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Introduction: Prior work has found incongruencies in injury information reported by crash and hospital records. However, no work has focused on child passengers. The objective of this study was to compare crash scene and hospital-reported injury information for crash-involved child passengers. This study also explored injury location and severity by child age and restraint type., Methods: Utilizing linked New Jersey data from 2017 through 2019, the authors identified crash-involved child passengers <13 years old and their injuries in crash and hospital reports. Then, they characterized the congruency of injury frequency, severity, and location, as well as the frequency of injuries by child age and restraint type. Analyses were conducted from December 2023 through February 2024., Results: Of 84,060 crash-involved child passengers, crash reports documented 7,858 (9%) children with at least "possible" injuries, while 2,577 (3%) had at least one injury in hospital events. Crash report and hospital data were incongruent for both body region of injury and injury severity. The proportion of children injured increased as children's ages increased and as restraint type progressed., Conclusions: Crash reports overestimated the number of injured child passengers and misrepresented injury severity and locations. Child restraint systems mitigated a child's injury risk. Importantly, injury information documented on crash reports currently informs the allocation of traffic safety resources. These results highlight the importance of improving these reports' accuracy and underscore calls to link administrative datasets for public health efforts., (Copyright © 2024 Elsevier Inc. All rights reserved.)

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., (Copyright © 2024 Society of Trauma Nurses.)

Objective: One of the main causes of death worldwide among young people are car crashes, and most of these fatalities occur to children who are seated in the front passenger seat and who, at the time of an accident, receive a direct impact from the airbags, which is lethal for children under 13 years of age. The present study seeks to raise awareness of this risk by interior monitoring with a child face detection system that serves to alert the driver that the child should not be sitting in the front passenger seat., Methods: The system incorporates processing of data collected, elements of deep learning such as transfer learning, fine-tunning and facial detection to identify the presence of children in a robust way, which was achieved by training with a dataset generated from scratch for this specific purpose. The MobileNetV2 architecture was used based on the good performance shown when compared with the Inception architecture for this task; and its low computational cost, which facilitates implementing the final model on a Raspberry Pi 4B., Results: The resulting image dataset consisted of 102 empty seats, 71 children (0-13 years), and 96 adults (14-75 years). From the data augmentation, there were 2,496 images for adults and 2,310 for children. The classification of faces without sliding window gave a result of 98% accuracy and 100% precision. Finally, using the proposed methodology, it was possible to detect children in the front passenger seat in real time, with a delay of 1 s per decision and sliding window criterion, reaching an accuracy of 100%., Conclusions: Although our 100% accuracy in an experimental environment is somewhat idealized in that the sensor was not blocked by direct sunlight, nor was it partially or completely covered by dirt or other debris common in vehicles transporting children. The present study showed that is possible the implementation of a robust noninvasive classification system made on Raspberry Pi 4 Model B in any automobile for the detection of a child in the front seat through deep learning methods such as Deep CNN.

Background: Adherence to child passenger safety recommendations is essential to prevent death and injury in children involved in motor vehicle crashes. Parents may not undertake the proper safety measures, which can lead to increase injury., Methods: A safety net, level I trauma center's database was used to identify admitted children (age<15 y/o) involved in motor vehicle crashes over a 2-y period to investigate safety restraint device use and compliance with state recommendations. Variables evaluated were crash characteristics, presence and method of passenger restraint, demographics, Glasgow Coma Scale, and Injury Severity Score. Excluded were patients where restraint characteristics could not be identified and those discharged from the trauma center., Results: Eighty patients met inclusion criteria. Thirty-two (40%) children were unrestrained. Safety restraint device was noted in 48 (60%) children with 13 (27.1%) patients improperly restrained. The most common method of improper restraint (6, 46.2%) was traveling in the front seat before the age state law recommends. With respect to proper, improper, and no restraint, age (7.31 ± 14.26, 5.76 ± 3.24, P = 0.36), female sex (17, 8, 13, P = 0.32), low-income status (14, 5, 24, P = 0.28), and race (P = 0.08) did not differ between the groups. The unrestrained children had statistically lower initial Glasgow Coma Scale and higher Injury Severity Score and were more often involved in high-risk mechanism of Injury motor vehicle crashes., Conclusions: Despite recommendations and regulations regarding child passenger safety measures, there are a significant number of children that remain suboptimally restrained who are admitted to a safety-net trauma center. Further research is needed to understand the barriers to increase the compliance with recommendations along with targeted educational campaigns in low-compliance populations., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: While there are clear racial/ethnic disparities in child restraint system (CRS) use, to date no studies have identified mediators that quantitatively explain the relationship between race and CRS use. Therefore, the objective of this study was to provide an example of how a proportion-eliminated approach to mediation may be particularly useful in understanding the complex relationship between race and CRS use., Methods: Sixty-two mothers with a child between 4-8 years old completed a survey and had their CRS use assessed by a Child Passenger Safety Technician using a structured assessment based on the 2018 American Academy of Pediatrics' Best Practice guidelines. Recruitment and data collection occurred in Birmingham, Alabama between June 2018 and January 2019. We used chi-squared tests, logistic regressions, and a proportion-eliminated approach to mediation to compare our variables of interest and to estimate the amount of the association between racial group membership and errors in restraint use that may be explained by sociodemographic, psychosocial, and parenting variables., Results: Before mediation, Nonwhite mothers in this sample had a 7.38 greater odds of having an error in CRS use than White mothers. Mediation analyses indicated that being married and self-reported seatbelt use explained 47% and 35% of the effect of race on CRS use errors, respectively., Conclusion: A proportion-eliminated approach to mediation may be particularly useful in child passenger safety research aiming to inform the development of interventions tailored for racial minority populations.

Introduction: Child weight and height are the basis of manufacturer and best practice guidelines for child restraint system use. However, these guides do not address behavioral differences among children of similar age, weight, and height, which may result in child-induced restraint use errors. The objective of this study was to characterize child behaviors across age in relation to appropriate restraint system use during simulated drives., Methods: Fifty mother-child (4-8 years) dyads completed an installation into a driving simulator, followed by a simulated drive that was video-recorded and coded for child-induced errors. Time inappropriately restrained was measured as the total amount of the simulated drive spent in an improper or unsafe position for the restraint to be effective divided by the total drive time. Kruskal-Wallis tests were used to determine differences across age in the frequency of error events and overall time inappropriately restrained., Results: Children in harnessed seats had no observed errors during trips. Within children sitting in booster seats there were differences in time inappropriately restrained across age (p = 0.01), with 4 year-olds spending on average 67% (Median = 76%) of the drive inappropriately restrained, compared to the rest of the age categories spending less than 28% (Medians ranged from 3% to 23%)., Conclusion: Some children may be physically compatible with booster seats, but not behaviorally mature enough to safely use them. More research is needed that examines how child behavior influences child passenger safety. Practical Applications: Not all children physically big enough are behaviorally ready to use belt positioning booster seats. Primary sources of information should provide caregivers with individualized guidance about when it is appropriate to transition children out of harnessed seats. Additionally, best practice guidelines should be updated to reflect what behaviors are needed from children to safely use specific types of child restraint systems., (Copyright © 2020 National Safety Council and Elsevier Ltd. All rights reserved.)

Children that are unrestrained while travelling in a motor vehicle are more vulnerable to serious injury and death. The greatest levels of crash protection are achieved when children use the most age or size appropriate form of restraint. In this study, we aimed to examine the effectiveness of the introduction of age-appropriate child restraint legislation on serious and fatal injury in five Australian states and territories. For this interrupted time series analysis, we used a segmented regression method to assess the association between the implementation of child-restraint legislation and motor-vehicle related serious injuries and fatalities using data obtained from transport authorities in each jurisdiction. We estimated the change in annual rates after the implementation of legislation with the number of motor-vehicle accidents resulting in fatalities or serious injuries as the outcome, and the total number of injuries (minor, serious and fatal) as an offset in the model. We identified 10882 motor-vehicle related crashes resulting in fatalities (n = 188), serious injuries (n = 1730) and minor injuries (n = 8964). In NSW and VIC, the rate ratio was statistically significant and positive, indicating an increase in the rate of serious injuries and fatalities in the period post-legislation compared to the period prior to legislation. In all other states and territories, we did not find a statistically significant effect of legislation Road safety programs incorporating interventions targeted at increasing awareness of optimal restraint practices, strengthened enforcement and measures to improve the affordability of restraints are needed to support legislation., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Child passenger safety is an important public health problem in China. This study aimed to examine the prevalence of child passenger restraint use while riding in a car in the city of Shantou in China from 2012 to 2017., Methods: Three large-scale cross-sectional observational studies were conducted in 2012, 2015 and 2017, respectively. The observation sites included randomly selected hospitals, kindergartens, and primary and secondary schools. The outcome measures included the changes in percentages of seating position (e.g., front vs. rear), whether sitting on lap, and use of child restraint systems (CRS) or seat belts by year and by age group. Descriptive statistics, Chi-square tests and logistic regression were used to address the study aims., Results: A total of 9858 commuting children aged 17 and younger were observed in passenger cars in Shantou, China during the study. The proportion of children aged 0-5 sitting on adult's lap decreased from 26.6% in 2012 to 24.6% in 2017, while the proportion of CRS use among the children sitting in the rear row increased among children aged 0-5 (from 0.7% in 2012 to 14.2% in 2017) and children aged 6-11 (from 0.7% in 2012 to 2.4% in 2017). Comparing children aged 0-11 in 2012, children in the same ages were less likely to sit in the front row in 2015 (OR = 0.42, 95%CI = 0.37, 0.48) and in 2017 (OR = 0.27, 95%CI = 0.23, 0.31). Children aged 0-11 were more likely to sit in the rear row with CRS use in 2015 (OR = 8.50, 95%CI = 5.44, 13.28) and in 2017 (OR = 10.95, 95%CI = 7.02, 17.08) comparing with children in the same ages in 2012. As for children aged 12-17, they were more likely to use seat belt in 2017 (OR = 1.40, 95%CI = 1.06, 1.85) compared with those children in 2012., Conclusions: While child passenger safety behaviors improved from 2012 to 2017 in Shantou, China, more efforts are needed to protect child passengers from injuries.

Background: Use of seat belts and car seats for children are among the most effective interventions to reduce injury severity when a crash occurs. The use should be enforced in order to have an increase in wearing these restraints. Romania has the lowest rate of using seatbelts in the backseat, 16%. The purpose of the study is to describe the use of child safety restraints and compare it with existing standards of good practice., Methods: An observational study on child safety restraint was conducted in Cluj-Napoca, Romania, between 2013 and 2014. Observational sites included 38 schools and kindergartens and three commercial areas, where drivers (n=768) and child passengers (n=892) were observed. Observations were conducted as vehicles parked or pulled to a stop and were followed by driver surveys on knowledge and attitudes towards restraint legislation and child safety behaviour as car occupants., Results: The proportion of observed child motor vehicle occupants wearing some type of restraint was 67.4% (n=601). The majority of children (82.6%) were in the back seat, and 14.2% of infants were in a rear-facing child seat. The proportion of restrained children declined with age, with children 5 years old or younger being almost five times more likely to be properly restrained (OR 4.87, 95% CI 2.93 to 8.07) when compared with older children., Conclusions: Although minimum legal requirements of child motor vehicle occupant safety were in place in Romania at the time of the study, the rates of using children restraints was low compared with other middle-income and high-income countries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine whether an antepartum educational leaflet distributed to parents before infant delivery affected the rate of infant car-seat (ICS) use 1 month after delivery, because to the best of our knowledge, only few reports have evaluated systematic attempts to improve the rate of always ICS use by mothers driving infants Methods: A multicenter questionnaire survey targeting pregnant Japanese women seeking antenatal care at the outpatient clinics of eight hospitals was designed. Women enrolled during the first half of the study period did not receive leaflets describing ICS safety guidelines (control group). Women enrolled during the latter half of the study period received the leaflet between gestational week 35 and 37 (intervention group). All women were requested to anonymously respond to the questionnaires within 1 month postpartum. The rates of ICS use, position, and direction after delivery were compared between both groups. Results: Of the 3534 women who responded to the questionnaire survey (response rate, 81.9%), 1772 women (50.1%) were assigned to the intervention group and 1762 (49.9%) women to the control group. The rates of ICS attachments (86.8% vs. 82.4% in the intervention and control groups, respectively, p  = 0.0003), always ICS use (80.5% vs. 76.2%, respectively, p  = 0.0019), ICS placement on the rear seat (78.6% vs. 74.1%, respectively, p  = 0.0020), and ICS placement in a rear-facing position (62.2% vs. 56.7%, respectively, p  = 0.0008) were significantly higher in the intervention group than those in the control group. The motor vehicle accident (MVA) rates within 1 month postpartum were similar between the intervention and control groups (0.51% vs. 0.57%, respectively, p  = 0.8229). Conclusions: Antepartum minimal intervention via the distribution of an educational leaflet recommending ICS safety guidelines was associated with increased rates of ICS attachments, always ICS use, and ICS placement on the rear seat and in rear-facing positions; however, it did not contribute to reduced MVA rates after delivery.

Objective: The aim of this study was to explore parents' awareness and usage of CRS, incentives and challenges in CRS use, as well as their perception about potential CRS legislation in Malaysia. Methods: This was a cross-sectional study conducted in a public tertiary care center in Northern Malaysia. A self-developed researcher-assisted questionnaire was developed in English and translated into Malay language, to explore parents' awareness ad CRS usage, as well as the incentives and barriers in CRS use. Parents of a newborn were conveniently sampled, excluding parents with pre-term newborn or those without a car. Upon obtaining written informed consent, the parents were allowed to answer the questionnaire within 20 minutes, assisted by the researchers. Parents who were found not using CRS for their newborn were given a digital pamphlet with CRS-related information via mobile devices. Results: A total of 200 parents were approached and 193 of them consented to participate in this study. The majority of the parents (87.6%) were aware of CRS, but only half of them (57.0%) provided a CRS for their current newborn. From 100 CRS users, most of them used a CRS for "child's safety" purposes (84.5%). Among 83 CRS nonuser, nearly half of them (45.8%) perceived that it is adequate to carry their child during traveling without using a CRS. When exploring previous experience in using CRS among all parents (n = 193), more than half of them (63.9%) faced difficulty as their child refused to use the CRS. More than half (54.9%) of all parents were not aware about the possible CRS legislation in Malaysia. However, the majority of them (90.7%) agreed with the implementation of CRS law. Conclusions: Although majority of the parents were aware about CRS, but only half had a CRS for their current newborn. Most of the parents supported CRS legislation in Malaysia, but assistance will be required to help them through challenges related to CRS use.

Importance: Caregiver-targeted interventions to improve the use of child restraint systems (CRS) in motor vehicles are common and heterogeneous in their implementation. The effectiveness of these interventions is unknown., Objectives: To quantify the effects of caregiver-targeted interventions using meta-analytic methods, assess the quality of published studies, and assess for publication bias., Data Sources: PubMed and PsychINFO (January 1, 2004, to April 1, 2019) were searched for English-language studies using a list of search terms. The search and screening process was completed between May 25, 2018, and April 1, 2019., Study Selection: Studies met inclusion criteria if they included a caregiver-targeted intervention that focused on increasing CRS use for children (age, ≤9 years) and report the use of CRS before and after the intervention., Data Extraction and Syntheses: Cochrane and PRISMA guidelines were used for the meta-analysis and risk-of-bias review. Information was extracted on intervention type, setting, implementation, and attributes of the study independently between 2 coders. Data were pooled from independent samples, with 1 outcome measure from each intervention implementation or study., Main Outcomes and Measures: This study was an exploratory random-effects meta-analysis. Unadjusted odds ratios were calculated using the sample size and the observed number of children in incorrect or correct restraints in motor vehicles before and after the intervention to determine the odds of incorrect CRS use after completing an intervention. Setting, measurement method, randomization, use of vouchers, and types of restraint were tested as moderators. A funnel plot was used to assess for publication bias., Results: Of 1240 potential articles, 51 were deemed eligible for screening and 10 (8238 participants total) were included in the meta-analysis. Caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS (odds ratio, 0.51; 95% CI, 0.36-0.71; P < .001). Variance in the averaged effect size was driven by self-report methods (when removed from analyses, I2 = 61.8%; R2 change = 26.3; P = .02) and hospital settings (when removed from analyses, I2 = 70.7%; R2 change = 17.4; P = .002). Risk of bias was high in most studies; however, there was low evidence for publication bias., Conclusions and Relevance: In this meta-analysis, caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS in motor vehicles; however, the methodological rigor of intervention studies should be enhanced.

Objective: Motor-vehicle crashes (MVC) remain a leading cause of preventable injury and death for children aged 0-3 in the United States. Despite advancement in legislation and public awareness there is continued evidence of inappropriate child restraint system (CRS) use among the youngest passengers. The current study focuses on appropriate CRS use from 2011 to 2015 using data from the Fatality Analysis Reporting System (FARS) for children aged 0-3., Methods: Child-, driver-, vehicle-, and trip-related characteristics were investigated within a sample of 648 children from 625 crashes over 5-years in which a child aged 0-3 was fatally injured while unrestrained or wearing an identified CRS type. Multivariable log-binomial regression was used to obtain relative risk., Results: Only 48% of the fatally injured children were appropriately restrained in a CRS. Premature transition to a booster seat and seat belt was evident. The largest proportion of rear-facing restraint use was reported in <1 year olds (40%), with less reported in 1 (11%) and 2 year olds (2%) and no usage in 3 year olds. Younger children were more likely to be in an appropriate CRS, while Black children, driver not restrained in a lap-shoulder belt configuration, and riding in a pickup truck were less likely to be restrained appropriately., Conclusions: Evidence of inappropriate CRS use supports the use of more stringent legislation and parental interventions to communicate best practice recommendations and educate caregivers regarding appropriate child restraint methods. Practical applications: Public health campaigns focused on increasing appropriate restraint use in children are of great importance as optimally restrained children are less likely to sustain injuries, or require crash-related hospitalization compared to unrestrained children. Researchers and practitioners may find these surveillance findings essential when developing education and interventions targeting child-parent dyads at the greatest risk for a MVC-related fatality., (Copyright © 2019 National Safety Council and Elsevier Ltd. All rights reserved.)

Aim: Child restraint practices among New Zealand children have fallen short of best practice recommendations. In 2013, New Zealand child restraint legislation was amended. The aim of the present study was to determine the child restraint practices of a cohort of children admitted to hospital and how practices have changed since the amendment in child restraint legislation., Methods: We conducted interviews with the parents of 300 paediatric inpatients aged 0-13 years. Data were recorded on their child's usual child restraint use, the restraint used during their trip to hospital, and parental knowledge of child restraint law and best practice recommendations. We compared their responses with those of our survey published in 2013, which was performed before the amendment in child restraint legislation., Results: The median age of the 300 children was three years: 181 (60%) were aged 0-4 years, 65 (22%) 5-9 years and 54 (18%) 10-13 years. One hundred and thirty-six (45%) were girls. Of children <5 years of age, 97% always used a child restraint. Of children 5-9 years of age, 60% always used a child restraint, 12% sometimes and 28% never. A significantly greater proportion of 5-9 year-old children used a child restraint at least some of the time in the present study compared to the 2013 study (47/65 versus 27/53, OR 2.49 [95%CI 1.09-5.81]). Child restraint use declined in children <6 years of age. On their journey to hospital, five children used no restraint, four of whom were held in the arms of a caregiver. Parental knowledge of child restraint recommendations correlated inversely with their compliance with the recommendations (OR 0.33 [95%CI 0.11-0.91])., Conclusions: Consideration should be given to extending child restraint legislation to children older than seven years of age. Further studies could explore the barriers parents face to the use of child restraints and the potential effect of extending child restraint laws to older children., Competing Interests: Nil.

Motor vehicle injuries are a leading cause of death among children worldwide, though many of these deaths are preventable. Buckling young children in age- and size-appropriate car seats, booster seats, or seat belts and also seating them in appropriate position can lead to a significant reduction of serious and fatal injuries. This study investigated sitting behaviour and restraint use among child passengers through cross-sectional observational surveys conducted in Kumasi, Ghana. A bivariate probit model was developed for simultaneous determination of the contributing factors influencing child passenger's sitting behaviour and restraint use. The results showed that 26% of the child passengers observed were occupying the front seat and the prevalence rate of restraint use was 4.5%. The developed bivariate probit model clearly highlights the existence of interrelationship between child passenger's sitting position and restraint use. The key factors simultaneously influencing child passenger's sitting position and restraint use include vehicle type, driver's gender, driver's belt use, child's age, and the presence of other child or adult passenger. Furthermore, time of day and day of week also influence child passenger sitting behaviour but not their restraint use. These findings provide insight for better understanding of child transporting practices and the contributing factors influencing their sitting behaviour and restraint use. The findings also highlight the need for policy makers to design effective countermeasures to promote rear sitting and restraint use among child passengers., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Although injury patterns after motor vehicle crashes (MVCs) are well documented, association between adequate restraint and injury severity is unclear. We aimed to determine if improper restraint affects injury rates and severity., Methods: A retrospective chart review of 477 children hospitalized in Pediatric Trauma Center after MVC was performed. Injuries in various age groups (0-7, 8-12, 13-16, 17-18 years) with different restraint quality measures (proper [PR] and improper/unrestrained [IUR]) as well as injury severity score (ISS: mild [1-9], moderate [10-15], severe [16-25], and profound [>25]) were evaluated and compared. Chi-square and Wilcoxon rank-sum tests were used for statistics., Results: In all age groups head/neck injuries were most common (55-63%), while abdominal and pelvic injuries were least likely except group 8-12 years where abdominal injuries ranked third (17.1%). Overall, 64.5% had PR and 35.5% IUR. Interestingly, that greatest proportion of IUR was in the youngest age group (0-7). It decreased with aging and children aged 17-18 years were significantly less likely to be IUR compared to those 0-7 years (OR[odds ratio] = 0.58; 95%CI[confidence interval] 0.35-0.94). We did not find significant differences in rates of various injuries between PR and IUR. However, ISS severity in IUR was significantly greater than in PR (median with interquartile range 6(2-14) and 5(1-9), respectively; P = 0.001). As a result, IUR compared to PR were less likely to have mild ISS (OR = 0.6, 95%CI 0.39-0.90) but more likely to have profound ISS (OR = 3.3, 95%CI 1.48-7.43)., Conclusion: Restraint quality has significant impact on injury severity in children after MVC., Level of Evidence: Level III., (Copyright © 2018. Published by Elsevier Inc.)

Background: Despite demonstrated effectiveness of child restraint systems (CRSs), use remains suboptimal. In this randomized pilot trial, we sought to determine the feasibility, acceptability, and potential efficacy of "Tiny Cargo, Big Deal" an ED-based intervention to promote guideline-concordant size-appropriate CRS use., Methods: Parents of children < 11 years old were recruited in two EDs and randomized in a 2 × 2 factorial design to four conditions: 1) generic information sheet, 2) tailored brochure mailed after the ED visit, 3) a single motivational interviewing-based counseling session in the ED, and 4) full intervention (counseling session plus tailored brochure). We assessed feasibility (recruitment, completion, follow-up rates) and acceptability (parent attitudes, uptake of information) in the ED, at 1 month and at 6 months. We obtained preliminary estimates of effect sizes of the intervention components on appropriate CRS use at 6-month follow-up., Results: Of the 514 parents assessed for eligibility, 456 met inclusion criteria and 347 consented to participate. Enrolled parents were mostly mothers (88.1%); 48.7% were 18 to 29 years old; 52.5% were non-Hispanic, white; and 65.2% reported size-appropriate CRS use. Completion rates were 97.7% for baseline survey, 81.6% for counseling, 51.9% for 1-month follow-up, and 59.3% for 6-month follow-up. In the ED, 70.5% rated thinking about child passenger safety in the ED as very helpful. At 1 month, 70.0% expressed positive attitudes toward the study. Of 132 parents who reported receiving study mailings, 78.9% reviewed the information. Parents randomized to the full intervention demonstrated an increase (+6.12 percentage points) and other groups a decrease (-1.69 to -9.3 percentage points) in the proportion of children reported to use a size-appropriate CRS at 6-month follow-up., Conclusions: Suboptimal CRS use can be identified and intervened upon during a child's ED visit. A combined approach with ED-based counseling and mailed tailored brochures shows promise to improve size-appropriate CRS use., (© 2019 by the Society for Academic Emergency Medicine.)

Background: In 2010, Brazil introduced child restraint legislation (CRL). We assessed the effectiveness of CRL in reducing child (aged 0-8 years) injuries and fatalities by race. We performed an evaluation study with an interrupted time-series design., Methods: We measured the effect of CRL on two outcomes-number of child deaths and number of child injured in traffic collisions per child population, stratified by race, from 2008 to 2014. We controlled for time, unemployment rate and oil consumption (barrels/day in thousands)., Results: The CRL was associated with a 3% reduction in the rate of child injuries among whites (incidence rate ratio (IRR): 0.97; 95% CI: 0.96-0.99), but no reduction in child injuries among non-whites (IRR: 0.99; 95% CI: 0.99-1.00). In the first month after the implementation of Brazil's CRL we observed a 39% reduction in all child fatalities (IRR: 0.61; 95% CI: 0.44-0.84), including a 52% reduction among whites (IRR: 0.48; 95% CI: 0.33-0.68), but no reduction in non-white fatalities (IRR: 0.87; 95% CI: 0.55-1.37)., Conclusions: Our results support the hypothesis that socially advantaged populations were more likely to consistently adopt and employ restraint devices following the reform. Countries should also consider complementary policies that facilitate an equitable distribution of safety devices that reach vulnerable populations., (© The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Child safety seat use reduces the risk of fatal injury by 71% for infants and 54% for toddlers, yet more than one-third of child passengers killed in traffic crashes in the US are unrestrained. Nearly half (47%) of crash injuries occur within 5 miles of the injured person's home. Mapping the location of motor vehicle crashes resulting in serious or fatal injury to unrestrained child passengers may pinpoint high-risk neighborhoods. Illinois Department of Transportation data were used to map crashes that resulted in a fatal or incapacitating injury to a child passenger (age 0 to 8) in Cook County, IL from 2011 to 2015. Maptitude® Geographic Information System (GIS) software was used to identify hot spots of unrestrained child passenger injury on the South Side and West Side of Chicago. Of 174 zip codes in Cook County, 3 zip codes on the South Side of Chicago (60620, 60621; 60628) accounted for 11% of the total unrestrained fatalities and incapacitating injuries among children. Results of this study reveal the feasibility of detecting geographic disparities in child passenger safety at the zip code and neighborhood level and indicate the potential for more targeted allocation of resources.

Motor vehicle crashes are a leading cause of death for youth. Appropriate occupant protection significantly reduces these preventable injuries. Secondary field observation survey records were studied to identify populations that would most likely benefit from youth occupant protection programs. Multivariate regression analysis showed that drivers of youth between 4 and 14 years were in need of programs promoting youth and driver occupant restraint use. When these drivers were using seat belts, it was 35 times more likely they had youth occupants in safety restraints. A focus on pickup truck drivers may also give these programs greater efficacy in increasing youth restraint use. This study was limited to a single state, but the approach should be transferable to other jurisdictions where youth occupant protection field observation studies are conducted.

Objective: To systematically review and summarize articles evaluating the effectiveness of child restraint system (CRS) interventions targeting parents/caregivers' knowledge of, overall rates of and/or proper use of CRSs published in a recent time period. Methods: Using multiple databases, we identified peer-reviewed journal articles published between January 1, 2007 and December 31, 2018 using selected key search terms. Inclusion criteria were: (1) evaluation of an intervention/program for child passenger safety targeting a parent or caregiver of a child (2) quantitative data-based results (i.e., change in knowledge, behavior, or observed outcomes), (3) English-language, and (4) peer-reviewed journal publication. Through a systematic review process and peer consensus, n = 23 articles met inclusion criteria. References of these articles were reviewed for inclusion using the same process and n = 12 additional articles were identified. Results: A total of n = 35 articles met inclusion criteria. Of the n = 35 articles, n = 9 were randomized controlled trials (RCTs), n = 4 were cluster RCTs, n = 11 were nonrandomized trials, and n = 11 were pretest post-test studies. Types of interventions included face-to-face education (n = 26), web/video-based education (n = 8) or written educational materials (n = 1). Of the articles reviewed, n = 20 involved distribution of free or subsidized CRSs to some or all subjects. N = 20 articles involved trained CRS technicians and/or CRS installation check-points. In terms of outcomes measured, n = 3 articles assessed changes in knowledge of CRS use, n = 22 assessed changes in CRS behaviors (which includes self-report or observed behavior change), and n = 10 assessed changes in both CRS knowledge and behaviors. All articles (n = 3) that measured changes in knowledge as their only outcome demonstrated positive effects while articles measuring behavioral outcomes (self-report or observed) (n = 32) had mixed results. Conclusions: This review included a wide range of articles of heterogeneous methodologies, sample sizes, and outcomes measured. Although different approaches to CRS interventions were effective in increasing awareness and knowledge, the effects on CRS use behaviors - whether self-reported or observed - were mixed. Future research is needed to increase appropriate CRS use and reduce the burden of motor vehicle crash-related injuries among children.

Objective: To assess the factors affecting parental childhood vaccine refusal and hesitancy (CVRH) intentions in Turkey., Methods: A total of 33 children's parents who were referred to two different child health care clinics because of CVRH and 99 controls were enrolled into this study from November through December 2017. The socio-demographic characteristics and perceptions of the parents who refused at least one vaccine for their child/children were compared with controls., Results: The monthly household income was significantly lower in CVRH group than control group. Refusal of the heel stick, refusal of hearing test, not using baby car seat, irregular use of vitamin D and iron prophylaxis, using alterative/complementary medicine, distrust in vaccines were the parameters which were found significantly higher in refused vaccine group than in control group. The beliefs "It may be dangerous for children" and "Distrust to the vaccines" were the most determined factors with a ratio of 51.5% in CVRH group., Conclusions: This is the first study conducted to investigate the social-demographic characteristics and perception of parental CVRH in Turkey. The beliefs "It may be dangerous for the children" and "Distrust the vaccines" were the most determined factors which may affect CVRH. Some child health protective strategies were less undertaken in CVRH group than in controls; including heel stick test, hearing test, using baby car seat and using of Vitamin D and iron prophylaxis. The parents who have CVRH intentions tend to behave irresponsibly in care of their children.

Objective: Road traffic accidents are a global issue and serious threat for public health. Children are at high risk of serious injury or death from motor vehicle crashes. Child safety seats (CSSs) can reduce the risk of death and serious injury in children. This study was done to determine the prevalence of child safety seat use in vehicles and the factors influencing their use in a safe society (Tehran, Iran) in 2015. Methods: In this cross-sectional study, 804 parents with children under 12 years old who owned private cars were questioned in different areas of Tehran. A questionnaire included demographic data, and 2 specific questionnaires were used for families that used a CSS and those did not use a CSS. Univariate and multivariate binary logistic regression analyses were conducted. Crude and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated. All analyses were carried out using SPSS 21. Results: The prevalence of child safety seat use was 18.7% and was significantly higher among parents with an income greater than 50 million rials/month, parents who received child safety seat recommendations, parents living in the north of Tehran, and fathers with more driving experience. Age, weight, and height of children were also factors that influenced the use of child safety seats. The most common reasons for parents to use child safety seats was awareness about the benefits of this device and fear of harm to the child, and the most common reasons for nonuse were child intolerance while sitting in the seat and cost. Conclusion: The prevalence of child safety seat use in Tehran is very low, and most parents are not aware of the importance of child safety seats. Comprehensive programs, including legislation, law enforcement, public education, and publicity to promote the benefits of using CSSs, in Tehran can be an effective step toward increasing the use of child safety devices.

Objective: Motor vehicle occupants aged 8 to 12 years are in transition, in terms of both restraint use (booster seat or vehicle belt) and anatomical development. Rear-seated occupants in this age group are more likely to be inappropriately restrained than other age groups, increasing their vulnerability to spinal injury. The skeletal anatomy of an 8- to 12-year-old child is also in developmental transition, resulting in spinal injury patterns that are unique to this age group. The objective of this study is to identify the upper spine injuries commonly experienced in the 8- to 12-year-old age group so that anthropomorphic test devices (ATDs) representing this size of occupant can be optimized to predict the risk of these injuries., Methods: Motor vehicle crash cases from the National Trauma Data Bank (NTDB) were analyzed to characterize the location and nature of cervical and thoracic spine injuries in 8- to 12-year-old crash occupants compared to younger (age 0-7) and older age groups (age 13-19, 20-39)., Results: Spinal injuries in this trauma center data set tended to occur at more inferior vertebral levels with older age, with patients in the 8- to 12-year-old group diagnosed with thoracic injury more frequently than cervical injury, in contrast to younger occupants, for whom the proportion of cases with cervical injury outnumbered the proportion of cases with thoracic injury. With the cervical spine, a higher proportion of 8- to 12-year-olds had upper spine injury than adults, but a substantially lower proportion of 8- to 12-year-olds had upper spine injury than younger children. In terms of injury type, the 8- to 12-year-old group's injury patterns were more similar to those of teens and adults, with a higher relative proportion of fracture than younger children, who were particularly vulnerable to dislocation and soft tissue injuries. However, unlike for adults and teens, catastrophic atlanto-occipital dislocations were still more common than any other type of dislocation for 8- to 12-year-olds and vertebral body fractures were particularly frequent in this age group., Conclusions: Spinal injury location in the cervical and thoracic spine moved downward with age in this trauma center data set. This shift in injury pattern supports the need for measurement of thoracic and lower cervical spine loading in ATDs representing the 8- to 12-year-old age group.

Objective: Motor vehicle accidents, which are among the main causes of child mortality in Iran and the Middle East, impose staggering costs for the community. Ignoring use of safety devices for children in most motor vehicle crashes will lead to death or serious injury. Because few studies have been performed on effective and predictive factors regarding use of child safety seats, the purpose of this study was to examine the factors affecting the use and nonuse of child safety seats, along with the factors that can facilitate how a child safety seat is used. Method: This study was conducted in the urban area of Gorgan using a questionnaire. Through random selection, 204 parents with at least one child, aged 8 years or younger, reported their knowledge about the benefits of using a child safety seat. Results: The results showed that 80% of parents never use a child safety seat, and 13% always use a child safety seat. More than 93% thought that it was necessary to make usage of the child safety seat obligatory. In addition, 80% of parents believed that a child safety seat prevents children from injury in crashes. In addition, 38% of parents were not aware of child safety devices and child safety, less than 20% said that they did not use a child safety seat because their spouse did not support its use, and 28% of them thought that a child safety seat does not affect the safety of the child. In general, 91% of parents reported that if child safety seat use were mandated, the frequency of use would increase. A law on the use of child safety seats is a very important variable in their use, which can enhance the chance of using a child safety seat by 6.5 times. Conclusion: Special instructions should be developed to create incentive strategies for using a child safety seat. Mandating the use of a child safety seat, equipping cars with a child safety seat, encouraging children to use it, and providing continuous education and training are important factors for increasing the use of child safety seats.

Objective: Estimates of child restraint misuse rates in the United States range from 49% to 95%, but not all misuse modes have similar consequences in terms of restraint effectiveness. A series of laboratory sled tests was conducted to determine the effects of common misuses and combinations of misuses, including loose harness, loose installation, incorrect installation angle, incorrect belt path, loose/no tether, and incorrect harness clip usage. Methods: Three commercial convertible child restraint models were loaded with the Hybrid III 3-year-old anthropomorphic test device (ATD) and secured by either LATCH or seat belt on a modified FMVSS No. 213 bench. Tests were conducted in forward-facing (FF) and rear-facing (RF) modes. The response variables included ATD accelerations, excursions, and restraint kinematics. Belt/LATCH loads, tether loads, ATD kinematics, and restraint structural response data were also documented. A fractional factorial test design on 8 factors was used to define an initial series of 32 tests. The first series also included 4 tests of correct CRS, 2 forward facing and 2 rearward facing. The analysis of those data determined the selection of conditions for the remaining 20 tests to focus on factors and interactions of high interest and significance. Results: In the RF condition, misrouting the LATCH belt or seat belt through the incorrect belt path was the only misuse that significantly affected outcomes of interest and was associated with high levels of undesirable CRS rotation. In FF tests, loose installation and tether misuse had large adverse effects on 3 of 4 key response variables. Conclusion: The study provides strong evidence for prioritizing tight restraint installation and proper tether use for FF restraints. In particular, use of the tether helped offset the adverse effects of loose installation or loose harness. Because the results show that performance of a RF child restraint system (CRS) installation is less affected by user error, they also provide support for extended RF restraint use. In addition, packaging convertible child restraints with the LATCH belt routed through the RF belt path could help prevent the most consequential RF CRS misuse.

Introduction: 96 countries in the world have enacted child restraints and booster legislation (CRBL). Yet, findings regarding the effectiveness of CRBLs are mixed. The current study is the first to examine the association between Israel's CRBL, implemented in November 2004, and the traffic injury and fatality rates among children aged 0-9 years. We extend on previous studies by accounting for risk exposure and by comparing populations of children affected by the legislation to those who were not., Methods: We used an interrupted time series design of kilometre driven-based traffic injury rates for children aged 0-4 years and children aged 5-9 years using childred aged 10-14 years as a comparison group. We estimated the effects of Israel's CRBL using monthly injury and fatality count data from the Israeli Central Bureau of Statistics. The sample includes all child vehicle occupants injured and killed in crashes in Israel between January 2003 and December 2011., Results: Children aged 0-4 years experienced a 5.17% yearly reduction in traffic injury rate (incidence rate ratio (IRR): 0.94(95% CI 0.92 to 0.96); p=0.000), and the injury rate for children aged 5-9 years was associated with a 4.10% yearly reduction (IRR: 0.95(95% CI 0.93 to 0.98); p=0.001). The comprehensive CRBL implemented in Israel was associated with a 6.3% (95% CI -7.2% to5.5%; p=0.001) reduction in traffic injuries and fatalities for children aged 0-9 years., Conclusion: This is the first study comparing traffic injury rates per kilometre driven for motor vehicle-occupant children before and after the implementation of the CRBL in Israel., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: To evaluate the effectiveness of parent-based child restraint system (CRS) education and hands-on CRS installation training., Methods: We conducted a randomized trial with cluster sampling from May 2016 to January 2017 in 6 selected kindergarten classes in Shantou and Chaozhou, China. Parents were randomly assigned to receive 1 of the 3 study conditions: CRS education only, CRS education plus hands-on CRS installation training, or control (child electricity safety)., Results: Three months after the intervention, significantly higher CRS use was reported in the CRS education plus hands-on CRS installation training group than was reported in the control group (41.2% vs 18.5%; P = .011). However, no significant difference in CRS use was found between the CRS education only and the control groups (26.7% vs 18.5%; P = .33). The ratings on child passenger safety awareness increased significantly in both intervention groups but remained unchanged in the control group after the intervention., Conclusions: The CRS education plus hands-on CRS installation training increased the use of child restraints, but the CRS education only condition did not. Both intervention methods helped to improve child passenger safety awareness.

Objectives: To examine characteristics associated with cell phone use while driving by parents and caregivers of children ages 4-10 years., Study Design: National cross-sectional online survey with a convenience sample (March 2017-April 2017)., Inclusion Criteria: Parent/caregiver of a child age 4-10 years in their home, age ≥18 years, read and spoke English, and drove child ≥6 times in previous 3 months. Adjusted logistic regression analyses were modeled for outcome measures of previous 3-month self-report cell phone use while driving with the child., Results: The analytic sample was n = 760. In the previous 3 months, 47% of parent/caregivers talked on a hand-held phone, 52.2% talked on a hands-free phone, 33.7% read texts, 26.7% sent texts, and 13.7% used social media while driving with their child in the vehicle. Compared with those who always used their typical child restraint system, participants who did not always use were more likely to talk on a hands-free phone (aOR 1.97, 95% CI 1.26-3.09), read a text (aOR 1.74, 95% CI 1.11-2.73), send a text (aOR 1.65, 95% CI 1.04-2.62), and use social media (aOR 2.92, 95% CI 1.73-4.94) while driving. Higher income, not wearing a seat belt (driver) on every trip, and driving under influence of alcohol also were associated with various types of cell phone use while driving., Conclusions: Inconsistent child restraint system use, lack of seat belt use, and driving under the influence of alcohol are associated with parent/caregiver cell phone use while driving. Screening and education related to parental driving behaviors should include addressing multiple risk behaviors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Motor vehicle crashes (MVCs) are a leading cause of death among children. Multivariable analyses of age-appropriate child restraint system (CRS) use in the "booster-aged" population are needed. The current study identified factors associated with age-appropriate CRS use in fatal MVCs for children 4 to 7 years old, using 2011 to 2015 data from the Fatality Analysis Reporting System. Of 929 MVC fatalities, 32% of fatally injured children were in an age-appropriate restraint. While age-appropriate CRS use was higher for 4-, 5-, and 6-year-olds relative to 7-year-olds (adjusted relative risk [aRR] = 2.57, 2.51, and 2.18, respectively; p < .01 for each comparison), black children (aRR = 0.62; p < .01) relative to white children, and drivers who had not used a lap-shoulder belt (aRR = 0.40; p < .01) relative to belted drivers were associated with lower levels of age-appropriate CRS use. Our findings underscore the continued importance of communicating best practice guidelines on CRSs to caregivers of young children.

Objective: To determine through systematic review and meta-analysis of observational studies if booster seats, compared to seatbelts alone, reduce injury and mortality from motor vehicle collisions among child passengers four to eight years of age., Methods: A comprehensive search of several data sources (including Medline, Embase, and PsycINFO) was conducted from inception to December 2016, to retrieve relevant publications in any language and from any geographic region. Data extraction was completed by two independent reviewers, capturing: study details, population characteristics, exposure (booster seat compared to seat belt use), outcomes (injury and fatality), and all associations reported between the exposure and outcomes. Risk of bias assessment was completed by two reviewers using the QUIPS tool. Meta-analysis of sufficiently similar studies was conducted using random effects models., Results: Eleven observational studies were included in qualitative syntheses. The systematic review and meta-analysis found no association between booster seat use, compared to seatbelts, and reduced injury (4 studies, OR 1.03; 95% CI 0.53-1.99) or fatality (2 studies, OR 0.91; 95% CI 0.73-1.13)., Conclusions: Evidence on booster seat effectiveness to protect against injury and mortality in real-world conditions is limited. This review identified the need for high quality studies assessing the effects of different models of booster seats on children of varying ages and weights., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: This study evaluated the effectiveness of a series of 1-year multifaceted school-based programs aimed at increasing booster seat use among urban children 4-7 years of age in economically disadvantaged areas., Methods: During 4 consecutive school years, 2011-2015, the Give Kids a Boost (GKB) program was implemented in a total of 8 schools with similar demographics in Dallas County. Observational surveys were conducted at project schools before project implementation (P 0 ), 1-4 weeks after the completion of project implementation (P 1 ), and 4-5 months later (P 2 ). Changes in booster seat use for the 3 time periods were compared for the 8 project and 14 comparison schools that received no intervention using a nonrandomized trial process. The intervention included (1) train-the-trainer sessions with teachers and parents; (2) presentations about booster seat safety; (3) tailored communication to parents; (4) distribution of fact sheets/resources; (5) walk-around education; and (6) booster seat inspections. The association between the GKB intervention and proper booster seat use was determined initially using univariate analysis. The association was also estimated using a generalized linear mixed model predicting a binomial outcome (booster seat use) for those aged 4 to 7 years, adjusted for child-level variables (age, sex, race/ethnicity) and car-level variables (vehicle type). The model incorporated the effects of clustering by site and by collection date to account for the possibility of repeated sampling., Results: In the 8 project schools, booster seat use for children 4-7 years of age increased an average of 20.9 percentage points between P 0 and P 1 (P 0 = 4.8%, P 1 = 25.7%; odds ratio [OR] = 6.9; 95% confidence interval [CI], 5.5, 8.7; P < .001) and remained at that level in the P 2 time period (P 2 = 25.7%; P < .001, for P 0 vs. P 2 ) in the univariate analysis. The 14 comparison schools had minimal change in booster seat use. The multivariable model showed that children at the project schools were significantly more likely to be properly restrained in a booster seat after the intervention (OR = 2.7; 95% CI, 2.2, 3.3) compared to the P 0 time period and compared to the comparison schools., Conclusion: Despite study limitations, the GKB program was positively associated with an increase in proper booster seat use for children 4-7 years of age in school settings among diverse populations in economically disadvantaged areas. These increases persisted into the following school year in a majority of the project schools. The GKB model may be a replicable strategy to increase booster seat use among school-age children in similar urban settings.

Objective: The objective of this study was to analyze booster and rear vehicle seat dimensions to identify the most frequent compatibility problems., Methods: Measurements were collected from 40 high-back and backless boosters and 95 left rear and center rear row seating positions in 50 modern vehicles. Dimensions were compared for 3,800 booster/vehicle seat combinations. For validation and estimation of tolerance and correction factors, 72 booster installations were physically completed and compared with measurement-based compatibility predictions. Dimensions were also compared to the International Organization for Standardization (ISO) volumetric envelopes of forward-facing child restraints and boosters., Results: Seat belt buckles in outboard positions accommodated the width of boosters better than center positions (success rates of 85.4 and 34.7%, respectively). Adequate head restraint clearance occurred in 71.9 to 77.2% of combinations, depending on the booster's head support setting. Booster recline angles aligned properly with vehicle seat cushion angles in 71.5% of combinations. In cases of poor angle alignment, booster angles were more obtuse than the vehicle seat angles 97.7% of the time. Head restraint interference exacerbated angle alignment issues. Data indicate success rates above 90% for boosters being fully supported by the length of the seat cushion and for adequate height clearance with the vehicle roofline. Comparison to ISO envelopes indicates that most boosters on the U.S. market are taller and angled more obtusely than ISO target envelopes., Conclusions: This study quantifies some of the common interferences between boosters and vehicles that may complicate booster usage. Data are useful for design and to prioritize specific problem areas.

Objective: Traffic crashes have high mortality and morbidity for young children. Though many specialized child restraint systems improve injury outcomes, no large-scale studies have investigated the cross-chest clip's role during a crash, despite concerns in some jurisdictions about the potential for neck contact injuries from the clips. This study aimed to investigate the relationship between cross-chest clip use and injury outcomes in children between 0 and 4 years of age., Methods: Child passengers between 0 and 4 years of age were selected from the NASS-CDS data sets (2003-2014). Multiple regression analysis was used to model injury outcomes while controlling for age, crash severity, crash direction, and restraint type. The primary outcomes were overall Abbreviated Injury Score (AIS) 2+ injury, and the presence of any neck injury., Results: Across all children aged 0-4 years, correct chest clip use was associated with decreased Abbreviated Injury Scale (AIS) 2+ injury (odds ratio [OR] = 0.44, 95% confidence interval [CI], 0.21-0.91) and was not associated with neck injury. However, outcomes varied by age. In children <12 months old, chest clip use was associated with decreased AIS 2+ injury (OR = 0.09, 95% CI, 0.02-0.44). Neck injury (n = 7, all AIS 1) for this age group only occurred with correct cross-chest clip use. For 1- to 4-year-old children, cross-chest clip use had no association with AIS 2+ injury, and correct use significantly decreased the odds of neck injury (OR = 0.49; 95% CI, 0.27-0.87) compared to an incorrectly used or absent cross-chest clip. No serious injuries were directly caused by the chest clips., Conclusions: Correct cross-chest clip use appeared to reduce injury in crashes, and there was no evidence of serious clip-induced injury in children in 5-point harness restraints.

Objectives: In this study, we sought to accomplish the following objectives: to (1) calculate the percentage of children considered appropriately restrained across 8 criteria of increasing restrictiveness; (2) examine agreement between age- and size-based appropriateness criteria; (3) assess for changes in the percentage of children considered appropriately restrained by the 8 criteria between 2011 (shortly after updates to U.S. guidelines) and 2015., Methods: Data from 2 cross-sectional surveys of 928 parents of children younger than 12 years old (n = 591 in 2011, n = 337 in 2015) were analyzed in 2017. Child age, weight, and height were measured at an emergency department visit and used to determine whether the parent-reported child passenger restraint was considered appropriate according to 8 criteria. Age-based criteria were derived from Michigan law and U.S., Guidelines: Weight, height, and size-based criteria were derived from typical restraints available in the United States in 2007 and 2011. The percentage appropriate restraint use was calculated for each criterion. The kappa statistic was used to measure agreement between criteria. Change in appropriateness from 2011 to 2015 was assessed with chi-square statistics., Results: Percentage appropriate restraint use varied from a low of 19% for higher weight limits in 2011 to a high of 91% for Michigan law in 2015. Agreement between criteria was slight to moderate. The lowest kappa was for Michigan law and higher weight limits in 2011 (κ = 0.06) and highest for U.S. guidelines and lower weight limits in 2011 (κ = 0.60). Percentage appropriate restraint use was higher in 2015 than 2011 for the following criteria: U.S. guidelines (74 vs. 58%, P < .001), lower weight (57 vs. 47%, P = .005), higher weight (25 vs. 19%, P = .03), greater height (39 vs. 26%, P < .001), and greater size (42 vs. 30%, P = .001)., Conclusions: The percentage of children considered to be using an appropriate restraint varied substantially across criteria. Aligning the definition of appropriate restraint use with current U.S. guidelines would increase consistency in reporting results from studies of child passenger safety in the United States. Potential explanations for the increased percentage of children considered appropriately restrained between 2011 and 2015 include adoption of the updated U.S. guidelines and the use of child passenger restraints with higher weight and height limits.

Seat belt and child restraint use is noted to be poor in developing countries such as Ghana. An unobstructive observational survey guided by the Theory of Planned Behaviour was therefore conducted to assess seat belt and child restraint use in the Cape Coast Metropolis, Ghana. The observational survey was carried out at the entrances of four nursery schools in medium and high class residential areas in the Metropolis to determine seat belt use by drivers and accompanied child being transported/dropped off in school. The results revealed that a total of 1922 vehicles comprising 826(43.0%) cars, 350(18.2%) SUV, 644(33.5%) taxis and 102(5.3%) mini buses with 3844 vehicle occupants comprising 1922 drivers and child apiece were successively observed. The majority of the drivers (53.1%) did not use the seat belt with 13.2% of the children been restrained. The gender of the driver has a relationship with the seat belt use. The vehicle type has a relationship with the child restraint use and the gender of the driver has a significant relationship with child restraint use. The enforcement of the Road Traffic Act 2004 and Road Traffic Regulation 2180 by the officials of Motor Transport and Traffic Department(MTTD) of the Ghana Police Service in collaboration with National Road Safety Commission (NRSC) can establish social norms that may have a greater potential to enhance seat belt and child restraint use in the Metropolis., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Motor vehicle collisions (MVCs) are a significant cause of pediatric morbidity, particularly in low- to middle-income countries. We describe car seat use in children on the USA-Mexico border. A retrospective review was conducted for children 0-9 years old, admitted to the region's only Level I trauma center. Simultaneously, data were obtained from the SAFE KIDS database, a program that encourages car seat use through city checkpoints. There were 250 MVC admissions and nine fatalities in children 0-9 years old from 2010 to 2015. Nine percent of MVCs occurred in Mexico and 49% in El Paso, TX. Comparing trauma admissions to SAFE KIDS, there was some correlation between the location of MVCs and screening checkpoints (r = .50). There was a weaker correlation between injured children's neighborhoods and screening locations (r = .32). Only 37% of parents knew the crash history of the car seat and 3% were using a car seat previously involved in an MVC. While 96% of inspected children were placed appropriately in the backseat, 80% of children were found to be inappropriately restrained. Younger children more likely to be restrained (p < .05). Children from New Mexico and Mexico had the lowest rates of proper restraint and the highest injury severity scores. Proper use of car seats is a public health concern on the USA-Mexico border, and children are not properly restrained. Screening may be improved by focusing where at-risk children live and where most accidents occur. Restraint education is needed, particularly in New Mexico and Mexico.

Booster seat use for 4-9 year olds remains the lowest of all age groups in many countries. The objective of this study is to examine whether parents' decision-making patterns, as measured by the Melbourne Decision Making Questionnaire, relate to car booster seat use. Israeli parents of 4-7 years old children (n = 398) answered a questionnaire about car safety and decision-making habits. Ninety per cent of parents reported having a booster seat; 70.5% reported consistent booster seat use in general and on short drives during the last month (booster seat use compliance index). Greater compliance index was positively related to a vigilant decision-making pattern, passenger compliance with rear seat belts and families with fewer children. Lower booster seat use compliance index was associated with buck-passing decision-making pattern. Health professionals and policy-makers should take into account parents' habitual decision-making patterns when designing interventions for car booster seat compliance.

Background: Unintentional injuries are the leading cause of death in children ages 1-18 years. Many of these injuries to young children occur in their own homes. Although research has explored injury risk prevention strategies, historically, much of this research has focused on environmental changes and teaching safety practices. Currently, there appears to be a gap in current research exploring how parenting influences children's risk of injury., Methods: Mothers (n = 119) of children 5 years and younger were recruited from a paediatric clinic as a part of a larger study and completed measures of parenting challenges, developmentally sensitive parenting, child neglect, parental efficacy, and risk of potential injury situations. Hierarchical logistic regression was used to explore the extent to which developmentally insensitive parenting behaviours put parents at higher risk for behaviours that lead to unintentional injury in children and whether developmentally sensitive parenting behaviours protects children from injury. The association between demographic characteristics and injury risk behaviours was also examined., Results: Parents who reported more frequent insensitive parenting behaviours (i.e., yelling, spanking, and putting child in time out) were more likely to report putting their child in an incorrect car seat or taking their child out of a car seat while the car is still moving. In addition, younger parents were at greater risk of storing cleaners and medications unsafely., Conclusion: Results from this study highlight the importance of supporting younger mothers and educating parents on effective parenting strategies when trying to prevent unintentional injury risks., (© 2017 John Wiley & Sons Ltd.)

Objective: Child restraint system (CRS) is designed to protect children from injury during motor vehicle crash (MVC). However, there is no regulation or enforcement of CRS use in Saudi Arabia. This study estimated the prevalence of CRS use and identified patterns of child transportation in Riyadh, Saudi Arabia., Methods: In this cross-sectional study, a self-administered questionnaire was distributed across Riyadh targeting families who drove with children aged less than 5 years. The questionnaire inquired about CRS availability, patterns of child transportation if a CRS was unavailable, seat belt use by the driver and adult passengers, and the perception of CRS., Results: Of 385 respondents, only 36.6% reported the availability of a CRS (95% CI: 31.8-41.7%), with only half of those reported consistent use 74 (52.2%). Nearly 30% of all children aged less than 5 years were restrained during car journeys. Sitting on the lap of an adult passenger on the front seat was the most common pattern of child transportation (54.5%). Approximately 13.5% of respondents were involved in an MVC while driving with children; 63.5% of these children were unprotected by any safety system. Seat belt use by drivers was low, with only 15.3% reporting constant use., Conclusion: The prevalence of CRS use in Riyadh is low, and safety practices are seldom used by drivers and passengers. In addition to legal enforcement of CRS use, implementation of a child transportation policy with age-appropriate height and weight specifications is imperative.

Objective: The objective of this article is to compare the performance of forward-facing child restraint systems (CRS) mounted on 2 different seats., Methods: Two different anthropomorphic test device (ATD) sizes (P3 and P6), using the same child restraint system (a non-ISOFIX high-back booster seat), were exposed to the ECE R44 regulatory deceleration pulse in a deceleration sled. Two different seats (seat A, seat B) were used. Three repetitions per ATD and mounting seat were done, resulting in a total of 12 sled crashes. Dummy sensors measured the head tri-axial acceleration and angular rate and the thorax tri-axial acceleration, all acquired at 10,000 Hz. A high-speed video camera recorded the impact at 1,000 frames per second. The 3D kinematics of the head and torso of the ATDs were captured using a high-speed motion capture system (1,000 Hz). A pair-matched statistical analysis compared the outcomes of the tests using the 2 different seats., Results: Statistically significant differences in the kinematic response of the ATDs associated with the type of seat were observed. The maximum 3 ms peak of the resultant head acceleration was higher on seat A for the P3 dummy (54.5 ± 1.9 g vs. 44.2 ± 0.5 g; P =.012) and for the P6 dummy (56.0 ± 0.8 g vs. 51.7 ± 1.2 g; P =.015). The peak belt force was higher on seat A than on seat B for the P3 dummy (5,488.0 ± 198.0 N vs. 4,160.6 ± 63.6 N; P =.008) and for the P6 dummy (7,014.0 ± 271.0 N vs. 5,719.3 ± 37.4 N; P =.015). The trajectory of the ATD head was different between the 2 seats in the sagittal, transverse, and frontal planes., Conclusion: The results suggest that the overall response of the booster-seated occupant exposed to the same impact conditions was different depending on the seat used regardless of the size of the ATD. The differences observed in the response of the occupants between the 2 seats can be attributed to the differences in cushion stiffness, seat pan geometry, and belt geometry. However, these results were obtained for 2 particular seat models and a specific CRS and therefore cannot be directly extrapolated to the generality of vehicle seats and CRS.

Objective: A child safety restraint (CSR) is an effective measure to reduce the risk of child injury from traffic collisions. This study aims to explore knowledge, attitudes, and behaviors regarding CSRs in a Chinese population., Methods: A cross-sectional survey regarding CSR use was conducted from April to May 2014 in Shenzhen municipality. Respondents were parents who had at least one child 0 to 6 years of age and owned a car. These parents provided a self-report of demographic characteristics as well as information about their knowledge, attitudes, and behaviors toward CSR use., Results: Most respondents had a fair level of knowledge about CSRs, with higher mean knowledge scores demonstrated among the respondents who were male, had an advanced degree, had a higher income, owned an expensive car, had an older child, drove frequently with children, and routinely drove greater distances with children. In addition, most respondents had a more positive attitude toward CSR use, with a higher mean attitude score among those who had an advanced degree, owned an expensive car, drove frequently with children, and routinely drove greater distances with children. However, some myths regarding CSR use also existed (e.g., parents can effectively protect their children in a car collision by holding them, they are not required to purchase the CSR for child safety if there is no mandatory provision by law, among others). Among 3,768 respondents who had at least one child and a car, 27.8% (1,047) had a CSR and 22.9% (864) used the CSR. A logistic regression model showed the likelihood of CSR ownership to be higher if respondents drove frequently or greater distances and was dependent on both the education level of the respondents and the age of the children. The frequency of CSR use increased as the age of children decreased (P = .0274). Respondents who owned a CSR and those who frequently used CSRs had higher mean knowledge and mean attitude scores., Conclusions: This observational study found that although the majority of respondents had fair levels of knowledge and positive attitudes, they had lower rates of CSR ownership and use. Therefore, efforts at developing opportunities to expand public awareness of CSR use should be made to improve child passenger safety practices and eliminate child injury caused by traffic collisions.

Objectives: The objective of this study was to determine whether the amount of tension required for proper child restraint system (CRS) installation varies with lower anchor spacing and to determine whether nonexperts can produce adequate tension on wider-than-standard lower anchor configurations., Methods: CRSs were installed by certified child passenger safety technicians (CPSTs; n = 6 subjects, n = 72 installations) and nonexperts (n = 30 subjects, n = 120 installations) on a mock-up vehicle seat fixture with lower anchors set at 11 (standard), 15, 19, and 23 in. apart from one another. Each CPST installed a rear-facing (RF) infant base, RF convertible, and forward-facing (FF) convertible into each of the 4 spacing configurations in random order. The CPSTs were instructed to tighten the lower connector strap until the tension was exactly at the threshold between passing and failing the 1-in. test. Each nonexpert installed one CRS model into all 4 spacing conditions in random order. Nonexperts were instructed to install the CRS to the best of their ability. The tension produced on the lower connector strap was recorded via load cell in the lower anchor assembly of the vehicle seat. Resultant tension magnitudes were compared across spacing conditions using matched pair t-tests. The CPSTs' mean 1-in. test threshold values were compared to tensions produced by nonexperts. Installations were visually evaluated for errors and qualitative usability feedback was collected via survey., Results: CPSTs installed the infant base with higher tensions in the 15-, 19-, and 23-in. configurations compared to the standard 11-in. configuration (P = .034, .032, and .003, respectively). The nonexperts installed the infant base with higher tension in the 15- and 23-in. configurations compared to the 11-in. configuration (P = .004 and .026, respectively). The RF convertible and FF convertible installations showed no significant differences in tension among any of the spacing configurations for either group. Only 19% of the nonexperts' installations were tight enough to pass CPST thresholds, and the pass rate did not vary with respect to lower anchor spacing. In feedback surveys, the nonexpert group did not show a consistent preference for either standard or wider-than-standard lower anchor configurations., Conclusions: The amount of tension required to pass the 1-in. rule did not vary with lower anchor spacing configurations for the RF and FF convertible CRS, but the infant base required more tension in wider anchor configurations. Nonexperts tended to produce less than ideal tension in all configurations, although their tension magnitudes increased for the infant base in wider configurations.

Background: Although morbidity and mortality in children increases in motor vehicle collisions (MVC) if child restraints are not used, no data exist correlating specific injuries with proper or improper use of safety restraints or age. The purpose of this study was to evaluate correlations between childhood MVC injuries, age, and restraint status., Methods: A medical record search for pediatric patients involved in a MVC was conducted at a pediatric hospital (level 1 trauma). Charts were reviewed for demographics and injury-specific information. Patients were grouped by age, restraint use, and injuries., Results: Nine hundred sixty-seven patients ≤12 years (average age 6.39 y) were identified. Being properly restrained was most common in all age groups except the 4- to 8-year age group in which being improperly restrained was most common. Unrestrained patients were most commonly found in the 9- to 12-year age group. A statistically significant difference was not observed for orthopaedic injuries among the restraint groups, but internal thoracic injuries, open head wound, and open upper extremity wounds were significantly more common in improperly or unrestrained patients. Improperly restrained infants had a significantly higher rate of intracranial bleeds and abrasions than those properly restrained. Unrestrained and improperly restrained 9- to 12-year olds had significantly more open head, open upper extremity, and vascular injuries. When comparing injury types with age groups, upper extremity fractures, femoral fractures, dislocations, and spinal fractures were found to be significantly higher in older children., Conclusions: Preventing orthopaedic injuries in older children may be accomplished by changes in regulations or automotive safety equipment. Rear-facing child safety seats could possibly be improved to prevent head trauma in the youngest patients. There is a continued need to reinforce the importance of proper use of child safety devices to parents. Knowledge of the patient's age, along with restraint status, might aid in diagnosis of less obvious MCV injuries., Level of Evidence: Level III.

Background: Few published studies have examined child passenger safety practices across countries. This study compared the prevalence and associated factors of child passenger restraint use among children, aged 0 to 17 in the state of Iowa in the United States, and the city of Shantou in China., Methods: Child restraint use observations were conducted in Iowa and in Shantou in 2012, respectively, among child passengers. Observations in Iowa were conducted at randomly selected gas stations, while in Shantou observations were completed at randomly selected schools or medical clinics. Research observers approached the driver, observed restraint use, and collected brief survey data., Results: A total of 3049 children from Iowa and 3333 children aged 0 to 17 years from Shantou were observed. For children aged 0 to 3 years, only 0.1% were compliantly restrained in Shantou as compared to 95.9% in Iowa. The proportion of children who were compliantly restrained in Shantou increased with age, but generally decreased with age in Iowa. In Shantou, 36.0% of children aged 0 to 3 were sitting in the front seat as compared to only 1.7% of children of the same age in Iowa. Driver seat belt use was significantly associated with child restraint in both Iowa and Shantou; the association was stronger in Iowa than Shantou for all age groups., Conclusions: A significantly higher prevalence of children who were not appropriately restrained was observed in Shantou than in Iowa. Our findings support the need of mandatory child safety restraint use legislation in China.

Objectives: The objective of this study was to identify factors that predict restraint use and optimal restraint use among children aged 0 to 13 years., Methods: The data set is a national sample of police-reported crashes for years 2010-2014 in which type of child restraint is recorded. The data set was supplemented with demographic census data linked by driver ZIP code, as well as a score for the state child restraint law during the year of the crash relative to best practice recommendations for protecting child occupants. Analysis used linear regression techniques., Results: The main predictor of unrestrained child occupants was the presence of an unrestrained driver. Among restrained children, children had 1.66 (95% confidence interval, 1.27, 2.17) times higher odds of using the recommended type of restraint system if the state law at the time of the crash included requirements based on best practice recommendations., Conclusions: Children are more likely to ride in the recommended type of child restraint when their state's child restraint law includes wording that follows best practice recommendations for child occupant protection. However, state child restraint law requirements do not influence when caregivers fail to use an occupant restraint for their child passengers.

Objective: Although numerous research studies have reported high levels of error and misuse of child restraint systems (CRS) and booster seats in experimental and real-world scenarios, conclusions are limited because they provide little information regarding which installation issues pose the highest risk and thus should be targeted for change. Beneficial to legislating bodies and researchers alike would be a standardized, globally relevant assessment of the potential injury risk associated with more common forms of CRS and booster seat misuse, which could be applied with observed error frequency-for example, in car seat clinics or during prototype user testing-to better identify and characterize the installation issues of greatest risk to safety., Methods: A group of 8 leading world experts in CRS and injury biomechanics, who were members of an international child safety project, estimated the potential injury severity associated with common forms of CRS and booster seat misuse. These injury risk error severity score (ESS) ratings were compiled and compared to scores from previous research that had used a similar procedure but with fewer respondents. To illustrate their application, and as part of a larger study examining CRS and booster seat labeling requirements, the new standardized ESS ratings were applied to objective installation performance data from 26 adult participants who installed a convertible (rear- vs. forward-facing) CRS and booster seat in a vehicle, and a child test dummy in the CRS and booster seat, using labels that only just met minimal regulatory requirements. The outcome measure, the risk priority number (RPN), represented the composite scores of injury risk and observed installation error frequency., Results: Variability within the sample of ESS ratings in the present study was smaller than that generated in previous studies, indicating better agreement among experts on what constituted injury risk. Application of the new standardized ESS ratings to installation performance data revealed several areas of misuse of the CRS/booster seat associated with high potential injury risk., Conclusions: Collectively, findings indicate that standardized ESS ratings are useful for estimating injury risk potential associated with real-world CRS and booster seat installation errors.

Belt-positioning booster seat use (BPB) is an effective technology to prevent severe child injury in cases of car crash. However, in many countries, age-appropriate car restraint use for children aged 4-7 years old remains the lowest among all age groups. The aim of this study was to identify the main determinants of BPB use through a comprehensive approach. An ecological model was used to analyze individual, parent-child relationships, and neighborhood characteristics. Parents of children enrolled in the first and second grades completed a self-reported questionnaire (n=745). The data were subjected to multilevel modeling. The first level examined individual and parent-child relationship variables; in addition the second level tested between neighborhood variance. According to parental self- reports, 56.6% of their children had used a BPB on each car trip during the previous month. The results indicated that the determinants positively related to BPB use were individual and parental; namely, the number of children in the family, the parents' car seat belt use, parental knowledge of children's car safety principles, and a highly authoritative parenting style. Children's temperaments and parental supervision were not associated with BPB use. At the neighborhood level, a small difference was found between neighborhoods for BPB users compared to non-users., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The objective of this study is to determine the association between Chile's 2005 child restraint legislation (CRL) and the incidence of severe paediatric motor vehicle-related injury., Methods: We analysed motor vehicle injury data from Chile's Road Safety Commission from 2000 to 2012 to determine the association between Chile's 2005 CRL and severe paediatric injury. Using Poisson time-series models we assessed the effect of the law on two outcome variables: (1) severely injured children per vehicle fleet; and (2) severely injured children per population., Results: Chile's 2005 CRL is significantly associated with a 24% reduction in severely injured children per vehicle, and 19% reduction in severely injured children per population in the 1st year of its enactment. In 2007 this law is also significantly associated with a 17% decrease in severely injured children per vehicle, and with an 11% decrease in severely injured children per population. However, this legislation had a short-term effect since no reductions in severely injured children per vehicle were observed after 2009 and no reductions for severely injured children per population were registered after 2008., Conclusions: This is the first study to examine the association between CRL and severe paediatric injury in a Latin-American country. This study suggests that Chile's CRL was only effective in the short term. To support this type of reforms in the long term, other measures such as police enforcement, public information campaigns and involvement of public health professionals in educating parents about the benefits of using child restraints should be considered., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)