Children In Motor Vehicle Crashes Research Articles

Prevalence of Abuse and Additional Injury in Young Children With Rib Fractures as Their Presenting Injury.

The primary objective of this study was to determine the prevalence of (a) additional injuries, (b) abuse as determined by a standardized scale, and (c) reports to child protective services (CPS) among children younger than 5 years in whom a rib fracture was the first presenting injury concerning for abuse. A retrospective study of children younger than 5 years diagnosed with rib fractures at a tertiary pediatric hospital between 2007 and 2018 was performed. Children in motor vehicle crashes, hospitalized after birth, or with previously diagnosed metabolic bone disease were excluded. We included only those children whose rib fractures were the first presenting injury. Demographic and clinical information was abstracted from the records. Prevalence of additional injuries, a diagnosis of abuse, and a report to CPS were calculated. Associations between patient demographic and clinical characteristics and the outcomes of interest were examined. Of the 67 cases included, additional injuries concerning for abuse were identified in 40 (60%), and 58% were deemed likely or definite abuse. Reports to CPS were filed in 72% of cases. Posterior rib fractures, multiple rib fractures, and presence of rib fractures of multiple ages were all associated with presence of additional injuries and classification as definite or likely abuse (all P ≤ 0.05). The presence of a rib fracture in young children is associated with a high likelihood of additional concerning injuries and should prompt a thorough evaluation for child abuse.

Construction of a Statistical Cervical Vertebrae Geometric Model for Children 3-10Years Old.

Cervical spinal injuries of children in motor vehicle crashes have high morbidity and mortality rates. Cervical vertebrae change rapidly in both size and shape during growth. To accurately assess the risk of spinal injury for children of different ages, it is necessary to understand how the spatial geometric features of vertebrae change with the child's age and neck size. In this study, an innovative semi-automated method was developed that can extract and align geometric points from computed tomography scans to accurately represent complex three-dimensional vertebral geometry. Based on these spatial geometric points, a statistical cervical vertebrae geometry model for children aged 3-10 YO was established based on principal component analysis and multivariate regression. According to this model, the vertebra spatial geometries for children of different ages and neck circumferences were represented, and its variation with age were accounted for. Statistical results show that age has a significant effect on anterior-posterior length (APL), transverse process width (TPW), vertebral body circumference (VBC) and height (VBH), whereas the significance of location and its interaction with age effects on these four parameters are different. The VBC and VBH increase more rapidly with age than the APL and TPW. In addition, the APL of C6 and C7 increase significantly faster than that of C3. As for the shape changes with child growth, the inclination angle of the upper surface of the lateral mass for C1 and the tilt angle of the articular process of the articular facet joint for C3-7 increase; and the shape of odontoid process of C2 becomes higher and steeper. This study can provide geometric basis for developing multiple pediatric cervical finite element models and anthropomorphic test devices to further quantify child neck injury risk with different ages and neck geometries.

Predicting Pediatric Patients Who Require Care at a Trauma Center: Analysis of Injuries and Other Factors

Triage decision correctness for children in motor vehicle crashes can be affected by occult injuries. There is a need to develop a transfer score (TS) metric for children that can help quantify the likelihood that an injury is present that would require transfer to a trauma center (TC) from a non-TC, and improve triage decision making. Ultimately, the TS metric might be useful in an advanced automatic crash notification algorithm, which uses vehicle telemetry data to predict the risk of serious injury after a motor vehicle crash using an approach that includes metrics to describe injury severity, time sensitivity, and predictability. Transfer score metrics were calculated in 4 pediatric age groups (0 to 4, 5 to 9, 10 to 14, 15 to 18 years) for the most frequent motor vehicle crash injuries using the proportions of children transferred to a TC or managed at a non-TC using the National Inpatient Sample years 1998 to 2007. To account for the maximum Abbreviated Injury Scale (MAIS) injury, a co-injury adjusted transfer score (TSMAIS) was calculated. The TS and TSMAIS range from 0 to 1, with 1 indicating highly transferred injuries. Injuries in younger patients were more likely to be transferred (median TS 0.48, 0.35, 0.25, and 0.23 for 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years, respectively). Injuries more likely to be transferred in younger children occurred in the thorax and abdomen. Regardless of age, spine (median TSMAIS 0.59), head (median TSMAIS 0.48), and thorax (median TSMAIS 0.46) injuries had the highest frequency for transfer. The TS metrics quantitatively describe age-specific transfer practices for children with particular injuries. This information can be useful in advanced automatic crash notification systems to alert first responders to the possibility of occult injuries and reduce undertriage of commonly missed injuries.

Disability risk in pediatric motor vehicle crash occupants.

Mortality rates among children in motor vehicle crashes (MVCs) are typically low; however, nonfatal injuries can vary in severity by imposing differing levels of short- and long-term disability. To better discriminate the severity of nonfatal MVC injuries, a pediatric-specific disability risk (DR) metric was created. The National Automotive Sampling System 2000 to 2011 was used to define the top 95% most common Abbreviated Injury Scale (AIS) 2+ injuries among pediatric MVC occupants. Functional Independence Measure scores were abstracted from the National Trauma Data Bank 2002 to 2006. Multiple imputation was used to account for missing data. The DR and coinjury-adjusted DR (DRMAIS) of the most common AIS 2+ MVC-induced injuries were calculated for 7-year-old to 18-year-old children by determining the proportion of those disabled after an injury to those sustaining the injury. DR and DRMAIS values ranged from 0 to 1, representing 0% to 100% DR. The mean DR and DRMAIS of all injuries were 0.290 and 0.191, respectively. DR and DRMAIS were greatest for injuries to the head (DR, 0.340; DRMAIS, 0.279), thorax (DR, 0.320; DRMAIS, 0.233), and spine (DR, 0.315; DRMAIS, 0.200). The mean DR and DRMAIS increased with increasing AIS severity but there was significant variation and overlapping values across AIS severity levels. Comparison of DRMAIS to coinjury-adjusted mortality risk (MRMAIS) revealed that among 118 injuries with MRMAIS of 0.000, DRMAIS ranged from 0.000 to 0.429. Incorporation of DR metrics into injury severity metrics may improve the ability to distinguish between the severity of different nonfatal injuries. This is especially crucial in the pediatric population where permanent disability can result in a high number of years lost due to disability. The accuracy of such severity metrics is crucial to the success of pediatric triage algorithms such as Advanced Automatic Crash Notification algorithms. Epidemiologic/prognostic study, level III.

Head injuries (TBI) to adults and children in motor vehicle crashes

ABSTRACTPurpose: This is a descriptive study. It determined the annual, national incidence of head injuries (traumatic brain injury, TBI) to adults and children in motor vehicle crashes. It evaluated NASS-CDS for exposure and incidence of various head injuries in towaway crashes. It evaluated 3 health databases for emergency department (ED) visits, hospitalizations, and deaths due to TBI in motor vehicle occupants.Methods: Four databases were evaluated using 1997–2010 data on adult (15+ years old) and child (0–14 years old) occupants in motor vehicle crashes: (1) NASS-CDS estimated the annual incidence of various head injuries and outcomes in towaway crashes, (2) National Hospital Ambulatory Medical Care Survey (NHAMCS)-estimated ED visits for TBI, (3) National Hospital Discharge Survey (NHDS) estimated hospitalizations for TBI, and (4) National Vital Statistics System (NVSS) estimated TBI deaths. The 4 databases provide annual national totals for TBI related injury and death in motor vehicle crashes based on differing definitions with TBI coded by the Abbreviated Injury Scale (AIS) in NASS-CDS and by International Classification of Diseases (ICD) in the health data.Results: Adults: NASS-CDS had 16,980 ± 2,411 (risk = 0.43 ± 0.06%) with severe head injury (AIS 4+) out of 3,930,543 exposed adults in towaway crashes annually. There were 49,881 ± 9,729 (risk = 1.27 ± 0.25%) hospitalized with AIS 2+ head injury, without death. There were 6,753 ± 882 (risk = 0.17 ± 0.02%) fatalities with a head injury cause. The public health data had 89,331 ± 6,870 ED visits, 33,598 ± 1,052 hospitalizations, and 6,682 ± 22 deaths with TBI. NASS-CDS estimated 48% more hospitalized with AIS 2+ head injury without death than NHDS occupants hospitalized with TBI. NASS-CDS estimated 29% more deaths with AIS 3+ head injury than NVSS occupant TBI deaths but only 1% more deaths with a head injury cause. Children: NASS-CDS had 1,453 ± 318 (risk = 0.32 ± 0.07%) with severe head injury (AIS 4+) out of 454,973 exposed children annually. There were 2,581 ± 683 (risk = 0.57 ± 0.15%) hospitalized with AIS 2+ head injury, without death. There were 466 ± 132 (risk = 0.10 ± 0.03%) fatalities with a head injury cause. The public health data had 19,251 ± 2,803 ED visits, 3,363 ± 255 hospitalizations, and 488 ± 6 deaths with TBI. NASS-CDS estimated 24% fewer hospitalized children with AIS 2+ head injury without death than NHDS hospitalization with TBI. NASS-CDS estimated 31% more deaths with AIS 3+ head injury than NVSS child deaths but 5% fewer deaths with a head injury cause.Conclusions: The annual national incidence of motor vehicle–related head injury (TBI) was estimated using 1997–2010 NASS-CDS from the Department of Transportation and NHAMCS (ED visits), NHDS (hospitalizations), and NVSS (deaths) from the Department of Health and Human Services. The transportation and health databases use different definitions and coding, which complicates direct comparisons. Future work is needed where ICD to AIS translators are used if comparisons of serious head injuries in NASS and health data sets are to be made.

Are there car seats in Qatar? Results and recommendations from a rapid market survey

Mortality for young children in motor vehicle crashes in Qatar was highest in those who were unrestrained1. Anecdotal reports have attributed low car seat use to their expense and unavailability prompting car seat giveaway programs, but an assessment of the local car seat market has not been conducted previously. This study will report the results of a rapid market survey (RMS) to understand the availability, characteristics and the cost of child restraints and make recommendations for future child restraint policies and legislation in Qatar. This RMS was conducted as part of the Young Kids in Safe Seats Project funded by the Qatar Foundation. The survey involved locating all retail outlets that sell child restraints in Qatar and collecting standard data on each restraint system: brand, model no. age/weight limits, compliance with standards, availability and language of owner's manual. The RMS showed a sufficient number and variety of car seat models [83] available at 19 retail outlets with a wide affordability range [$46 - $810]. All of the car seats complied with the European standard. Only 2% showed a date of manufacture or expiry. A user manual was available in only 71% of seats and in a variety of different languages, but only 36% in the native language of Arabic. This RMS demonstrates the availability and variety of child restraint systems in Qatar. Unavailability and expense cannot be cited as barriers to their use and the market is prepared for legislation requiring car seats for children in Qatar. Areas for improvement include: requiring user manuals for all seats, especially in Arabic, that all car seats comply with globally accepted safety standards, especially expiry/manufacturing dates, given the harsh local climate, and encouraging more variety in the local markets.

Association Between Weight and Risk of Crash-Related Injuries for Children in Child Restraints

To determine the association between weight and the risk of injury in motor vehicle crashes (MVCs) for children 1 through 8 years of age who were using child restraints. This was a cross-sectional study of children 1 to 8 years of age in MVCs, in which cases from the National Automotive Sampling System Crashworthiness Data System were used. Abbreviated Injury Scale scores of ≥2 indicated clinically significant injuries. The National Automotive Sampling System Crashworthiness Data System study sample included 650 children 1 to 5 years of age in forward-facing child restraints who weighed 20 to 65 lb and 344 children 3 to 8 years of age in belt-positioning booster seats who weighed 30 to 100 lb. With adjustment for seating position, type of vehicle, direction of impact, crash severity, and vehicle model year, there was no association between absolute weight and clinically significant injuries in either age group (odds ratio: 1.17 [95% confidence interval: 0.96-1.42] for children 1-5 years of age in forward-facing child restraints and 1.22 [95% confidence interval: 0.96-1.55] for children 3-8 years of age in belt-positioning booster seats). The risk of clinically significant injuries was not associated with weight across a broad weight range in this sample of children in MVCs who were using child restraint systems. Parents should continue to restrain their children according to current recommendations from the American Academy of Pediatrics and the National Highway Traffic Safety Administration.

Head Injury Causation Scenarios for Belted, Rear-Seated Children in Frontal Impacts

Objectives: Head injuries are the most common serious injuries sustained by children in motor vehicle crashes and are of critical importance with regard to long-term disability. There is a lack of understanding of how seat belt–restrained children sustain head injuries in frontal impacts. The aim of the study was to identify the AIS2+ head injury causation scenarios for rear-seated, belt-restrained children in frontal impacts, including the set of parameters contributing to the injury. Method: In-depth crash investigations from two National Highway Traffic Safety Administration (NHTSA) databases, the National Automotive Sampling System–Crashworthiness Data System (NASS-CDS; 1997–2008) and the Crash Injury Research and Engineering Network (CIREN; 1996–2009), were collected and analyzed in detail. Selection criteria were all frontal impacts with principal direction of force (PDOF) of 11, 12, and 1 o’clock involving rear-seated, three-point belt-restrained, with or without booster cushion, children from 3 to 13 years with an AIS2+ head injury. Cases were analyzed using the BioTab method of injury causation assessment in order to systematically analyze the injury causation scenario for each case. Results: There were 27 cases meeting the inclusion criteria, 19 cases with MAIS2 head injuries and 8 cases with MAIS3+ head injuries, including 2 fatalities. Three major injury causation scenarios were identified, including head contact with seatback (10 cases), head contact with side interior (7 cases,) and no evidence of head contact (9 cases). Conclusions: Head injuries with seatback or side interior contact typically included a PDOF greater than 10 degree (similar to the Insurance Institute for Highway Safety [IIHS] and EuroNCAP offset frontal testing) and vehicle maneuvers. For seatback contact, the vehicle's movements contributed to occupant kinematics inboard the vehicle, causing a less than optimal restraint of the torso and/or torso roll out of the shoulder belt. For side interior contact, the PDOF and/or maneuvers forced the occupant toward the side interior. The cases without evidence of head/face contact were characterized by high crash severity and accompanied by severe injuries to the thorax and spine. These data lead to increased understanding of the injury patterns and causation in this crash restraint scenario so that interventions to mitigate the burden of injury can be advanced.

Passenger Compartment Intrusion as a Predictor of Significant Injury for Children in Motor Vehicle Crashes

Passenger compartment intrusion, loss of integrity of the vehicle occupant compartment due to a motor vehicle crash, has frequently been used as a triage criterion. Data to support intrusion as a proxy for injury severity in child occupants are lacking. The purpose of this study was to examine the association between intrusion and injury to children in motor vehicle crashes. Crash investigation data were reviewed from the partners for child passenger safety database, a large, child-focused crash surveillance system. Data included: intrusion (centimeters), direction of impact, age of occupant, and Abbreviated Injury Scale (AIS) score. Analyses examined the relationship between the amount of intrusion and the risk of any AIS > or = 2, or > or = 3 injury. Data were available on 880 children, age 0 year to 15 years. AIS > or = 2 and > or = 3 injuries occurred in 40.3% and 12.6% of child occupants, respectively. Intrusion was strongly and positively associated with the odds of both an AIS > or = 2 and > or = 3 injury (p < 0.0001). The odds of at least one AIS > or = 2, or > or = 3 injury increased on average by 2.9% (95% CI = 1.9-3.8%), or 4.0% (95% CI = 2.7-5.2%), respectively, for each additional centimeter of intrusion, adjusting for age, restraint use, seating row, and direction of impact. The association between passenger compartment intrusion and injury in children supports its application in triage, and usefulness in injury predictive models. Future studies should determine methods for providing valid field information on intrusion to the trauma team.

Injuries to belted older children in motor vehicle crashes

Context The American Academy of Pediatrics and the National Highway Traffic Safety Administration currently recommend that, unless they are under 57 in. in height, 8–12-year-old children use seat belts and all should ride in the rear seats of vehicles. These recommendations assume that the vehicle seat belt should provide adequate protection for these older children in the event of a crash. Objectives To describe characteristics of older children in the rear seat using seat belts in crashes, to estimate their risk and body region distribution of injury, and to identify risk factors for injury. Methods A representative sample of 6680 seat belt-restrained occupants, 8–12 years of age, seated in the rear seat during crashes involving insured vehicles in 16 US states between December 1998 and December 2007. A telephone interview was conducted with the driver of each vehicle. The main outcome was the parent-reported injury defined as Abbreviated Injury Scale (AIS) 2 or greater injuries. Results The risk of injury for belted 8–12 year olds in the rear seat was 1.3%. Head injury was the most common injury (60%), followed by injuries to the face (9%), upper extremity (9%) and abdomen (9%). One out of five (21%) 8–12 year olds either did not use the shoulder portion of the vehicle seat belt or placed it incorrectly behind their back or under their arm. Bivariate analyses indicated a higher risk of injury for these children (1.8%) as compared to children using both the lap and shoulder portions of the seat belt (1.1%). However, this difference was not statistically significant when other risk factors such as crash severity and characteristics of the driver were considered. Conclusions Injuries to the head, face, abdomen and upper extremity are the most common injuries to target for improved protection among 8–12 year olds in seat belts. Driver and crash characteristics are important risk factors for injury. A recent federal motor vehicle safety standard requiring lap and shoulder belts in all rear seat positions has the potential to further decrease the risk of injury to older children using seat belts.

A Latent Class Analysis of Injury Patterns Among Rear-Seated, Seat-Belted Children

The objective of the study was to determine the constellation of injury patterns in rear-seated, seat-belt-restrained children using data-driven latent class methodology novel to injury prevention research. A cross-sectional probability sample of rear-seated, belt-restrained children aged 5 to 15 years in crashes was obtained via insurance claims records and a telephone survey. Eight body regions of AIS 2 or greater injury (concussion, nonconcussive head injury, face, chest, abdomen, neck/spine/back, upper extremity, lower extremity) were determined, and a latent class model was fit to determine whether underlying "injury clusters" were present. A three-class model appears to best fit to observed data: an "abdominal/spine" cluster that contained 11% of the population, a "concussion" cluster that contained 56% of the population, and a residual "mixture" cluster that contained the remaining 33% of the population. When compared with the mixture cluster, the abdomen/spine cluster was associated with 4 to 8 year old children, lap-only belt restraint, frontal impacts, and minivans. The concussion cluster was also more common among 4 to 8 and 9 to 12 year olds, with side or rear impact crashes, and with pickup trucks. Latent class analysis allows injury clusters to be estimated from the data, not predetermined by the investigator, and suggests that distinct mechanisms of abdominal injury and concussive head injury exist in a population-based sample of children in motor vehicle crashes.

Effects of Seating Position and Appropriate Restraint Use on the Risk of Injury to Children in Motor Vehicle Crashes

Currently, many states are upgrading their child restraint laws to include provisions for the use of age-appropriate restraints through 6 to 8 years of age, with some also requiring rear seating for children, enabling the laws to be in closer alignment with best-practice recommendations. To evaluate the relationships of seating position and restraint status to the risk of injury among children in passenger vehicle crashes. This was a cross-sectional study of children <16 years of age who were involved in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 17980 children in 11506 crashes, representing 229106 children in 146613 crashes, was collected between December 1, 1998, and November 30, 2002. Parent reports were used to define restraint status, seating position, and occurrence of clinically significant injuries, with the use of a previously validated instrument. Approximately 62% of the children used seat belts, 35% used child restraints, and 3% used no restraint. Nearly 4 of 5 children sat in the rear seat, with one half of all children being restrained appropriately for their age in the rear, although this varied according to the age of the child. Overall, 1.6% of children suffered serious injuries, 13.5% had minor injuries, and 84.9% did not have any injury. Unrestrained children in the front were at the highest risk of injury and appropriately restrained children in the rear were at the lowest risk, for all age groups. Inappropriately restrained children were at nearly twice the risk of injury, compared with appropriately restrained children (odds ratio [OR]: 1.8; 95% confidence interval [CI]: 1.4-2.3), whereas unrestrained children were at >3 times the risk (OR: 3.2; 95% CI: 2.5-4.1). The effect of seating row was smaller than the effect of restraint status; children in the front seat were at 40% greater risk of injury, compared with children in the rear seat (OR: 1.4; 95% CI: 1.2-1.7). Had all children in the study population been appropriately restrained in the rear seat, 1014 serious injuries (95% CI: 675-1353 injuries) would have been prevented (with the assumption that restraint effectiveness does not depend on a variety of other driver-related, child-related, crash-related, vehicle-related, and environmental factors). Age-appropriate restraint confers relatively more safety benefit than rear seating, but the 2 work synergistically to provide the best protection for children in crashes. These results support the current focus on age-appropriate restraint in recently upgraded state child restraint laws. However, it is important to note that considerable added benefit would be realized with additional requirements for rear seating.

Ejections of young children in motor vehicle crashes.

The purpose of this study was to report the incidence of ejection from the vehicle among children involved in motor vehicle crashes, and to describe a novel mode of ejection from child safety seats. The U.S. National Automotive Sampling System General Estimates System and the Fatality Analysis Reporting System databases from 1995 through 1999 were analyzed. A prospective two-center study of children involved in severe car crashes in Canada was performed. Only 0.2% of 5.5 million children involved in crashes experienced ejection, but 1924 (29%) of 6570 child fatalities involved ejections. Only 2.2% of children experienced rollover crashes, but these contributed 1832 (28%) of 6570 child passenger fatalities. Among 56 crashes, 5 restrained young children were ejected, 4 in rollover crashes. Ejection of a toddler through the shoulder straps of a forward-facing child safety seat was the mechanism of ejection in three of the five cases. Ejection from the vehicle is common (29%) among fatally injured children. Shoulder straps alone (as found in T-shield or overhead shield child seats) may not prevent the ejection of toddlers from child safety seats during rollovers.

Update for the Pediatrician on Child Passenger Safety: Five Principles for Safer Travel

For many parents, the confusion about how best to restrain their children and the myriad of restraint types that are available can be a major source of frustration. Child safety seat inspectors and advocates whose full-time job is to educate parents, caregivers, and advocates find it challenging to stay current with developments and changes in child occupant protection. For pediatricians who work less frequently and less intensively with child safety seats, the challenge of staying current with information is monumental. However, understanding a few basic principles of child safety seat usage and knowing when and where to refer families for additional information can help pediatricians provide parents and caregivers with the information they need to effectively restrain their children in motor vehicles. Significant reduction of deaths of children in motor vehicle crashes, especially those involving children <5 years old, has occurred over the past 20 years.1 This has been largely attributable to improvement in child safety seat and vehicle design, intense educational efforts of safety specialists and health professionals, and enforcement of child safety seat laws. Pediatricians have played a prominent role in this process from the early efforts of the First Ride/Safe Ride program of the American Academy of Pediatrics and continue to do so through the formation of policy recommendations and dissemination of public education materials. National statistics show that 80% to 90% of child safety seats are used incorrectly or misused.2,3 Although many of these misuses are minor, other misuses are considered gross and may render the child safety seat “virtually useless.”4,5 It is common to find child safety seats installed in family vehicles with multiple misuses, and this can collectively degrade performance of the child safety seat. Most parents assume that simply placing their child in a safety seat, placing the seat in …

Restraint use and rear seating were associated with fewer serious injuries and deaths for children in motor vehicle crashes

Berg MD, Cook L, Corneli HM, et al . Effect of seating position and restraint use on injuries to children in motor vehicle crashes. Pediatrics2000 Apr; 105 : 831 –5....

Effect of seating position and restraint use on injuries to children in motor vehicle crashes.

To determine the effect of restraint use and seating position on injuries to children in motor vehicle crashes, with stratification by area of impact. Children <15 years old involved in serious automobile crashes in Utah from 1992 through 1996 were identified from statewide motor vehicle crash records. Serious crashes are defined as those resulting in occupant injuries with broken bones or significant bleeding or property damage exceeding $750. Probabilistic methods were used to link these records with hospital records. Analysis used logistic regression controlling for age, restraint use, occupant seating position, and type of crash. We studied 5751 children and found 53% were rear seat passengers. More than 40% were unrestrained. Sitting in the rear seat offered a significant protective effect (adjusted odds ratio: 1.7; 95% confidence interval: 1.6-2.0), and restraint use enhanced this effect (adjusted odds ratio: 2.7; 95% confidence interval: 2.4-3.1). Mean hospital charges were significantly greater for front seat passengers. Rear seat position during a motor vehicle crash provides a significant protective effect, restraint use furthers this effect, and usage rates of restraint devices are low. The rear seat protective effect is in addition to and independent of the protection offered from restraints.