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Background. Nonuse of child car safety seats (CSSs) remains significant; in 2000, 47% of occupant fatalities among children Methods. Focus groups (in English and Spanish) were conducted with individuals cited for violation of the law (N = 24). A thematic analysis of notes made by an observer, supplemented by audiotapes of the sessions, was conducted. In addition, a study of the effects of exposure to a violator class on knowledge and correct CSS use was conducted among violators. Certified CPS technicians conducted the classes and interviews. Subjects were parents cited as the driver with a child of 20 to 40 pounds, between 12 and 47 months of age. One hundred subjects recruited from the class were compared with 50 subjects who did not attend a class. Follow-up home interviews, with inspection of CCS use, were conducted 3 months after payment of the fine and completion of all court requirements. Fisher’s exact test was used for 2 × 2 tables, because some of the tables had small cell sizes. The Mann-Whitney rank sum test was used for child restraint use, knowledge, and correct use scales, because some of these variables were not normally distributed. Linear and logistic regression models were used to examine the effects of several variables on these parameters.Results. Factors influencing CSS nonuse were 1) lifestyle factors, 2) transportation and trip circumstances, 3) nonparent or nondriver issues, 4) parenting style, 5) child’s behavior, and 6) perceived risks of nonuse. Violator subjects were mostly Hispanic and female, with incomes of less than $30 000 per year. Those exposed to the class (citation and education group) scored 1 point higher on a knowledge test and had 1 more item correct on a CSS use instrument than did the group not exposed to the class (citation only group). In the logistic model, the citation and education group scored higher on the 2 items that were corrected by the instructor during the class.Conclusion. Our focus group study of CPS law violators revealed that multiple complex factors influence consistent use of a CSS. The interplay of the particular vehicle, the trip circumstances, and family/parent/child factors affected the use of a CSS at the time of parent citation. Addressing transportation issues and parenting skills in CPS programs is necessary. Among parents who had been ticketed for not restraining their children, exposure to a violator class demonstrated some benefit, compared with a fine alone. Correct CSS use improved most on items corrected by the instructor. Violator classes that include “hands-on” training show promise for improving rates of correct use of CSSs.

Objective. To identify environmental risk factors on residential streets for pediatric pedestrian injuries. Method. The sample consisted of 39 Latino children 0 to 14 years of age injured as pedestrians on a street in the same block as their home and 62 randomly selected neighborhood control subjects matched to the case by city, age or year of birth, ethnicity, and gender. The cases were identified from a population-based hospital and coroner's office surveillance system established in north-central Orange County, CA. Neighborhood assessments were performed from 3:45 PM to 5 PM, a fairly active time for young pedestrians. The cases were compared with the controls using conditional logistic regressions; in this study design, the odds ratios were interpreted as estimates of the incidence rate ratios. Results. Children living in a multifamily residence had an incidence of injury greater than that of children living in single-family residence on a single lot (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.3-7.6). The ORs in the highest category were several times those in the lowest category for both parked vehicles (OR 9.6, 95% CI 2.6-36) and total number of pedestrians observed (OR 4.7, 95% CI 1.4-16). Vehicle parking, total pedestrians, vehicular traffic volume, and speed were examined in a multivariate model. The association of vehicles parked on the street with pedestrian injury risk remained significant. Unlike the crude results, progressively greater vehicular speed was associated with a marked increase in risk. Progressively higher vehicular traffic volume was associated with a progressively lower adjusted OR. Conclusion. The results of this analysis would indicate that residential streets with a high proportion of multifamily residences, over 50% of the curb occupied with parked vehicles, and a large number of pedestrians observed in unenclosed areas should receive high priority for intervention programs to reduce pediatric pedestrian injuries. The analysis suggests that on these streets, measures to reduce the amount of street parking (thus increasing visibility) and reductions in vehicular speed should be considered to decrease pedestrian injuries.

Objective. To compare child pedestrian injury events occurring in driveways and parking lots and at midblock and intersections with respect to characteristics and activity of the child, injury outcome measures, and characteristics of the vehicle and roadway. Design. Descriptive case series. Setting. Data were obtained from a multihospital/coroner monitoring system, during 2 years in an urban county, by record review and interviews. Patients. The sample consisted of 345 pedestrians 0 through 14 years of age treated for injuries at one of the participating facilities. Results. Eleven percent were injured in driveways, 8% in parking lots, 53% at midblock, and 28% at intersections. Median age was 2 years for driveways, 4 years for parking lots, 6 years for midblock, and 10 years for intersection. Events in driveways and parking lots had significantly more vehicles backing up, fewer automobiles, and more pedestrians with adults. Events at intersections occurred more often on streets with more than two lanes, with speed limits >25 mph, and with moderate or heavy traffic than events at midblock. Sixteen percent of those injured in driveways and parking lots sustained head injury of moderate or greater severity versus 35% injured in the street. Conclusions. Interventions to prevent child pedestrian injuries must consider normal child behavior and driver awareness as it relates to location of the events. Driveway events involve small children, larger vehicles, and backing up. Midblock events involve children too young to cross even quiet residential streets safely. Traffic controls and safe street crossing skills are measures to consider for intersection events involving older children.

Thirty-six extremely low birth weight (

To test the hypothesis that chioral hydrate can cause direct hyperbilirubinemia (DHB) in the newborn, two retrospective analyses of the medical records of patients admitted to a neonatal intensive care unit during an 18-month period were conducted. In one analysis of 14 newborns who had nonhemolytic DHB, 10 did not have an identified cause of DHB, and all 10 had received chloral hydrate. In the second retrospective study, all newborns who received chloral hydrate were divided into groups according to whether or not DHB had developed. The newborns with DHB, compared with those without DHB, had received a higher total accumulative dose of chloral hydrate (1035 ± 286 vs 183 ± 33 mg/kg [±1 SEM], respectively). In the patients with DHB, the direct serum bilirubin levels increased 6.8 ± 0.8 days after the chioral hydrate administration began and resolved after the chloral hydrate was discontinued or markediy decreased. These data support the hypothesis that prolonged use of chloral hydrate in newborns can be associated with DHB.

OBJECTIVE. High rates of use of child safety seats have been achieved. A remaining challenge in child passenger safety is to reach the Healthy People 2010 objective of child safety seat use to 100%. Several factors have been reported to influence child safety seat use. A child safety seat Hassles Scale was developed to explore hassles that are associated with child safety seat nonuse.METHODS. Focus groups with violators of the California Child Passenger Safety Law provided data to construct the 29-item Hassles Scale. The scale was used in an interview that was conducted with 132 parents who were cited for violation of the law and whose children were 12 to 47 months of age and weighed 20 to 40 pounds. Interviews were conducted 3 months after parents paid the fine for the citation. Each hassle was rated 0 to 3 on frequency and intensity. Parent report of child safety seat use was obtained. Factor analysis was used to construct subscales. Relationship of subscale frequency and intensity scores to reported child safety seat use was assessed with linear regression.RESULTS. The sample was 86% Latino, 45% Spanish-speaking, and 55% with income CONCLUSIONS. In this low-income largely Latino population of violators, self-report of “always using a child safety seat” when transporting their child was low (59%). Child safety seat nonuse was related to hassles that are associated with child behaviors and vehicle crowding/inconvenience. The child safety seat Hassles Scale documented barriers and difficulties with the use of a child safety seat in a high-risk population for nonuse. These concepts can be explored by clinicians and others who work to increase consistent child safety seat use. Additional evaluation and development of the instrument requires validation for its use as a screening or educational tool.

Objective. Mortality and morbidity data on childhood injury are used to construct developmentally appropriate intervention strategies and to guide pediatric anticipatory counseling on injury prevention topics. Effective anticipatory guidance depends on detailed injury data showing how risks change as children develop. Conventional age groupings may be too broad to show the relationship between children’s development and their risk of various causes of injury. Previous studies revealed differences in overall rates and specific causes of injury by year of age. However, single year of age rates for children younger than 4 years may not reflect the variations in risk as a result of rapid developmental changes. This study was designed to analyze injury rates for children younger than 4 years by quarter-year intervals to determine more specifically the age period of highest risk for injury and for specific causes.Methods. We used data from 1996–1998 California hospital discharges and death certificates to identify day of age and external cause of injury (E-code) for children younger than 4 years. The number of California residents for each day of age was estimated from US Census of estimates of California’s population by year of age for the midpoints (1996–1998). Rates were calculated by 3-month intervals. We grouped the E-codes into major categories that would be particularly relevant for developmentally related risks of injury specific to young children. The categorization took into account physical, motor, behavioral, and cognitive developmental milestones of children 0 to 3 years.Results. There were a total of 23 173 injuries; 636 resulted in death. The overall annual rate for children aged 0 to 3 years was 371/100 000. Beginning at age 3 to 5 months, the overall rate of injury rapidly increased with increased age, peaking at 15 to 17 months. The mean injury rate calculated for each single year of age did not reflect the variation and the highest rate of injury by quarter year of age for children younger than 1 year, 1 year, and 2 years. The leading major causes of injury in descending order were falls, poisoning, transportation, foreign body, and fires/burns. The overall rate of the major category of falls exceeded poisoning, the second leading cause of injury, by a factor of 2. Age-related differences were detected within each major cause of injury. For children 0 to 12 months of age, there was a different leading cause of specific injury for each 3-month period: other falls from height (0–2 months), battering (3–5 months), falls from furniture (6–8 months), and nonairway foreign body (9–11 months). Hot liquid and vapor injuries were the leading specific causes for children 12 to 17 months. Poisoning by medication was the leading specific cause of injury for all age groups from 18 to 35 months and exceeded poisoning by other substances. Pedestrian injury was the leading specific cause of injury for all age groups from 36 to 47 months. Fall from furniture has the highest rates of specific causes of falls from age 3 to 47 months. Fall from stairs peaked at age 6 to 8 months and 9 to 11 months. Fall from buildings was highest at 24 to 26 months. Poisoning by medication peaked at age 21 to 23 months, but poisoning by other substances peaked at 15 to 17 months. The motor vehicle occupant injury rates were fairly stable over the age span of this study. The pedestrian injury rate increased beginning at age 12 to 14 months and by 15 to 17 months was double that of the motor vehicle occupant. Foreign body had a marked peak at age 9 to 11 months. Both battering and neglect rates were highest among infants 0 to 2 and 3 to 5 months. Bathtub submersions had a narrow peak at age 6 to 11 months. Other submersions peaked at 12 to 14 months and remained high until 33 to 35 months.Conclusions. We departed from usual groupings of E-codes and devised groupings that would be reflective of age-related developmental characteristics. Differences in rates by narrow age groups for young children can be related to developmental achievements, which place the child at risk for specific causes of injury. We found marked variability in both rates and leading causes of injury by 3-month interval age groupings that were masked by year of age analyses. Children aged 15 to 17 months had the highest overall injury rate before age 15 years. This coincides with developmental achievements such as independent mobility, exploratory behavior, and hand-to-mouth activity. The child is able to access hazards but has not yet developed cognitive hazard awareness and avoidance skills. A remarkable finding was the high rate of battering injury among infants 0 to 5 months, suggesting the need to address potential child maltreatment in the perinatal period. Poisoning was the second major leading cause of injury; more than two thirds were medication. Cultural factors may influence views of medications, storage practices, use of poison control system telephone advice, and risk of toddler poisoning. The pedestrian injury rate doubled between 12 and 14 months and 15 and 17 months and exceeded motor vehicle occupant injury rates for each 3-month interval from 15 to 47 months. Pedestrian injury has not received sufficient attention in general and certainly not in injury prevention counseling for children younger than 4 years. Anticipatory guidance for pedestrian injury should be incorporated before 1 year of age. Effective strategies must be based on the epidemiology of childhood injury. Pediatricians and other pediatric health care providers are in a unique position to render injury prevention services to their patients. Integrating injury prevention messages in the context of developmental assessments of the child is 1 strategy. These data can also be used for complementary childhood injury prevention strategies such as early intervention programs for high-risk families for child abuse and neglect, media and advocacy campaigns, public policies, and environmental and product design.

Objective. To determine the level of child safety seat (CSS) and airbag safety knowledge in parents who utilize emergency care services for their children and to determine factors that influence knowledge of safe transportation of children. Methods. A prospective survey study was conducted in a 42 000-visit-per-year Level I trauma center and emergency department (ED) in Southern California from May through October 2000. Subjects were parents of ED-registered children (≤6 years). Research assistants administered the survey in the subject’s native language. Parent knowledge of age-appropriate restraint use and airbag safety was collected. Results. Six hundred fifty-five subjects were enrolled. Most parents (97%) reported a regular source of pediatric medical care, and 57% had a previous ED visit. Eighty-six percent reported owning a CSS or booster seat. Eighty-one percent were aware that infants in rear-facing CSSs should never be placed in front of an airbag. Only 46% knew that a child weighing 40 to 60 lb should travel in a booster seat, and 59% knew that the State law required CSS use for children up to 4 years and weighing up to 40 lb. When knowledge scores were examined by ethnicity, fluency in English, income, and years of education, fluency was found to have the greatest influence on both CSS and airbag knowledge. Conclusions. Although nearly all of our subjects admitted that their children had a regular source of care, many parents showed evidence of lack of knowledge of CSS and airbag safety. Furthermore, many parents were not familiar with the state law regarding child restraints. Our findings suggest that parents of small children who utilize emergency care services could benefit from child passenger safety education during their ED visit and that non-English media and materials may be important to reaching this population.

Objective.The purpose of this study was to analyze causes of injury hospitalization/death by individual year of age and by specific causes of injury and to examine how well aggregate age groups represented individual year-of-age rates.Methods.Hospital discharge data and death certificate data for California residents age 0 to 19 years with a principal external cause of injury code (E-code) of E800 to E869, E880 to E929, or E950 to E999, calendar year 1997, were analyzed. Annual rates of injury hospitalization/death by year of age were calculated using combined hospital discharges and deaths as the numerator for major causes and important subcategories. For comparison, rates of injury hospitalization/death were calculated for conventional vital statistics age groups: Results.In 1997 in California, 35 277 children and adolescents 0 to 19 years were hospitalized and 1934 died as a result of injury, a ratio of 17 hospitalizations to 1 death. The distribution was bimodal with rates highest among 18-year-olds (732/100 000) and 1-year-olds (495/100 000). Except for children who were 5 to 9 years of age, the group rates for all injuries were not reflective of the individual year-of-age rates. In specific categories of injuries, variation in rates by year of age were masked by age group rates for unintentional poisoning among 1- to 4-year-olds, self-inflicted poisoning for 10- to 19-year-olds, falls from playground equipment among 5- to 9-year-olds, falls from furniture among 1- to 4-year-olds, and motor vehicle occupant injury rates among 10- to 19-year-olds. The peak rate of falls from playground equipment among 6-year-olds (34/100 000) was more than twice the rate for 9-year-olds (15/1000,000). Motor vehicle occupant injury rates doubled between 10 and 14 years of age and quadrupled between 14 and 18 years of age.Conclusions.Analyses using conventional age groups did not identify the age of highest risk for many causes of childhood injury. Changes in the rates often transected the traditional age groups and were not apparent with conventional age group analysis. These data can inform on the age at which to begin a specific injury intervention and on how to allocate resources. These data allow pediatricians and other health professionals to be anticipatory in providing injury prevention counseling. The greatest impact can be achieved by making the counseling topic most age appropriate in anticipation of the high-risk period.

To the Editor. In Southern California, Agran et al1 found that Hispanic (mainly Mexican) children had much higher rates of serious injury requiring hospitalization than did non-Hispanic white children. To investigate possible reasons for this disparity, we designed an ethnographic study involving in-depth interviews and observations in homes in geographical areas where large numbers of such injuries had occurred. Our subjects consisted of Mexican mothers (born and educated in Mexico), Mexican American mothers (of Mexican ancestry but born and educated in the United States), and non-Hispanic US-born white mothers. We assumed that the children in these families would have the same racial and ethnic …

Objective. This study was designed to characterize the restraint use of children in fatal crashes and to determine factors that were related to child restraint use. Methods. Crashes in which a vehicle occupant died were selected from the 1994 Fatal Analysis Reporting System data. Restraint use of children (0–9 years) in these crashes was characterized and examined in relation to vehicle and driver characteristics. Results. Restraint use declined with increasing age of children and increasing number of occupants. Restraint use was also lower in older vehicles, in pickups and large vans, between 3am and 6 am, and in rural areas. Driver characteristics associated with lower restraint use of child passengers included unrestrained drivers, younger drivers, and alcohol use at the time of crash. Driver restraint use was the strongest predictor of child restraint use. Differences in restraint use by age of the child, number of occupants, time, urban/rural area, and driver restraint use persisted in a logistic model. Conclusion. Restraint use in crashes is substantially lower than that in observational studies, suggesting that these studies are not reflective of high-risk conditions for crashes in which children are involved. Child occupant protection counseling must stress restraint use under all conditions of travel. Local, state, and national efforts must be aimed at increasing family occupant protection for the entire family.

Trapped occluded fourth ventricle has been considered a rare occurrence. Intraventricular hemorrhage followed by repeated shunt revisions may increase the risk (8/47 cases). Because premature infants with intraventricular hemorrhage and shunted hydrocephalus often have preexisting neurologic abnormalities, dilation may produce clinically undetected further neurologic damage. Shunting improved function in both currently treated as well as 13 of 14 previously treated patients. In light of this observation, the importance of recognition is stressed.

Dr. Haggerty commenting on the article by Duff (Pediatrics, 50:839, 1973) raised several considerations in regard to effective student teaching in the outpatient setting. It would seem that one of the solutions to the many issues Haggerty raises lies in the office of the community pediatrician. (1) Patients with considerably less complex problems are seen in the private office in contrast to the complex problems usually presenting themselves in the university outpatient departments.