.67; 95% CI: 0.30–1.49 [control]). Moreover, the intervention county did not experience significantly greater overall improvements in household storage practices for handguns or long guns than did control counties.Conclusions. In both the intervention and control counties, households were more likely to lock all handguns in 2001 compared with 1996. After accounting for temporal trends, this educational campaign, combined with economic incentives to purchase lock boxes, did not seem to significantly change safe storage practices in households with handguns and children. Even if the campaign did result in small improvements in firearm safe storage, simultaneous national and state-specific gun-safety activities or legislative efforts may have drawn increasing attention to gun-related issues in the control counties, thereby making it more difficult to identify effects of our specific handgun storage intervention.

Objective. To assess the effectiveness of an emergency department (ED)-based home safety intervention on caregivers’ behaviors and practices related to home safety.Methods. We conducted a randomized, clinical trial of 96 consecutive caregivers of children who were younger than 5 years and presented to an urban pediatric ED for evaluation of an acute unintentional injury sustained in the home. After completing a structured home safety questionnaire via face-to-face interview, caregivers were randomly assigned to receive either comprehensive home safety education and free safety devices or focused, injury-specific ED discharge instructions. Participants were contacted by telephone 2 months after the initial ED visit for repeat administration of the safety questionnaire. The pretest and posttest questionnaires were scored such that the accrual of points correlated with reporting of safer practices. Scores were then normalized to a 100-point scale. The overall safety score reflected performance on the entire questionnaire, and the 8 category safety scores reflected performance in single areas of home injury prevention (fire, burn, poison, near-drowning, aspiration, cuts/piercings, falls, and safety device use). The main outcome was degree of improvement in safety practices as assessed by improvement in safety scores.Results. The intervention group demonstrated a significantly higher average overall safety score at follow-up than the control group (73.3% ± 8.4% vs 66.8% ±11.1) and significant improvements in poison, cut/piercing, and burns category scores. Caregivers in the intervention group also demonstrated greater improvement in reported use of the distributed safety devices.Conclusions. This educational and device disbursement intervention was effective in improving the home safety practices of caregivers of young children. Moreover, the ED was used effectively to disseminate home injury prevention information.

Objective. Children who have outgrown child safety seats and been placed in adult seat belts are at increased risk for injury. Pediatricians and other advocates have been called on to encourage booster seat use in these children. The objective of this study was to identify barriers to booster seat use and strategies to increase their use. Methods. A qualitative study consisting of focus groups and follow-up in-depth discussions were conducted among parents and/or children to elicit barriers and strategies to appropriate/best practice child restraint system use. Phase I focus groups (parents and children) identified barriers to booster seat use along with children’s self-reported likes and dislikes about booster seats. Phase II focus groups (parents only) identified additional barriers to booster seat use and suggestions for strategies to increase the use of booster seats. In-depth telephone discussions (parents only) were conducted after each phase of focus groups to identify new themes and to explore further previously emerged topics that were not conducive to probing in focus group settings. Results. This study demonstrated that although 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, differences in risk perception, awareness/knowledge, and parenting style were noted when comparing parents of children in booster seats with those whose children were in seat belts. Media campaigns, improved laws, parenting education, and extending the use of child restraints to older ages were among the strategies suggested by parents to increase booster seat use. Conclusions. Anticipatory guidance regarding booster seats may be new for many pediatricians. This article arms pediatricians with insights from parents about their perceptions regarding booster seats and how parents think that the booster seat message can be most effectively delivered. Furthermore, it gives insight into how parents make safety decisions for their children and the important role of children in this decision-making process.

PURPOSE:Car seats should be used to prevent injury or death in children during motor vehicle crashes. When used improperly or for unintended purposes, car seats can place children at risk for injury or death. The objective of this article is to describe patterns of hazardous use of car seats outside the car for infants (METHODS:The National Electronic Injury Surveillance System of the US Consumer Product Safety Commission database was accessed to obtain information regarding car seat–related injuries treated in emergency departments from 2003 to 2007. Injuries sustained during motor vehicle crashes were excluded. Demographic data, type of injury, body location, disposition, injury circumstances, and other pertinent information were extracted and analyzed.RESULTS:An estimated 43 562 car seat–related injuries were treated in emergency departments from 2003 to 2007. This national estimate was based on a weighted sample of 1898 infants. The average age of these infants was 4.07 ± 2.73 months, 62.4% of the injuries occurred in infants younger than 4 months, and 54.4% occurred in boys. Of these injuries, 49.1% occurred at home, 8.4% of the infants had to be hospitalized, and 84.3% of the infants suffered a head injury. The most common mechanisms of injury were infants falling from car seats, car seats falling from elevated surfaces, and car seats overturning on soft surfaces.CONCLUSIONS:Injury-prevention efforts should be focused on eliminating hazardous use of car seats outside the car. Caregivers should be cautioned against the placement of car seats on elevated or soft surfaces.

Information learned during medical training changes frequently with advances in nearly every field of medicine. Now we are asked to learn new advice to give parents and caregivers of infants and young children regarding the safest way for them to ride in a car. Child fatalities and injuries in motor vehicles have been significantly reduced since initiation of occupant-protection measures in the 1970s.1 The combined efforts of the counseling of primary medical care providers, the education and research provided by the National Highway Traffic Safety Administration, the car safety seat manufacturers, and many research facilities, and the support of child passenger safety advocates across the country have been largely responsible for these results. Many challenges remain as we strive to continue to reduce the rates of injury to children on our nation's highways. It is critical to realize that, despite marked improvement in rates of restraint in all age groups, over half of children killed are improperly restrained or unrestrained. Our first priority must be to ensure that every child is restrained appropriately for his or her age and size for every trip in a car. Helping parents make the best decisions for selection and proper use of car safety seats and seat belts is very important. Continual evolution of knowledge, safety information, and changes in car safety seat designs make this task … Address correspondence to Marilyn J. Bull, MD, 4747 N Meridian St, Indianapolis, IN 46208. E-mail: mbull{at}iupui.edu

BACKGROUND. Conventional residential tone smoke alarms fail to awaken the majority of children during slow wave sleep. With the objective of identifying a more effective smoke alarm for children, we compared a personalized parent voice smoke alarm with a conventional residential tone smoke alarm, both presented at 100 dB, with respect to their ability to awaken children 6- to 12-years-old from stage 4 sleep and prompt their performance of a simulated self-rescue escape procedure. METHODS. Using a randomized, nonblinded, clinical research design, a volunteer sample of healthy children 6- to 12-years-old was enrolled in the study. Children were trained how to perform a simulated self-rescue escape procedure when they heard a smoke alarm. Each child's mother recorded a voice alarm message, “First name! First name! Wake up! Get out of bed! Leave the room!” For each child, either the voice or tone smoke alarm was randomly selected and triggered during the first cycle of stage 4 sleep, and then the other alarm was triggered during the second cycle of stage 4 sleep. Children's sleep stage was monitored by electroencephalography, electro-oculography, and chin electromyography. The 4 main outcome measures included the number of children who awakened, the number of children who escaped, the time to awakening, and the time to escape. RESULTS. Twenty-four children were enrolled. The median age was 9 years, and 11 (46%) were boys. One half of the children received the parent voice alarm first, and one half received the tone alarm first; however, the order that the alarm stimuli were presented was not statistically associated with awakening or escaping. Twenty-three (96%) of the 24 subjects awakened to the parent voice alarm compared with 14 (58%) to the tone alarm. One child did not awaken to either stimulus. Nine children awakened to their parent's voice but not to the tone, whereas none awakened to only the tone and not the voice. Twenty (83%) of the subjects in the parent voice alarm group successfully performed the escape procedure within 5 minutes of alarm onset compared with 9 (38%) in the tone alarm group. The median time to awaken was 20 seconds in the voice alarm group compared with 3 minutes in the tone alarm group. The median time to escape was 38 seconds in the voice alarm group compared with the maximum allowed 5 minutes in the tone alarm group. When exposed to the tone alarm, older children were more likely to awaken and were more likely to escape than younger children. There was no association between child's age and awakening or escaping for children exposed to the parent voice alarm. There was no association between child's gender and awakening or escaping for either alarm type. CONCLUSIONS. To our knowledge, this study is the first to compare the ability of different types of smoke alarms to awaken children while monitoring sleep stage. The personalized parent voice smoke alarm at 100 dB successfully awakened 96% of children 6- to 12-years-old from stage 4 sleep with 83% successfully performing a simulated self-rescue escape procedure, significantly outperforming the 100-dB conventional residential tone smoke alarm. These findings suggest a clear direction for future research, as well as important fundamental changes in smoke alarm design, that address the unique developmental needs of children. The development of a more effective smoke alarm for use in homes and other locations where children sleep provides an opportunity to reduce fire-related morbidity and mortality among children.

OBJECTIVE. Sudden cardiac death that results from chest wall blows (commotio cordis) the second leading cause of death in young athletes. Most events are caused by blows from projectiles, such as baseballs or lacrosse balls, with a substantial proportion occurring despite the use of a chest protector. In the present experiment, we tested the effectiveness of commercially available chest protectors in preventing ventricular fibrillation (VF) that results from chest wall strikes with baseballs and lacrosse balls. METHODS. Twelve different baseball or lacrosse chest protectors were evaluated in juvenile swines that were subjected to 40-mph baseball or lacrosse ball blows to the precordium during the vulnerable period of repolarization for VF and were compared with control impacts without chest protectors. Seven baseball chest protectors were hit by regulation baseballs, and 5 lacrosse chest protectors were tested by blows with standard lacrosse balls. Each animal received 2 chest blows for each protector and 2 control impacts without a chest protector, with the sequence of impacts assigned randomly. RESULTS. VF was elicited by 12 (32%) of 37 strikes in control animals without baseball chest protectors. None of the baseball chest wall protectors tested were shown to decrease significantly the occurrence of VF when compared with controls. VF was elicited by 11 (46%) of 24 strikes in control animals without lacrosse chest protectors. None of the lacrosse chest wall protectors tested decreased significantly the occurrence of VF when compared with controls. CONCLUSION. In our experimental animal model of commotio cordis, commercially available baseball and lacrosse chest wall protectors were ineffective in protecting against VF that was triggered by chest blows and, by inference, sudden cardiac death. Improvements in materials and design of chest wall barriers are necessary to reduce the occurrence of these tragic events and make the athletic field safer for youths.

Objective. To describe the incidence, circumstances, and types of stroller-related injuries among US children. Design. Retrospective review of data for children 3 years old and younger from the National Electronic Injury Surveillance System of the United States Consumer Product Safety Commission for 1994–1998. Results. There were an estimated 64 373 stroller-related injuries (95% confidence interval [CI]: 49 223–79 514) to children 3 years old and younger treated in hospital emergency departments in the United States during the 5-year study period. The median age at the time of the injury was 11 months; 51% were males. The annual rate of injury among children Conclusions. Injuries related to strollers are common, particularly among children in the first year of life. They often result from falls from the stroller. The data suggest that restraint use would prevent many stroller-related injuries.

Skateboard-related injuries account for an estimated 50 000 emergency department visits and 1500 hospitalizations among children and adolescents in the United States each year. Nonpowered scooter-related injuries accounted for an estimated 9400 emergency department visits between January and August 2000, and 90% of these patients were children younger than 15 years. Many such injuries can be avoided if children and youth do not ride in traffic, if proper protective gear is worn, and if, in the absence of close adult supervision, skateboards and scooters are not used by children younger than 10 and 8 years, respectively.

Occupant protection policies for children younger than 2 years on aircraft are inconsistent with all other national policies on safe transportation. Children younger than 2 years are not required to be restrained or secured on aircraft during takeoff, landing, and conditions of turbulence. They are permitted to be held on the lap of an adult. Preventable injuries and deaths have occurred in children younger than 2 years who were unrestrained in aircraft during survivable crashes and conditions of turbulence. The American Academy of Pediatrics recommends a mandatory federal requirement for restraint use for children on aircraft. The Academy further recommends that parents ensure that a seat is available for all children during aircraft transport and follow current recommendations for restraint use for all children. Physicians play a significant role in counseling families, advocating for public policy mandates, and encouraging technologic research that will improve protection of children in aircraft.

The use of personal watercraft (PWC) has increased dramatically during the past decade as have the speed and mobility of the watercraft. A similar dramatic increase in PWC-related injury and death has occurred simultaneously. No one younger than 16 years should operate a PWC. The operator and all passengers must wear US Coast Guard-approved personal flotation devices. Other safety recommendations are suggested for parents and pediatricians.

All hospitals should set policies that require the discharge of every newborn in a car safety seat that is appropriate for the infant's maturity and medical condition. Discharge policies for newborns should include a parent education component, regular review of educational materials, and periodic in-service education for responsible staff. Appropriate child restraint systems should become a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers.

In-line skating has become one of the fastest-growing recreational sports in the United States. Recent studies emphasize the value of protective gear in reducing the incidence of injuries. Recommendations are provided for parents and pediatricians, with special emphasis on the novice or inexperienced skater.

Despite the existence of laws in all 50 states requiring the use of car safety seats or child restraint devices for young children, many children continue to be killed each year while riding in motor vehicles. Pediatricians and other health care professionals need to provide up-to-date, appropriate information for parents regarding their car safety seat choices and use. This policy statement discusses current recommendations based on the latest research and the factors parents should consider before selecting and using a car seat.

Objective. To describe types of injuries, mechanisms of injury, and treatment of injuries caused by scooter use in children, and to discuss issues of injury prevention in children who use scooters. Study Design. Data were collected from 14 children seen by a general pediatrician and an orthopedic surgeon over a 3-month period in the summer of 2000. Detailed histories were obtained from patients and their families, and medical records were reviewed. Results. Eleven of the 14 patients suffered fractures. The injuries in the other 3 patients were a large abrasion, a laceration, and a septic knee. Half (7) of the children were injured within the first day of riding their scooter, and 13 of the 14 injuries occurred within the first month of scooter use. Only 5 patients used protective gear at the time of their injuries, and those patients were injured in unprotected parts of their bodies. Conclusions. The popularity of scooters presents a new cause of pediatric injuries and a significant health hazard to children. In our study, most injuries occurred shortly after children began scooter use, and younger children suffered the most severe injuries. Additional studies are needed to determine how scooter-related injuries can be prevented or minimized. scooters, injuries.

Objectives. To determine the prevalence of proper fencing around outdoor swimming pools among US households and to describe this fencing in relation to demographic and other household factors. To estimate the number of drownings among children Methods. A 1994, randomly dialed national telephone survey contacted 5238 adults who reported demographic information and household characteristics including whether the household had an outdoor swimming pool and the fencing around the pool. Data were weighted to obtain national estimates and percentages. The number of preventable drownings was estimated with a population-attributable risk equation. Results. Approximately 18.5 million American households owned or had access to an outdoor swimming pool in 1994, and 76% (13.9 million) of them appeared to have had adequate fencing. Adequate fencing was associated with household income and type of home. We estimate that 19% of pool-related drownings among children Conclusions. Adequate pool fencing prevents a child from having access to a swimming pool if a responsible adult is not present and has been promoted as a method to prevent drowning. Our research suggests that even if all residential pools in the United States were properly fenced, most drownings among children

Since the American Academy of Pediatrics instituted the "First Ride-Safe Ride" campaign, many child passenger safety programs have reported that they have achieved less than optimal results. The present study compared two comprehensive programs for encouraging new parents to use child restraint devices consistently and correctly and compared the present results with the results of a previous program that was conducted at the same hospital. A total of 129 mother-newborn pairs were randomly assigned to two groups. All of the participants had their babies at a hospital that had an established car seat loaner program with strong support from the medical staff, the nursing staff, and the hospital administration; the hospital was in a state that had a law mandating child restraint seat usage. One group was exposed to the regular hospital program and the other group had, in addition: a mock-up demonstration for the mothers on the correct method of fastening the baby into the car seat and the car seat into the automobile seat; written handouts of how to use a car seat with an infant; a physician's order for the mock-up demonstration; and a physician's order to be discharged in a car seat. Although there was no significant difference between the two groups, both groups had correct usage rates above 90% at hospital discharge and maintained usage at better than 80% for one full year. A comparison with an earlier study at the same hospital suggested that the duration and comprehensiveness of the programs accounted for the significant increase in the usage rates. The task now is to adapt the program for use with less motivated parents.

There has been little critical evaluation of which methods achieve the desired results in health education. Using purchase of proper infant auto restraint devices as an objective, we assessed the effectiveness of three educational approaches. Only 37% of control families had purchased an acceptable car seat, compared to 54% of those who received descriptive literature alone, 71% of those that received literature and had been shown a descriptive film, and 60% of those who were given literature, shown the film, and been provided with a demonstration of the seat. Purchase of car seats was positively correlated with social class and knowledge of auto safety, but not with a history of auto accidents. Utilization of auto restraint devices is an example of how social learning theory can be applied in health education.

Three in-hospital educational programs for postpartum women, designed to increase the crash protection of infants in cars, were evaluated in comparison to a group that received no education. The programs consisted of (1) literature, plus making infant carriers readily accessible and convenient to purchase; (2) literature, plus a personal discussion, plus making infant carriers readily accessible and convenient to purchase; and (3) literature, plus the offer of a free infant carrier. The programs increased the extent to which infant carriers were used to transport babies in cars, but had little or no effect on the key outcome measure: use of infant carriers fastened by the car seat belt so that crash protection is provided. Rates of such use were low in all groups. It is concluded that ways of providing increased crash protection to infant and child travelers in addition to use of restraint systems requiring the active, voluntary cooperation of parents must be encouraged. "Passive" (automatic) protection techniques, such as air bags and vehicle interior modifications, have great potential in this regard.

The ability of hospital-based car seat rental programs to provide car seats inexpensively throughout an entire state and the effect of these rental programs on car seat usage by newborns were evaluated. In July 1979 individuals and groups committed to child passenger safety formed a coalition called Vermont SEAT (Seatbelts Eliminate Automobile Tragedies). During the next 3 years SEAT asked the major hospitals in the state to allow volunteers to operate car seat rental programs on their premises. The number of rental programs increased from 0 to 13; the percentage of newborns born in a hospital with a rental program increased from 0% to 99%. The estimated statewide rate of car seat usage by newborns, based on observations at discharge at five hospitals, increased from 15% to 70%. These findings suggest that a network of hospital-based car seat rental programs operated by volunteers can make car seats readily available throughout a state or region, and can significantly increase car seat usage by newborns. It is recommended that such programs be a part of comprehensive strategies to improve child passenger safety.