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Since all-terrain vehicles (ATVs) were introduced in the mid-1970s, regulatory agencies, injury prevention researchers, and pediatricians have documented their dangers to youth. Major risk factors, crash mechanisms, and injury patterns for children and adolescents have been well characterized. Despite this knowledge, preventing pediatric ATV-related deaths and injuries has proven difficult and has had limited success. This policy statement broadly summarizes key background information and provides detailed recommendations based on best practices. These recommendations are designed to provide all stakeholders with strategies that can be used to reduce the number of pediatric deaths and injuries resulting from youth riding on ATVs.

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.

Interview data from 100 lower income Hispanic and 50 White mothers from a nutritional service clinic extended prior research on cultural differences in the risk for unintentional pediatric injuries. Group differences were expected in reported injury incidence and in the prevalence and impact of contributing factors. As predicted, White mothers reported more injuries for a young child, and among Hispanic mothers, English language preference and use were associated with more reported injuries. Hierarchical regression analysis revealed that risky behaviors, mother's judgment about child compliance, and stressful life events were better predictors of injuries than housing quality, but among Hispanics, the impact of certain factors (e.g. child temperament) was qualified by mother's acculturation level. Stress and child temperament explained injury differences between more- and less-acculturated Hispanic families but only partially accounted for differences between White mothers and less-acculturated Hispanics. Pediatric injury risk and protective factors seemed to operate in concert with cultural processes.

Although the annual number of farm deaths to children and adolescents has decreased since publication of the 1988 American Academy of Pediatrics statement, “Rural Injuries,” the rate of nonfatal farm injuries has increased. Approximately 100 unintentional injury deaths occur annually to children and adolescents on US farms, and an additional 22 000 injuries to children younger than 20 years occur on farms. Relatively few adolescents are employed on farms compared with other types of industry, yet the proportion of fatalities in agriculture is higher than that for any other type of adolescent employment. The high mortality and severe morbidity associated with farm injuries require continuing and improved injury-control strategies. This statement provides recommendations for pediatricians regarding patient and community education as well as public advocacy related to agricultural injury prevention in childhood and adolescence.

To guide interventions to prevent injuries to pickup-truck occupants, we characterized pickup truck ownership, drivers and use in the 1995 National Personal Transportation Survey, which collects travel data from the civilian noninstitutionalized population of the US. SUDAAN software was used to account for the complex nature of the sample. Pickup truck ownership was more common in households with more vehicles, in rural households, in households living in single family homes and mobile homes, and in middle-income households. Among US regions, pickup truck ownership was highest among households in the mountain west. Pickup truck ownership was greater in households with two adults, whether or not children or youths were present, but this was largely due to the number of vehicles in these households. Driving a pickup on the sample day was more frequent among men, among drivers with less education and among full-time workers. A higher proportion of trips to work, work-related trips, longer trips and trips with fewer people were by pickup truck. Seat belt use was lower among pickup truck drivers than drivers of other vehicles. For only 0.5% of households (those with three or more members and a pickup truck as their only vehicle), restrictions on travel in cargo areas might be burdensome. Restrictions on cargo area travel, strengthening existing seat belt laws and social marketing strategies might increase the safety of pickup truck occupants.

Several studies indicate that rates of serious pediatric injury are higher among Hispanics than among non-Hispanic whites in the USA. To investigate possible contributory factors, we interviewed 50 Mexican, 30 Mexican American, and 30 non-Hispanic white mothers in their own homes in the same low-income neighborhoods of Southern California. Mothers were identified via door-to-door canvassing in areas with high rates of pediatric injury. We observed household conditions and behaviors and obtained a detailed family history, including accounts of any occurrence of serious injury in a child under 5 years old, the highest-risk age group for pediatric injury. Results show that Mexican families were poorer, less educated, and lived in more hazardous and crowded conditions than did families in the other two groups. Nevertheless, they benefited from strong family bonds and a cultural tradition in which responsible older children typically supervise younger siblings. In contrast, a number of Mexican American and white mothers had been abused as children and were estranged from their own mothers; hence they lacked support and models of good parenting. There was much less self-reported smoking, drug use, and mental dysfunction among the Mexican mothers and their male partners as well as much less excessively active and/or aggressive behavior among their children. The nature of the injuries reported by the various groups seemed to reflect these differences. Appropriate interventions for each group are discussed. The study illustrates the importance of using ethnographic methods to examine the context of pediatric injury at the household level.

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.

This study was designed to compare pickup truck drivers who carried passengers in the back with those who did not, with respect to driving behaviors, sociodemographic features, and issues related to use of the pickup truck. A computerized assisted telephone survey was conducted in Riverside County, California. One thousand ten motor vehicle drivers were interviewed with respect to demographics, restraint use, driving behaviors, and variables related to vehicle use. Thirty-six percent (364) of the households had a pickup truck driver. Pickup drivers were grouped into those who stated that they had carried occupants in the back (n = 119) and those who had not (n = 245). A higher proportion of 16- to 24-year-old and 35- to 44-year-old pickup truck drivers carried passengers in the back of pickup trucks. Those who carried occupants in the back were significantly more likely to be Hispanic, to be students, and to live in a household that included teenagers. They also had a larger mean household size. They were less likely to own the pickup and less likely to be the principal wage earners. They were more likely to report four high-risk driving behaviors. They also used the pickup truck for multiple purposes, i.e. recreation, work, school transportation, and daily transportation. In the multivariate analysis, the presence of teenagers in the household, three high-risk driving behaviors, and three indicators of pickup truck use were independently related to carrying passengers in the back of a pickup. Those who allowed passengers in the back were significantly less likely to agree with statements suggesting restriction of travel in the back. Finally, only 9% of the respondents who carried passengers in the back of a pickup reported that the pickup truck was the only vehicle available in the household.

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.

School systems are responsible for ensuring that children with special needs are safely transported on all forms of federally approved transportation provided by the school system, and a plan should be developed to provide the most current and proper support to children with special transportation requirements. This statement provides current guidelines for the protection of child passengers with specific health care needs, including those with a tracheostomy, those requiring use of car seats, or those transported in wheelchairs. Guidelines that apply to general school transportation should be followed, including the training of staff, provision of nurses or aides if needed, establishment of a written emergency evacuation plan, and a comprehensive infection control program. Research provides the basis for recommendations concerning occupant securement for children in wheelchairs and children with other special needs who are transported on a school bus. Pediatricians can help their patients by being aware of guidelines for restraint systems for children with special needs and by remaining informed of new resources. Pediatricians can also play an important role at the state and local level in the development of school bus specifications.

As awareness of the huge human and other costs of injury has grown, research has expanded. There has not been any standard set of terminology for use in this research. As a result, research and surveillance data are too often difficult to interpret and compare. To overcome this impediment to gains in needed knowledge about childhood injuries, a conference was held in 1989 by the National Institute of Child Health and Human Development to develop a set of standard definitions. The full conference report is available from the US Government Printing Office. This report presents excerpts, emphasizing those—core—variables likely to be of use to the largest number of investigators. The conference recommendations presented address cross-cutting factors (age, race/ethnicity, location, socioeconomic status, and biopsychosocial development), effect modifiers (exposure, medical risk factors, substance abuse, time, injury severity, and social risk factors), and specific injuries (motor vehicle injuries, central nervous system injuries, falls, fire/burns, drowning, and violence). It is expected that childhood injury investigators will strive to meet the recommendations of this conference and that use of these definitions will lead to improvements in research and, ultimately, to revision of the definitions.

Snowmobiles continue to pose a significant risk to children younger than 15 years and adolescents and young adults 15 through 24 years of age. Head injuries remain the leading cause of mortality and serious morbidity, arising largely from snowmobilers colliding, falling, or overturning during operation. Children also were injured while being towed in a variety of conveyances by snowmobiles. No uniform code of state laws governs the use of snowmobiles by children and youth. Because evidence is lacking to support the effectiveness of operator safety certification and because many children and adolescents do not have the required strength and skills to operate a snowmobile safely, the recreational operation of snowmobiles by persons younger than 16 years is not recommended. Snowmobiles should not be used to tow persons on a tube, tire, sled, or saucer. Furthermore, a graduated licensing program is advised for snowmobilers 16 years and older. Both active and passive snowmobile injury prevention strategies are suggested, as well as recommendations for manufacturers to make safer equipment for snowmobilers of all ages.

Historically, research on pediatric pedestrian injuries has analyzed children younger than 5 years of age as a single group. However, in this study, these children were divided into two age groups which were reflective of differences in behavior and development. The data demonstrate differences in the circumstances of the pedestrian injury events between toddlers (0 through 2 years and ambulatory) and preschoolers (3- and 4-year-olds). Toddlers were more likely to be injured in nontraffic events whereas preschoolers were more frequently injured in traffic situations. A high proportion of toddler injuries occurred in residential driveways and were caused by vehicles backing up. The majority of preschoolers, often without supervision, were injured while crossing/darting midblock on residential streets near their homes. Reflecting these differences in circumstances and also developmental differences between toddlers and preschool children, there is a need for agespecific interventions to reduce pedestrian injuries in children younger than 5 years of age.

Among ethnic groups in the United States, American Indian and Alaska Native (AI/AN) children experience the highest rates of injury mortality and morbidity. Injury mortality rates for AI/AN children have decreased during the past quarter century, but remain almost double the rate for all children in the United States. The Indian Health Service (IHS), the federal agency with the primary responsibility for the health care of AI/AN people, has sponsored an internationally recognized injury prevention program designed to reduce the risk of injury death by addressing community-specific risk factors. Model programs developed by the IHS and tribal governments have led to successful outcomes in motor vehicle occupant safety, drowning prevention, and fire safety. Injury prevention programs in tribal communities require special attention to the sovereignty of tribal governments and the unique cultural aspects of health care and communication. Pediatricians working with AI/AN children on reservations or in urban environments are strongly urged to collaborate with tribes and the IHS to create community-based coalitions and develop programs to address highly preventable injury-related mortality and morbidity. Strong advocacy also is needed to promote childhood injury prevention as an important priority for federal agencies and tribes.

Proper record-keeping of emergency department visits and hospitalizations of injured children is vital for appropriate patient management. Determination and documentation of the circumstances surrounding the injury event are essential. This information not only is the basis for preventive counseling, but also provides clues about how similar injuries in other youth can be avoided. The hospital records have an important secondary purpose; namely, if sufficient information about the cause and mechanism of injury is documented, it can be subsequently coded, electronically compiled, and retrieved later to provide an epidemiologic profile of the injury, the first step in prevention at the population level. To be of greatest use, hospital records should indicate the “who, what, when, where, why, and how” of the injury occurrence and whether protective equipment (eg, a seat belt) was used. The pediatrician has two important roles in this area: to document fully the injury event and to advocate the use of standardized external cause-of-injury codes, which allow such data to be compiled and analyzed.

Motor vehicle crashes remain the leading cause of death and acquired disability to U.S. children, despite safer vehicles, safer roads, and more children than ever before traveling in age-appropriate child occupant restraint systems. In 2006, an average of five children 14 years and younger were killed, and 568 children were injured in motor vehicle crashes each day. ABOUT THE AUTHORS Phyllis F. Agran, MD, MPH, FAAP, is Professor Emeritus, Department of Pediatrics Faculty Associate, Center for Trauma and Injury Prevention Research, University of California, Irvine School of Medicine. Benjamin Hoffman MD, FAAP, is Assistant Professor and Director, Pediatric Residency Program, NHTSA Child Passenger Safety Technician/Instructor, Department of Pediatrics, University of New Mexico, Albuquerque. Address correspondence to: Phyllis Agran, MD, MPH, 1201 West La Veta Ave. Suite 307, Orange, CA 92868; fax: 714-744-6033; e-mail: pagran@uci.edu or pagran@cox.net. Dr. Agran and Dr. Hoffman have disclosed no relevant financial relationships. EDUCATIONAL OBJECTIVES Describe the most significant risk factors for injury and death in a motor vehicle accident. Understand the four basic tenets of child safety seat use: selection, direction, location, and proper installation. Discuss the progression of child passenger safety options for children and appropriately determine when to change from one type of restraint system to another.

Police reports were compared to the information provided by a hospital monitoring system for children under 15 years old injured as pedestrians and bicyclists by moving motor vehicles in Orange County, California. The analysis was limited to identifying caveats in the police report database. Underreporting by police was conservatively estimated at 20% for pedestrians and 10% for bicyclists. Comparison of the pedestrian databases suggested underreporting by police of incidents involving 0-4-year-olds, nontraffic incidents, incidents in which the vehicle was backing up, and cases not involving a child crossing a street. Comparison of the bicyclist databases indicated an underreporting by police of nontraffic cases. These caveats, in part, are related to police agency reporting requirements. The police injury severity scale was found to correlate poorly with a scale based on medical diagnoses, and substantial underreporting by police of serious injuries was demonstrated. We suggest that utilization of police injury severity scales be limited to categories of fatal, injured, and not injured (when available).

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.

An estimated 8500 individuals, approximately 45% of them children younger than 15 years, were treated in US hospital emergency departments during 1999 for fireworks-related injuries. The hands (40%), eyes (20%), and head and face (20%) are the body areas most often involved. Approximately one third of eye injuries from fireworks result in permanent blindness. During 1999, 16 people died as a result of injuries associated with fireworks. Every type of legally available consumer (so-called “safe and sane”) firework has been associated with serious injury or death. In 1997, 20 100 fires were caused by fireworks, resulting in $22.7 million in direct property damage. Fireworks typically cause more fires in the United States on the Fourth of July than all other causes of fire combined on that day. Pediatricians should educate parents, children, community leaders, and others about the dangers of fireworks. Fireworks for individual private use should be banned. Children and their families should be encouraged to enjoy fireworks at public fireworks displays conducted by professionals rather than purchase fireworks for home or private use.

National observational studies indicate that infants who are not restrained in child safety seats (CSSs) in motor vehicles are usually riding on the lap of another occupant. This study was undertaken to determine the conditions under which children travel on-lap. The extent to which injuries would be reduced if these children were restrained in CSSs was also examined. Data were taken from a multihospital monitoring system for pediatric occupant injuries and from the coroner's office in a single urban county (1980 through 1989). One hundred ten children younger than 1 year of age evaluated in the monitored emergency departments after involvement in a crash had been traveling on-lap. On-lap travel did not appear to result from overcrowding. Eighty-eight percent were riding in vehicles with five or fewer occupants; 83% were in the front seat; 58% sustained injury; 22% of those evaluated were hospitalized; and 15% sustained intracranial injury. A 30% reduction in overall injury, a 75% reduction in hospitalization, and a 69% reduction in intracranial injury were projected for those riding on-lap, had they been restrained in CSSs. Applying national rates of on-lap travel (16.8%) to National Highway Traffic Safety Administration estimates of the number of infants injured in crashes each year indicates that approximately 2218 of these children would be on the lap of another passenger. Substantial savings in terms of injury and associated costs can be realized if children traveling on-lap were in CSSs. Parent education as well as strict enforcement of CSS laws must be implemented. Parents must be convinced that this practice of travel in vehicles is not protective and, in fact, poses a significant risk for injury.

We sought to describe the fatalities to occupants of pickup truck cargo areas and to compare the mortality of cargo area occupants to passengers in the cab. From the Fatality Analysis Reporting System (FARS) files for 1987-1996, we identified occupants of pickup trucks with at least one fatality and at least one passenger in the cargo area. Outcomes of cargo area occupants and passengers in the cab were compared using estimating equations conditional on the crash and vehicle. Thirty-four percent of deaths to cargo occupants were in noncrash events without vehicle deformation. Fifty-five percent of those who died were age 15-29 years and 79% were male. The fatality risk ratio (FRR) comparing cargo area occupants to front seat occupants was 3.0 (95% Confidence Interval [CI] = 2.7-3.4). The risk was 7.9 (95% CI = 6.2-10.1) times that of restrained front seat occupants. The FRR ranged from 92 (95% CI = 47-179) in noncrash events to 1.7 (95% CI = 1.5-1.9) in crashes with severe vehicle deformation. The FRR was 1.8 (95% CI = 1.4-2.3) for occupants of enclosed cargo areas and 3.5 (95% CI = 3.1-4.0) for occupants of open cargo areas. We conclude that passengers in cargo areas of pickup trucks have a higher risk of death than front seat occupants, especially in noncrash events, and that camper shells offer only limited protection for cargo area occupants.

This study compares pickup truck driver-owners and drivers who owned only automobiles with respect to demographic factors, conditions of use, risk-taking driving behavior, prior driving history and attitudes towards motor vehicle laws. A telephone survey conducted in Riverside County, CA determined that 36% of the households had a pickup truck. Pickup truck owners were primarily male, aged 30-39 years, married, reported lower restraint use and more risky driving behaviors, and had more traffic citations. Differences in behaviors and attitudes were largely a function of age and gender. There is a need to design appropriate occupant safety interventions for those most likely to own pickup trucks.

Objectives —In an earlier population based surveillance study of pediatric injuries, the rate of Hispanic children injured as pedestrians was 63/100 000 compared with 17/100 000 for non-Hispanic white children. The present study was designed to examine the effect of family, social, and cultural factors on the rate of pedestrian injury in a population of Hispanic children in the southwestern US. Methods —A case-control study of pedestrian injuries among Hispanic children. The sample consisted of 98 children 0–14 years of age hospitalized as a result of a pedestrian injury and 144 randomly selected neighborhood controls matched to the case by city, age, gender, and ethnicity. Cases were compared with controls using conditional logistic regression; in the study design the odds ratio (OR) estimates the incidence rate ratio. Results —The following family and cultural variables were associated with an increased risk of injury: household crowding (OR=2.8, 95% confidence interval (CI) 1.1 to 7.1 for 1.01–1.5 persons per room, compared with ≤ 1.0 persons per room), one or more family moves within the past year (OR 2.2, 95% CI 1.2 to 4.1), poverty (OR 1.9, 95% CI 1.1 to 3.3), and inability of mother (OR 3.6, 95% CI 1.3 to 10) or father (OR 5.6, 95% CI 1.5 to 20) to read well. However, children in single parent households and children whose parents did not drive a car, had less education, or were of rural origin, did not have an increased rate of injury. Conclusions —These results have implications for childhood pedestrian prevention efforts for low income, non-English speaking Hispanic populations, and perhaps for other immigrant and high risk groups. Prevention programs and materials need to be not only culturally sensitive but also designed for those with limited reading skills. In addition, environmental interventions that provide more pedestrian friendly neighborhoods must be considered.

Using 1994 Fatal Accident Reporting System (FARS), restraint use of children (0-9 years) in fatal crashes was characterized and outcomes of children in vehicles with a fatality were examined. Restraint use declined with age and was lower in older vehicles, in pickups and large vans, and during non-daylight hours. Infants had the highest proportion of deaths, sole fatalities, child restraint system (CRS) use, and on-lap and CRS fatalities. Children in seat belts were killed in proportions similar to unrestrained children. These findings identify infant occupant safety issues that need to be examined related to fragility, adequacy of child restraints and on-lap travel. Improvements in occupant protection are also needed for older children. (A) For the covering abstract of the conference see IRRD 899572.

Objective: To compare the incidence and causes of injury requiring hospitalization or resulting in death or both between Hispanic children and non-Hispanic white children. Design: Population-based surveillance of children younger than 15 years residing in eight Orange County cities and communities who were hospitalized or died of injuries sustained during 1991 and 1992. Setting: Eight hospitals and the coroner's office in central Orange County, California. Participants: Study population was 213 906 children residing in the study area. Forty-nine percent were Hispanic, 37% were non-Hispanic white, 12% were Asian or Pacific Islander, and 3% were of other racial origin. Results: A total of 1361 severe injuries were identified (crude annual rate was 318 per 100 000 population). The crude incidence rate ratio comparing Hispanics and nonHispanic whites was 1.82. After adjustment for census block group, Hispanic children had a 60% higher injury rate and incidence rate ratios of more than 2 for pedestrian injuries, asphyxia, aspirations, foreign-body ingestions, and poisonings. Conclusions: Hispanic children had higher injury rates than non-Hispanic white children, even when controlling for census block group. These rate differences may be related to differences in exposure to various causes of injury, injury prevention practices, parenting practices, family size, and language. Injury rate differences by ethnicity that address specific injury hazards must be explored to guide prevention efforts. More culturally and linguistically appropriate interventions are needed to provide injury prevention programs to the Hispanic population. (Arch Pediatr Adolesc Med. 1996;150:400-406)

OBJECTIVES: This study was designed to determine the incidence and causes of injury hospitalizations/fatalities to children less than 15 years of age. SETTING: Central Orange County, California. DESIGN: Cases were identified through a population based hospital and coroner's office surveillance system. SUBJECTS: The sample consisted of children 0-14 years of age who were residents of the study area and sustained an injury between 1 January 1991 and 31 December 1992 resulting in hospitalization or death. RESULTS: Over the two year study period, 1361 children 0-14 years of age were hospitalized or died as a result of injury. This represents a crude annual injury rate of 318/100,000 children. Rates were highest for children less than 5 years--this age group sustained the highest rate for eight of nine specific causes of injury. Falls were the leading cause of hospitalizations for all ages. Pedestrian injuries were more common among children 1-4 years and 5-9 years, while bicycle injuries were more common among older children. CONCLUSIONS: This study, one of the first population based studies in a Southern California urban/suburban community, found lower rates of injury hospitalization than studies conducted over a decade ago. These lower rates may reflect changes in hospitalization trends and/or injury prevention programs. Comparisons with more recent studies in inner city communities in the north east also show regional differences in rates and causes. Injury prevention efforts should particularly address the higher injury rates among children less than 5 years of age. This study also illustrates the need for regional and local data to guide injury control.

Lawn mower-related injuries to children are relatively common and can result in severe injury or death. Many amputations during childhood are caused by power mowers. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries.

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 …

The use of personal watercraft (PWC) has increased dramatically during the past decade as have the speed and mobility of the watercraft. A similar dramatic increase in PWC-related injury and death has occurred simultaneously. No one younger than 16 years should operate a PWC. The operator and all passengers must wear US Coast Guard-approved personal flotation devices. Other safety recommendations are suggested for parents and pediatricians.

Pickup trucks have become increasingly popular in the United States, accounting for about one in five vehicles involved in fatal motor-vehicle crashes. A critical factor in these deaths is the practice of carrying passengers in truck cargo areas, which are not designed for this purpose. Each year approximately 200 deaths occur to occupants riding in the back of pickup trucks. Over half the states have laws dealing with preventable injury problem, but these laws vary widely and most are too limited to be effective. We have reviewed existing laws, as well as crash injury data, and we have developed and recommend a model bill. The bill focuses on intended use, restricting passengers to only those portions of a vehicle designed for human transport. We have also conducted and report on a survey of legislative sponsors of pickup truck legislation.

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.

This study compares injuries of restrained and unrestrained 4- to 14-year-olds in nine emergency rooms and the Coroner's office in Orange County, California from 1983 to 1989. Analyses were performed separately for 4- to 9- and 10- to 14-year-olds because of differences related to the fit of the seat belt. Significantly fewer intracranial injuries and a significantly lower mean Injury Severity Score (ISS) were seen between the restrained and unrestrained for 10- to 14-year-olds in the front passenger and back seats; but for 4- to 9-year-olds in the back seat only. These same differences were noted between restrained 4- to 9-year-olds in the back compared with those in the front passenger seat. Except for 4- to 9-year-olds in the front passenger seat, our findings are consistent with similar studies of occupants of all ages. Our results suggest that lap-shoulder belts (primary restraint in front seat) may provide less protection for 4- to 9-year-olds than for 10- to 14-year-olds and adults.

Travel in the back of pickup trucks has not been adequately addressed as an occupant protection issue. This study compares injuries sustained by children riding in the back of pickup trucks with those of children riding in the cab. Data were obtained from a multihospital monitoring system and the coroner in a single urban county. The series of injured children consisted of 290 children 0 through 14 years of age, 201 of whom had been riding in the cab and 89 in the back. Age distribution of the children demonstrated that it is most frequently the 10- to 14-year-olds who travel in the back. Children riding in the back were more frequently injured in noncrash events (absence of a collision), had more ejections, had more injuries, and sustained more severe injuries as measured by the Maximum Injury Score. With increased restraint use in the cab, it is likely that even greater differentials in injury severity and patterns would be realized. Education regarding the hazards of travel in the back of pickups and stronger legislation limiting the transport of children in the back of trucks are recommended.

Motor vehicle occupant trauma is the major cause of mortality among the pediatric population. The mortality rate for adolescents is approximately 10 times that of the younger age groups. Despite enactment of child passenger safety laws in all states and mandatory seat belt use laws in two thirds of the states, mortality rates have not decreased to the extent expected. Additional interventions targeted at the adolescent driver, substance use and driving, and improved occupant protection for all children will be required to further decrease occupant trauma. Lack of comprehensive trauma data is a major roadblock to the calculation of morbidity and disability rates.

In a sample of children less than 4 years of age, treated in an emergency room after a motor vehicle accident, 22% were restrained in a child safety seat (improper and proper), 12% were restrained by a vehicle seat belt, and 70% were unrestrained. Trauma and injury patterns related to the various restraint use patterns are described. Most children in safety seats and seat-belted children, if injured, sustained minor contusions, abrasions, or lacerations. Injury among properly restrained children in safety seats was primarily the result of unavoidable mechanisms (eg, flying glass, intrusion). Improper use contributed to injury among safety-seat-restrained children, primarily by allowing the child to hit against the vehicle interior. Seat-belted children also were injured, primarily by hitting against the vehicle interior. Although some of the restrained children were seriously injured, in general, restrained children tended to sustain less serious and fewer injuries than the unrestrained children.

This study represents a series of cases of fetal death secondary to maternal involvement in a motor vehicle accident. During the period 1982 to 1985, nine cases were reported to the county coroner's office. In approximately 50% of the cases, other injuries to the victim, excluding injuries related to the pregnancy, were minor. Evidence of fetal distress was not always apparent at the time of initial evaluation. In all cases, placental abruption was documented. The injury mechanism was generally impact with the steering wheel. At the time of the accident, none of the patients were using seat belts. These cases demonstrate that minor maternal trauma without apparent maternal distress may result in fetal demise. The data indicate the need for prolonged continuous fetal monitoring for all pregnant women involved in motor vehicle accidents.

This study provides descriptions of the types of injuries sustained by a sample of children (0-14 years of age) who were using a vehicle seatbelt at the time of a motor vehicle accident and who were subsequently evaluated and treated in a hospital emergency room. Data were obtained from a hospital monitoring system established in nine emergency room facilities in a single county in California. The analysis indicates that in some cases injured seatbelted children were injured in circumstances in which the seatbelt could not have been protective, e.g., vehicle deformation into the child, flying glass, etc. The analysis of the remaining cases of seatbelted children suggests that there are significant variations in mechanisms of injury as well as injury patterns for different aged children. In many of the cases of injury observed in this sample, even though the child had been restrained in the adult seatbelt, the anatomic characteristics of the child prevented optional protection. The research provides further evidence for the necessity for utilizing specially designed restraints for children at least up to the age of 10 years.

Data on injuries sustained by child occupants in motor vehicles occurring in noncrash events are generally unrecorded. This study was undertaken to ascertain the occurrence of medically confirmed injuries sustained by child occupants in motor vehicles as a result of noncrash events. Seventy-nine children were seen in the emergency room for evaluation of injuries that they incurred as occupants in motor vehicle incidents over a period of 18 months. The majority of injuries occurred in crash events. However, 18 (23%) were injured in noncrash events. These events included sudden stops, swerves, turns, and movement of an unrestrained child within the vehicle. The mechanism of injury was either ejection from the vehicle or impact with an interior area of the vehicle. In five of the 18 cases safety restraint use could not be established. Of the 13 cases in which information was obtained, no child was restrained. Although the injuries were predominately minor (Abbreviated Injury Scale (AIS) 1), two children sustained moderate injury (AIS 2), and one child sustained severe injury (AIS 3). These results need to be confirmed by a larger study and if confirmed, the additional hazard of injury from noncrash events should be incorporated into health education messages that currently place primary emphasis on the potential for injury in crash events.

Injuries caused by hitting against the vehicle interior during a noncrash motor vehicle accident are noteworthy. Data on children 0 to 15 years of age involved in motor vehicle accidents were obtained from an ongoing multihospital monitoring system. Approximately 12% of the passengers were injured in a noncrash accident. One half of the noncrash injuries were caused by a child hitting against the vehicle interior during a sudden stop, turn, or swerve or after losing balance in a moving vehicle. Most of these accidents involved a child between 1 and 4 years of age who was traveling in the front passenger seat unrestrained. While most of the injuries were minor, some children sustained serious injuries. An analysis of the cases indicated that most of these injuries could have been avoided if the child had been restrained. Medical costs as well as use of medical resources could have been saved by preventing these noncrash injuries.

Two sources of data for the investigation of noncrash-related injuries are compared: police accident reports and a hospital emergency room monitoring system. Two main issues are considered: the extent to which these sources provide similar descriptions of the noncrash event, and an assessment of these data sources for investigation of noncrash events. Several critical features between the two types of data collection systems can be summarized from the analysis. First, reliance solely on police reports would indicate that there are very few cases of injuries as a result of noncrash events. Second, a narrow view of causes of injuries in noncrash events are found in the police report cases: most were ejections, while interior impacts were more common in the hospital cases. Third, noncrash events appear to be similar to other "household" accidents, with the injured child transported by the parent/guardian to the hospital. In summary, the police report investigations provide a limited view of the extent of noncrash events. Data sources such as hospital monitoring systems are more productive than police reports in studies directed at nonstandard traffic accident events, such as the noncrash.

This article critiques studies, such as that reported by Guerin and MacKinnon in the American Journal of Public Health. These studies are urgently needed in order to evaluate the effectiveness of child passenger safety laws. Using motor vehicle traffic accident reports from local police jurisdictions and California Highway Patrol field officers, Guerin and MacKinnon reported an eight percent decrease in injuries to children in the first year (1983) following implementation of the California Child Passenger Safety Law. In considering the implication of this study, however, some of its limitations need to be kept in mind. One limitation is the reliance on police records. Several studies in the past two years have indicated that police report data appear to underestimate the magnitude of motor vehicle injury rates. Furthermore, the impact of child passenger safety laws on the severity and patterns of injury are not reflected in the gross numbers reported in official statistics. Also to be considered is the extent to which the eight percent decrease in injuries reported by Guerin and MacKinnon can be accounted for by factors other than the restraint laws themselves. Another factor to be taken into account is possible misuse of child restraints. Evaluation of the effectiveness of mandatory child restraint use law is complex and requires a variety of measures and methods. Hospital based data systems may provide additional trauma data. However, additional measures would be required including correct restraint use, law enforcement activities and intensity of educational activities.

• Four- to 9-year-old children are a special group with respect to motor vehicle occupant restraints. Having outgrown child safety seats, they are often placed in adult seat belts. This study was undertaken to examine patterns of injury among restrained 4- to 9-year-olds by seat location and crash impact site. The data were obtained from an ongoing hospital-based monitoring system. Seventy percent of the sample sustained a head or face injury. Upper-torso and extremity injuries were infrequent. Lower torso injuries occurred primarily in frontal impacts in both the back and front seats. Frontal impacts resulted in a greater proportion of serious injuries than rear impacts. The most serious injuries, however, occurred to children seated on the side of impact in lateral collisions. Questions must be raised regarding the appropriateness of the present restraint system for young children. Recommendations, given current seat belt systems, are provided. However, technological improvements in vehicle design and belt systems are needed to improve protection, particularly in lateral impacts. ( AJDC . 1989;143:1317-1321)