Pediatric Pedestrian Injuries Research Articles

Pediatric Pedestrian Injuries: Striking Too Close to Home

BackgroundPediatric pedestrian injuries (PPI) are a major public health concern. This study utilized geospatial analysis to characterize the risk and injury severity of PPI. MethodsA retrospective chart review of PPI patients (age < 18) from a level 1 trauma center was performed (2013–2020). A geographic information system geocoded injury location to home and other public landmarks. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association statistic tested for spatial clustering of injury rates per 10,000 children. Predictors for increased injury severity were assessed by logistic regression. ResultsPPI encompassed 6% (n = 188) of pediatric traumas. Most patients were black (54%), male (58%), >13 years (56%), and with Medicaid insurance (68%). Nine zip codes comprised a statistically significant cluster of PPI. Nearly half (40%) occurred within a quarter mile of home; 7% occurred at home. Most (65%) PPI occurred within 1 mile of a school, and 45% occurred within a quarter mile of a park. Nearly all (99%) PPI occurred within a quarter mile of a major intersection and/or roadway. Using admission to ICU as a marker for injury severity, farther distance from home (OR 1.060, 95% CI 1.001–1.121, p = 0.045) and age <13 years (3.662, 95% CI 1.854–7.231, p < 0.001) were independent predictors of injury severity. ConclusionsThere are significant sociodemographic disparities in PPI. Most injuries occur near patients’ homes and other public landmarks. Multidisciplinary injury prevention collaboration can help inform policymakers, direct local safety programs, and provide a model for PPI prevention at the national level. Level of EvidenceLevel IV.

Injury patterns in motor vehicle collision-pediatric pedestrian deaths

Objective To describe fatal pediatric pedestrian injury patterns and correlate them with motor vehicle collision (MVC) characteristics and pedestrian kinematics using data from medicolegal death investigations of MVCs occurring in the current Canadian MV fleet and determine the applicability of the classical “Waddell’s triad” comprising knee, hip (femur) or pelvis and craniocerebral injuries to present data injury patterns. Methods An Injury Data Collection Form was used to extract MV, MVC, pedestrian demographic and injury information from the Office of the Chief Coroner for Ontario database using autopsy data from 2013 to 2018. Injuries were coded using the Abbreviated Injury Scale (AIS) 2015 revision. The study focused on AIS ≥3 injuries utilizing the Maximum Abbreviated Injury Scale (MAIS), MAIS by Body Region (MAISBR) and Injury Severity Score (ISS). Results Between 2013 and 2018, there were 25 pediatric deaths. The pedestrians were either struck and run over (n = 17, 68%; 56% low speed) or struck and projected (n = 8, 32%). Twenty-two deaths were from frontal impacts; three were from reversing vehicles. Fourteen of the 17 (82.4%) run over cases occurred at low speed (<30 km/h). In 9 (36%) cases, the vehicle was turning at impact (right n = 3, left n = 6). A majority of the vehicles had a high hood edge. The head was the most severely injured (median MAISBR = 5 overall and ≤10 years; median MAISBR = 6 for 11–14 years old) followed by the neck (MAISBR = 3 overall; 6–14 years old), and the thorax (median MAISBR = 3 overall; all age groups). For the early adolescents (11-14 years old), the serious injury pattern included the abdomen (median MAISBR = 3.5). Nearly half (n = 11, 44%) sustained brainstem injuries. Over fifty percent of the 16 cases with neck injuries (n = 9, 56.3%) had atlanto-occipital or axial dislocation. Conclusion More than half of the deaths occurred during low speed run overs. MAIS ≥3 injuries trended to a dyad of head and thorax in ≤5 years old, a triad of head, neck, and thorax injuries in children 6–10 years old and a tetrad with the addition of abdominal injuries in pedestrians ≥11 years old. Waddell’s triad was not applicable to the fatal cases in the present study.

Pediatric Pedestrian Facial Fracture Patterns and Management Following Motor Vehicle Collisions.

Pedestrian trauma due to motor vehicle crashes can be especially destructive to the pediatric population as the facial skeleton is immature and developing. Almost half of crashes resulting in pedestrian death involved alcohol consumption, and children are often victims of irresponsible driving. The objective of this study was to examine the prevalence of facial fractures in this patient population in order to analyze management strategies that optimize functional recovery. A retrospective chart review was performed for all facial fractures resulting from motor vehicle collisions with pedestrians in the pediatric population at a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. During the time period examined, 55 patients were identified as 18 years of age or younger and having sustained a facial fracture as the result of being struck by a motor vehicle. The mean age was 11.3 (range 1-18) years, with a male predominance of 69.0%. There were a total of 125 fractures identified on radiologic imaging via CT or X-ray. The most common fractures were those of the orbit (20.0%), mandible (19.2%), and nasal bone (10.4%). The mean Glasgow Coma Scale on arrival was 12.1 (range 4-15). Fifteen patients were intubated on, or prior to, arrival to the trauma bay. The most common concomitant injuries were intracranial hemorrhage, long bone fractures, and cervical spine fractures. The mean operative time was 216.9 (range 63-515) minutes. Surgery was required in 36 patients, with most undergoing open reduction and internal fixation with titanium plates and screws. Two patients required resorbable plates, and one required Medpor implants. The mean hospital length of stay was 9.9 (range 1-59) days. Two patients expired. There is currently a dearth of literature regarding the management and patterns of injury for pediatric pedestrian injuries due to motor vehicle collisions. The impact of these injuries can be devastating with concomitant life-threatening complications, and may influence the future development of the facial skeleton after healing of the bone and soft tissue. The authors hope this study can provide insight and further investigation regarding prevention and management.

WalkSafe Keeps Walking for 15 Years: A Program Review.

Unintentional injury is the leading cause of death among children aged 5 to 14 years. The WalkSafe program was developed in response to the number of children admitted to Miami-Dade County, Florida, level-1 trauma centers. WalkSafe was piloted in an initially high-risk neighborhood, which now exhibits a low density of pedestrian crashes. Following countywide implementation of WalkSafe, trauma data exhibit a 78% decrease in pediatric injuries. This article provides a 15-year review of WalkSafe and its role in decreasing pediatric pedestrian injuries in Miami-Dade County. Every year, an alarming number of child pedestrians are injured on the nation's roadways. In Miami-Dade County, Florida, the WalkSafe program aims to reduce pediatric injury through targeted education and multitiered collaboration with community partners.

Abstract: Pediatric Pedestrian Facial Fractures from Motor Vehicle Collisions: What Are the Patterns and Appropriate Management Strategies?

PURPOSE: Pedestrian injury due to motor vehicle crashes can be especially destructive to the pediatric population as the facial skeleton has immature growth centers, leading to possible long-term defects in form and function. To our knowledge, there are few studies examining fractures patterns of this etiology, and thus a lack of literature for management strategies to optimize functional recovery in this specific population. METHODS: A retrospective chart review was performed for all facial fractures resulting from motor vehicle collisions with pedestrians in the pediatric population at a level 1 trauma center in an urban environment (University Hospital in Newark, NJ) from 2002 to 2012. Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. RESULTS: During the time period examined, 55 patients were identified as 18 years of age or younger and having sustained a facial fracture as the result of being struck by a motor vehicle. The mean age was 11.3 (range 1 – 18) years, with a male predominance of 69.0%. There were a total of 107 fractures identified on radiologic imaging via CT or X-ray. The most common fractures were those of the orbit (23.4%), mandible (22.4%), and nasal bone (17.8%). The mean Glasgow Coma Scale on arrival was 12.1 (range 3 – 15). Twenty-one patients were intubated on, or prior to, arrival to the trauma bay. The most common concomitant injuries were skull fractures (25.3%), intracranial hemorrhage (22.2%), long bone fractures (15.2%), and intrathoracic injuries (15.2%). Of the 55 patients, 72.7% suffered from traumatic brain injury. The mean operative time was 216.9 (range 63 – 515) minutes. Surgery was required in 20 patients, with most undergoing open reduction and internal fixation with titanium plates and screws. Two patients required resorbable plates, and one required Medpor implants. The mean hospital length of stay was 9.3 (range 1 – 59) days. Three patients expired. CONCLUSION/SIGNIFICANCE: There is currently a dearth of literature regarding the management and patterns of injury for pediatric pedestrian injuries due to motor vehicle collisions. The impact of these injuries can be devastating with concomitant life-threatening complications, and may influence the future development of the facial skeleton after healing of the bone and soft tissue. The authors hope this study can provide insight and further investigation regarding prevention and management.

Pediatric emergency department visits for pedestrian and bicyclist injuries in the US

BackgroundDespite reductions in youth pedestrian and bicyclist deaths over the past two decades, these injuries remain a substantial cause of morbidity and mortality for children and adolescents. There is a need for additional information on non-fatal pediatric pedestrian injuries and the role of traumatic brain injury (TBI), a leading cause of acquired disability.MethodsUsing a multi-year national sample of emergency department (ED) records, we estimated annual motorized-vehicle related pediatric pedestrian and bicyclist (i.e. pedalcyclist) injury rates by age and region. We modeled in-hospital fatality risk controlling for age, gender, injury severity, TBI, and trauma center status.ResultsED visits for pediatric pedestrian injuries declined 19.3% (95% CI 16.8, 21.8) from 2006 to 2012, with the largest decreases in 5-to-9 year olds and 10-to-14 year olds. Case fatality rates also declined 14.0%. There was no significant change in bicyclist injury rates.TBI was implicated in 6.7% (95% CI 6.3, 7.1) of all pedestrian and bicyclist injuries and 55.5% (95% CI 27.9, 83.1) of fatalities. Pedestrian ED visits were more likely to be fatal than bicyclist injuries (aOR = 2.4, 95% CI 2.3, 2.6), with significant additive interaction between pedestrian status and TBI.ConclusionsTBI in young pedestrian ED patients was associated with a higher risk of mortality compared to cyclists. There is a role for concurrent clinical focus on TBI recovery alongside ongoing efforts to mitigate and prevent motor vehicle crashes with pedestrians and bicyclists. Differences between youth pedestrian and cycling injury trends merit further exploration and localized analyses, with respect to behavior patterns and interventions. ED data captures a substantially larger number of pediatric pedestrian injuries compared to crash reports and can play a role in those analyses.

Roadway Characteristics and Pediatric Pedestrian Injury

Changing the built environment is a sound, but often underutilized approach to injury control. The authors reviewed the literature and conducted a meta-analysis to synthesize the evidence on the association of roadway characteristics with risk of pediatric pedestrian injury. To synthesize the data, they converted results to odds ratios based on direct results or abstracted outcomes and used Bayesian meta-analytic approaches by modeling outcomes as the logit of a normally distributed set of outcomes with vague prior distributions for the central measure of effect and its variance. On the basis of 10 studies of roadway features restricted exclusively to pediatric populations, the synthesized effect estimate for the association of roadway characteristics with pedestrian injury risk was 2.5 (95% credible interval: 1.8, 3.2). The probability of a new study showing an association between the built roadway and pediatric pedestrian injury was nearly 100%. The authors concluded that the built environment is directly related to the risk of pedestrian injury. This review and meta-analysis suggests that even modest interventions to the built roadway environment may result in meaningful reductions in the risk of pediatric pedestrian injury.

Targeting Pediatric Pedestrian Injury Prevention Efforts: Teasing the Information Through Spatial Analysis

Pediatric pedestrian injuries remain a major cause of childhood death, hospitalization, and disability. To target injury prevention efforts, it is imperative to identify those children at risk. Racial disparities have been noted in the rates of pediatric pedestrian injury and death. Children from low-income families living in dense, urban residential neighborhoods have a higher risk of sustaining pedestrian injury. Geographic information systems (GIS) analysis of associated community factors such as child population density and median income may offer insights into prevention. Using trauma registry E-codes for pedestrian motor vehicle crashes, children younger than 16 years were identified, who received acute care and were hospitalized at the University of Chicago Medical Center, a Level I pediatric trauma center, after being struck by a motor vehicle from 2002 to 2009. By retrospective chart review and review of the Emergency Medical Services run sheets, demographic data and details of the crash site were collected. Crash sites were aggregated on a block by block basis. A "hot spot" analysis was performed to localize clusters of injury events. Using Gi* statistical method, spatial clusters were identified at different confidence intervals using a fixed distance band of 400 m (≈ ¼ mile). Maps were generated using GIS with 2000 census data to evaluate race, employment, income, density of public and private schools, and density of children living in the neighborhoods surrounding our medical center where crash sites were identified. Spatial correlation is used to identify statistically significant locations. There were 3,521 children admitted to the University of Chicago Medical Center for traumatic injuries from 2002 to 2009; 27.7% (974) of these children sustained injuries in pedestrian motor vehicle injuries. From 2002 to 2009, there were a total of 106 traumatic deaths, of which 29 (27.4%) were due to pedestrian motor vehicle crashes. Pediatric pedestrian motor vehicle crash sites occurred predominantly within low-income, predominantly African-American neighborhoods. A lower prevalence of crash sites was observed in the predominantly higher income, non-African-American neighborhoods. Spatial analysis using GIS identified associations between pediatric pedestrian motor vehicle crash sites and the neighborhoods served by our pediatric trauma center. Pediatric pedestrian motor vehicle crash sites occurred predominantly within low-income, African-American neighborhoods. The disparity in prevalence of crash sites is somewhat attributable to the lower density of children living in the predominantly higher income, non-African-American neighborhoods, including the community immediately around our hospital. Traffic volume patterns, as a denominator of these injury events, remain to be studied.

Annual Pediatric Pedestrian Education Does Not Improve Pedestrian Behavior

Pediatric pedestrian injuries are a major health care concern, specifically in urban centers. An educational program (WalkSafe), given one time during the school year, has been shown to improve childhood pedestrian safety. We examined whether this program could create similar long-term cognitive and behavioral changes in our school-aged children. An established pediatric pedestrian curriculum was modified slightly for use in our area. Students K-fourth grade were exposed to the program once annually for 2 years. The program was carried out weekly for 3 consecutive weeks. The first and third sessions consisted of an educational module given by the classroom teacher. The second week consisted of an interactive assembly that allowed the children to demonstrate good pedestrian safety using a simulated street. Short- and intermediate-term cognitive knowledge was evaluated using standardized pre-, post- and 3-month follow-up tests. Long-term knowledge was assessed by comparing scores as students advanced in grade from year 1 to 2 of the program (K to first, first to second, etc.). At six schools during year 2, pedestrian behavior was measured through direct observation of children on city streets before and after administering the program. The project was approved by university and school board institutional review boards. During the 2 years, 1,564 students from nine schools were educated. In both years of the program, students in all grades had a significant gain in test scores immediately after and at 3 months compared with baseline knowledge. In contrast, only students moving from grade 3 to 4 demonstrated long-term retention (K→1: 7.7 vs. 6.7; grade 1→2: 7.8 vs. 6.7; grade 2→3: 7.3 vs. 6.8; grade 3→4: 7.1 vs. 8.0; all p < 0.05 year 2 pretest vs. year 1 3-month posttest; analysis of variance and generalized linear model). Only 30% of children walk with an adult. Direct observation showed 64% of children stopped at the curb but only 8% looked left-right-left. Children walking alone were more likely to cross mid-block compared with those walking with an adult (12% vs. 3%; p < 0.001) and also tend to look left-right-left significantly more than those walking with an adult (67% vs. 20%; p < 0.0001). A one-time annual educational program resulted in long-term knowledge retention between grades 3 and 4 only. In contrast, scores in younger grades reverted to baseline pretest values seen in year 1. Short- and intermediate-term knowledge gains were seen in all grades for both years. Because older children more often walk alone, we postulate that the improved retention may be the result of repeated exposure and practice as a pedestrian. Cognitive knowledge did not appear to translate into improved pedestrian behavior. Walking with an adult also had a negative impact on observed pedestrian safety behavior. The efficacy and impact of a one-time educational program may be insufficient to change long-term behavior and must be reevaluated.

Pediatric Pedestrian Injuries and Associated Hospital Resource Utilization in the United States, 2003

The objective was to calculate national estimates of pedestrian-related hospitalizations and associated use of healthcare resources among children <or=19 years of age and to explore the effects of sociodemographic, hospital-related factors, and injury severity on total charges and lengths of stay (LOS) in the United States. Data from the 2003 Healthcare Cost and Utilization Project Kids' Inpatient Database were used. The sample included patients <or=19 years hospitalized with pedestrian-related injuries, from 3,438 hospitals in 36 states. National estimates of pedestrian-associated hospitalizations, rates, resource use, injury severity, and demographics were calculated. Potentially significant covariate associations were studied using hospital charges and LOS. In 2003, 9,172 pedestrian-associated hospitalizations occurred among children <or=19 years in the United States, resulting in USD 290.8 million (standard deviation [SD] = USD 23.6 million) in inpatient charges and 44,895 (SD = 2,964) days of hospitalization. Mean (SD) hospital charges and LOS were $32,059 ($74,778) days and 4.9 (10.9) days, respectively. Thirty-six percent of patients suffered a traumatic brain injury, and 21% sustained severe injury with an injury severity scale score >or=16. A traffic-related event was the cause of 92.7% of hospitalizations. Older age, higher injury severity, urban and Western hospital location, children's hospital type, and longer LOS were significantly associated with higher total hospital charges. Older age and higher injury severity were significantly associated with longer LOS. Pediatric pedestrian injuries contribute substantially to the healthcare resource burden in the United States, accounting for approximately 45,000 days of hospitalization and >USD 290 million in inpatient charges annually.

Establishing an Injury Prevention Program to Address Pediatric Pedestrian Collisions

The implementation of a pedestrian safety education program in public schools can change the knowledge and beliefs about safe pedestrian behaviors among students and their parents or caregivers with the goal of reducing morbidity and mortality of children. WalkSafe is a well-established, multiphase pedestrian safety intervention program. This program has been shown to improve pedestrian safety knowledge of school-aged children in kindergarten through grade 5 after receiving a 3-day educational curriculum. A reduction in pediatric pedestrian struck injuries is anticipated following program implementation in an urban area with significantly increased incidence of such injuries.

Pedestrian Safety

Each year, approximately 900 pediatric pedestrians younger than 19 years are killed. In addition, 51000 children are injured as pedestrians, and 5300 of them are hospitalized because of their injuries. Parents should be warned that young children often do not have the cognitive, perceptual, and behavioral abilities to negotiate traffic independently. Parents should also be informed about the danger of vehicle back-over injuries to toddlers playing in driveways. Because posttraumatic stress syndrome commonly follows even minor pedestrian injury, pediatricians should screen and refer for this condition as necessary. The American Academy of Pediatrics supports community- and school-based strategies that minimize a child's exposure to traffic, especially to high-speed, high-volume traffic. Furthermore, the American Academy of Pediatrics supports governmental and industry action that would lead to improvements in vehicle design, driver manuals, driver education, and data collection for the purpose of reducing pediatric pedestrian injury.

Commentary: Pedestrians: Truly Vulnerable Road Users

Commentary: Pedestrians: Truly Vulnerable Road Users

Preventing Pediatric Pedestrian Injuries

Pedestrian-related crashes cause an estimated 1.2 million deaths and 50 million injuries worldwide. There were 32,590 nonfatal injuries reported among children 0 to 14 years of age in the United States in 2006. The incidence of pedestrian injuries seems to be decreasing due to improvements in trauma care and a nationwide decline in walking. This article is a special communication and overview of selected literature regarding efforts to decrease the frequency of pediatric pedestrian trauma. WalkSafe an elementary school-based pedestrian injury prevention program will be discussed as an example of a program that has been able to demonstrate a decrease in injuries in children.

Application of Electronic Surveillance and Global Information System Mapping to Track the Epidemiology of Pediatric Pedestrian Injury

To compare the epidemiology of pediatric pedestrian injury in Jacksonville, FL to national trends, to analyze geographic distribution of these injuries, and to analyze pedestrian injury severity trends over time. Hospital emergency department and trauma registry data were analyzed for calendar year 2002 to define the incidence by age of vehicular pedestrian injury (Classification of Diseases--9th Revision--Clinical Modification E-code 814.7) in children less than 18 years old. The group was then stratified into the cohort living in the urban center (health zone 1-HZ1), and all other children in the region served by our state designated regional pediatric trauma referral center. To identify specific areas of cluster within and outside HZ1, FL Department of Highway Safety and Motor Vehicles (DHSMV) pedestrian crash data were analyzed for years 2002 to 2004. Global information system (GIS) mapping was performed based upon crash data geographic information. A recently deployed electronic injury surveillance system that combines both emergency department and trauma registry databases was then used to perform a similar analysis for calendar year 2006, which was the second of a 2-year program of enhanced prevention education specifically focused on the children and families of HZ1. This data were complied with 2006 DHSMV data to identify any decrease or change in GIS distribution of 2006 crashes compared with those of 2002. The 71 total crashes encountered during the 2002 included 21 children (30%) with injury severity that required admission to the trauma service. Children from HZ1 represented 34% of the 2002 cohort (N = 24). Comparison of victim age distribution to a national sample recorded in the National Pediatric Trauma Registry demonstrated a statistically significantly higher proportion of adolescents injured in Jacksonville. Epidemiologic evaluation of a larger sample of DHSMV data for 2002 to 2004 identified 236 crashes, in which males constituted a majority (64.4%). Fall was the largest season with 30.9% of incidents. Most crashes occurred from 1 pm to 8 pm (61.4%) and were distributed predominantly during weekdays. A major portion of crashes occurred at nonintersections (40.3%). As indicated in the 2002, cohort adolescents aged 11 to 15 were the largest age group struck (35% for 2002, 48% for 2002-2004). GIS mapping revealed a high density of crashes in the urban core of northwest Jacksonville. Data from 2006 identified 74 children struck by vehicles, including only 9 (12%) who required admission to the trauma service. The proportion of HZ1 victims remained the same (35%); however no HZ1 child required admission to the trauma service. The overall incidence was unchanged either in age distribution or occurrence within HZ1. Comparison of 2006 GIS data to 2002 highlights a persistence of pedestrian incidents in north and west components of urban Jacksonville. Analysis of 2006 DHSMV data reveal similar epidemiologic trends to 2002 to 2004. Although Jacksonville is similar to national trends in terms of gender, hour, day, and location of pedestrian injury, it differs from previous reports in terms of seasonality and the high proportion of adolescents struck. The effect of enhanced education appears to have diminished injury severity, although comparison of GIS plots clearly demonstrates that effective control will require changing environmental factors. Moreover, this report mandates further investigation and prevention efforts specifically targeting adolescents in urban areas.

The WalkSafe Program: Developing and Evaluating the Educational Component

Miami-Dade County, FL, has one of the highest numbers of pediatric pedestrian injuries in the country. To respond to this problem, WalkSafe an elementary school-based pedestrian injury prevention program was created. The purpose of this study was to evaluate the effectiveness of the 3-day WalkSafe educational curriculum in a high-risk district. Sixteen elementary schools were identified and enrolled in the study. Children (n = 10,621) in grades K-5 participated in the WalkSafe program in October 2006. Four of the 16 schools were randomly selected to receive pre-, post-, and 3-month posteducational testing of pedestrian safety knowledge. Teachers (n = 462) were asked to complete teacher surveys to gain feedback about the program. A total of 2,987 tests were collected during the three different testing times. Grades were combined to form groups (K-1), (2-3), and (4-5). Significant differences were observed (p value <0.05) between pre- and posttesting for grades K-1 and 2-3. No significant differences were found between pre- and posttesting for (4-5) and between post- and 3-month testing across all grades (p value >0.05). There were 154 (30%) of the teacher surveys returned. The 3-day WalkSafe educational curriculum implemented in a high-risk district was shown to increase the pedestrian safety knowledge of elementary school age children. From recommendations made by teachers and multiple agencies, the modified 3-day program was approved to implement on a yearly basis in all public elementary schools in Miami-Dade County. Further studies will investigate the transfer of knowledge gain to behavioral change among elementary school-aged children.

Effect of Cell Phone Distraction on Pediatric Pedestrian Injury Risk

Early adolescents are using cell phones with increasing frequency. Cell phones are known to distract motor vehicle drivers to the point that their safety is jeopardized, but it is unclear if cell phones might also distract child pedestrians. This study was designed to examine the influence of talking on a cell phone for pediatric pedestrian injury risk. Seventy-seven children aged 10 to 11 years old completed simulated road crossings in an immersive, interactive virtual pedestrian environment. In a within-subjects design, children crossed the virtual street 6 times while undistracted and 6 times while distracted by a cell phone conversation with an unfamiliar research assistant. Participants also completed several other experimental tasks hypothesized to predict the impact of distraction while crossing the street and talking on a cell phone. Children's pedestrian safety was compromised when distracted by a cell phone conversation. While distracted, children were less attentive to traffic; left less safe time between their crossing and the next arriving vehicle; experienced more collisions and close calls with oncoming traffic; and waited longer before beginning to cross the street. Analyses testing experience using a cell phone and experience as a pedestrian yielded few significant results, suggesting that distraction on the cell phone might affect children's pedestrian safety no matter what their experience level. There was some indication that younger children and children who are less attentive and more oppositional may be slightly more susceptible to distraction while talking on the cell phone than older, more attentive, and less oppositional children. Our results suggest that cell phones distract preadolescent children while crossing streets.

Validation of virtual reality as a tool to understand and prevent child pedestrian injury

In recent years, virtual reality has emerged as an innovative tool for health-related education and training. Among the many benefits of virtual reality is the opportunity for novice users to engage unsupervised in a safe environment when the real environment might be dangerous. Virtual environments are only useful for health-related research, however, if behavior in the virtual world validly matches behavior in the real world. This study was designed to test the validity of an immersive, interactive virtual pedestrian environment. A sample of 102 children and 74 adults was recruited to complete simulated road-crossings in both the virtual environment and the identical real environment. In both the child and adult samples, construct validity was demonstrated via significant correlations between behavior in the virtual and real worlds. Results also indicate construct validity through developmental differences in behavior; convergent validity by showing correlations between parent-reported child temperament and behavior in the virtual world; internal reliability of various measures of pedestrian safety in the virtual world; and face validity, as measured by users’ self-reported perception of realism in the virtual world. We discuss issues of generalizability to other virtual environments, and the implications for application of virtual reality to understanding and preventing pediatric pedestrian injuries.

Pediatric Pedestrian Injuries

Pedestrian traffic injuries are a growing public health threat worldwide. The global economic burden of motor vehicle collisions and pedestrian injuries approximates $500 billion. In the United States, the number of pedestrian fatalities increased from 4675 in 2004 to 4881 in 2005. In addition nearly 60,000 injuries occurred during the same year. Injury patterns vary depending on the age, sex, and socioeconomic status of the individual. Children comprise one of the most vulnerable populations in pedestrian traffic injuries. Pedestrian injury remains the second leading cause of unintentional injury-related death among children aged 5 to 14 years. The burden of injury, upon the individual, families, and society, is frequently overwhelming. From recent data, pedestrian injuries and deaths are increasing in the United States and the World, and they require particular attention by emergency care providers and policy makers.

Deterrent to Healthy Lifestyles in Our Communities

To the Editor .— We certainly agree with the recent letter to the editor of Pediatrics 1 that emphasized that the current epidemic of obesity requires prevention work on several fronts including the identification of barriers to healthy lifestyles in our communities. In addition, we also believe that it is important to identify best practices of obesity prevention irrespective of whether they are active or passive. However, the author raised a very important perspective: “Our reliance on the automobile and our propensity to design our urban environments for cars rather than for people may well be an additional root cause of the obesity epidemic.”1 Transport is an important determinant of public health. It affects physical activity levels, crashes and injuries, social and economic opportunities, and general well-being.2 Extensive literature on the various health benefits of physical activity has necessitated the understanding of determinants, risks, and barriers to physical activity. It has been highlighted that one of the biggest epidemics facing the world in the 21st century is the growing obesity in children. This epidemic has been attributed largely to sedentary lifestyles. Therefore, it is critical to identify the barriers and the potentially effective strategies for surmounting the problems that hinder walking and cycling.3 …