Commentary

Abstract

[McKay MP. Commentary: Broken Children: 100% Preventable. Ann Emerg Med. 2010;56:688-689.] In 2008, 454 vehicle occupants aged 7 years and younger were fatally injured in crashes on public roads in the United States.1National Highway Traffic Safety AdministrationFatality analysis reporting system encyclopedia Queried using year 2008, ages 0-7, passenger in passenger vehicle of body type 1-49, killed.http://www-fars.nhtsa.dot.gov/QueryTool/QuerySection/Report.aspxGoogle Scholar In every single one of these cases, someone—an emergency physician, a trauma surgeon, or a police officer—had to tell the parents their infant, toddler, or young child was dead. Telling families bad news is never an easy part of our jobs, but telling the parents that we could not save their daughter or son is truly onerous. Telling them while recognizing that the fatal injury could have easily been prevented (often by the parents themselves) makes the job even more painful. Today's report from the National Highway Traffic Safety Administration (NHTSA) outlines the details surrounding some of these cases.2Hanna R. Children Injured in Motor Vehicle Traffic Crashes. National Highway Traffic Safety Administration, Washington, DC2010http://www-nrd.nhtsa.dot.gov/Pubs/811325.PDFGoogle Scholar The first group of analyses used the National Automotive Sampling Survey, which investigates a sample of tow-away crashes and uses a weighting process to provide national estimates of various crash details. There are 2 particularly frightening results of this section of the report. The first is the number of children riding without an appropriate restraint when they were involved in the crash: 15% of infants, 27% of 1- to 3-year-olds, and 86% of 4- to 7-year-olds were not using an age-appropriate child restraint at their crash. Child safety seats unequivocally save lives. They are 71% effective in reducing fatalities among infants and 54% effective for toddlers (1 to 4 years old) in passenger cars. For infants and toddlers in light trucks, the effectiveness in reducing fatalities is 58% and 59%, respectively.3National Highway Traffic Safety AdministrationTraffic safety facts 2006: children.http://www.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/810618.pdfGoogle Scholar And for children aged between 4 and 8 years, belt-positioning booster seats decrease the risk of injury to children in crashes by 45% to 59% compared with the use of vehicle safety belts alone.4Durbin D.R. Elliott M.R. Winston F.K. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes.JAMA. 2003; 289: 2835-2840Crossref PubMed Scopus (273) Google Scholar, 5Arbogast K.B. Jermakian J.S. Kallan M.J. et al.Effectiveness of belt position booster seats: an updated assessment.Pediatrics. 2009; 124: 1281-1286Crossref PubMed Scopus (137) Google Scholar The results of the report today further demonstrate that child restraints prevent injuries: those who were properly restrained were much less likely to have any injury. The greatest benefit of child restraints in this report was for children involved in rollovers, in which the restraint may have prevented as many as two thirds of the incapacitating injuries otherwise sustained. NHTSA first established minimum standards for child restraints in 1971, and the first legislation requiring the use of child safety seats was passed in Tennessee in 1978.6Governor's Highway Safety AssociationOccupant protection.http://www.ghsa.org/html/issues/occupantprotection.htmlGoogle Scholar Child passenger restraints were mandatory across the United States for children younger than 4 years by 1991, and vehicle models from 1999 and later are required to include the LATCH system (lower anchor and tethers for children) to make accurate installation easier (see http://www.nhtsa.gov/Safety/LATCH for more information). During the decade of this report, nearly all states upgraded their legislation by requiring booster seats for children older than 3 years. As of August 2010, only 1 state (Florida) has not yet done so. Two states cover children through age 4 years (South Dakota and Arizona), 12 cover children through age 5 years, 6 cover children up to age 6 years, 27 states and the District of Columbia through age 7 years, and 2 states (Wyoming and Tennessee) require boosters through age 8 years.7Insurance Institute for Highway SafetyChild restraint laws, August 2010.http://www.iihs.org/laws/ChildRestraint.aspxGoogle Scholar Observed use of child restraints in 2008 (the most recent data available) paints a somewhat rosier picture, but there are significant decreases in observed car seat use if the driver is not using his or her safety belt. These are observations from the side of the road, conducted during the day, and the observers do have to make some assumptions about the occupant's age. Infants were in rear-facing seats 98% of the time, toddlers (1 to 3 years old) were in child seats 95% of the time if the driver was belted but only 73% of the time if the driver was unbelted, and children aged 4 to 7 years were using a booster seat 87% of the time if the driver was belted but only 39% of the time if the driver was unbelted.8National Highway Traffic Safety AdministrationTraffic safety facts, research note Child restraint use in 2008—overall results.National Highway Traffic Safety Administration. May 2009http://www-nrd.nhtsa.dot.gov/Pubs/811135.PDFGoogle Scholar A piece of this story is probably willingness to take risks and understanding the benefits of restraint use. The idea that drivers who are not belted are both less likely to restrain their young passengers and more likely to be involved in a crash explains many of the above results. The second highly concerning finding from today's report is that among vehicles in crashes between 1999 and 2008, 8% of both infants and toddlers and 16% of 4- to 7-year-olds were riding in the front seat. Much of the importance of this result has to do with risk of injury from air bags. On May 1, 1996, NHTSA issued the following statement: “Infants in rear-facing child safety seats should never be placed in the front seat if the vehicle has a passenger-side air bag. The safest place for children of all ages is the back seat. If riding in the back seat is not an option, toddlers and older children may ride in the front seat of a vehicle with a passenger-side air bag, but only if buckled up properly and with the seat moved as far back as possible.”9Kahane C. Fatality Reduction by Air Bags: Analyses of Accident Data Through Early 1996. National Highway Traffic Safety Administration, Washington, DC1996http://www.nhtsa.gov/cars/rules/regrev/evaluate/808470.htmlGoogle Scholar NHTSA spent a lot of money and effort to promote the concept of “babies ride in back” to prevent fatal injuries from the deploying passenger air bag, which became required standard equipment in all passenger vehicles in 1999. However, as of August 2010, only 16 states had enacted legislation aimed at ensuring that children of any age are seated in a rear seat.7Insurance Institute for Highway SafetyChild restraint laws, August 2010.http://www.iihs.org/laws/ChildRestraint.aspxGoogle Scholar (Most states with such legislation have an “escape clause” if the air bag has been deactivated or there is no ability to place the child in back: no seat, too many children, too much necessary cargo.) Again the data from observed traffic paints a rosier picture: 99% of infants, 98% of toddlers, and 88% of 4- to 7-year-olds were observed riding in a rear seat.8National Highway Traffic Safety AdministrationTraffic safety facts, research note Child restraint use in 2008—overall results.National Highway Traffic Safety Administration. May 2009http://www-nrd.nhtsa.dot.gov/Pubs/811135.PDFGoogle Scholar The second section of today's report deals with the types and severity of injuries sustained by 1- to 7-year-olds in the National Trauma Data Bank's National Sample Project. These cases are limited to significantly injured children rather than all children involved or injured in crashes and cannot accurately reflect restraint use (it is a medical database) but provide a lot more detail about the injuries sustained. The results are not likely to surprise emergency physicians; by far the body area mostly likely to be injured in this group was the head, followed by the thorax for infants and the lower extremity for the toddlers and 4- to 7-year-olds. More than half the head injuries in all age groups involved intracranial bleeding (contusion, subarachnoid, subdural, or other); lung injuries were present in one third of chest injuries among infants but were found in two thirds of chest injuries to older children. Although no case-specific information is available, these injured children were quite likely to have been unrestrained, according to the effectiveness described above. What does all this have to do with the local emergency physician working an everyday shift? Plain and simple, our adult patients are more likely to be risk-taking, non-belt-wearing, more-likely-to-crash drivers than patients who routinely show up in the primary care physician's office for preventive care. We may be the biggest source for “physician's advice” that some high-risk adults are going to have. Thus, when patients come in with young children (whether the adult or the child is the patient), it is important to make sure that we ask about restraint use (rear-facing until both age 1 year and 20 pounds, forward facing with a 5-point harness until age 4 years, and booster seat until 4 feet 9 inches) and where the child sits in the family vehicle (in back). If we can prevent just one of us from having to deliver awful news about a fatal injury with such a truly brief intervention, it is worth it. In addition, our nursing staff can reinforce it, aided by a quick table outlining age/size and the appropriate restraint type printed automatically on discharge instructions, something already shown to be helpful in getting parents to use the right restraint.10Zonfrillo M.R. Mello M.J. Palmisciano L.M. Usefulness of computerized pediatric motor vehicle safety discharge instructions.Acad Emerg Med. 2003; 10: 1131-1133Crossref PubMed Google Scholar So the first thing we should do is talk to our adult patients. The second thing is to work on improving the legislation in each state to include a requirement that young children ride in a rear seat. The absence of such legislation in 34 states and the District of Columbia means that police officers will be less effective in keeping kids riding in the back, and just knowing there is a chance of a ticket may motivate some drivers to move the young kids rearward. Emergency physicians can work on this through state American College of Emergency Physicians chapters, in conjunction with the American Academy of Pediatrics (http://www.aap.org/) and such groups as SafeKids (http://www.safekids.org/) and other local groups. Bottom line? If every kid rode in an age- and size-appropriate child restraint in a rear seat on every single trip, we would have to do about two thirds fewer painful notifications. That sounds like something worth working on to me. Children Injured in Motor Vehicle Traffic CrashesAnnals of Emergency MedicineVol. 56Issue 6Preview[National Highway Traffic Safety Administration. Children Injured in Motor Vehicle Traffic Crashes. Ann Emerg Med. 2010;56:687-688.] Full-Text PDF