Best Practice Recommendation 1.) Rear Facing Car Safety Seats

Best Practice Recommendation 1.) Rear Facing Car Safety Seats
The American Academy of Pediatrics
UPDATED CHILD PASSENGER SAFETY RECOMMENDATIONS
Summary of the Evidence &
Practical Implications
Presenter
Dennis R. Durbin, MD, MSCE
Lead Author and Co-scientific Director, Center for Injury
Research and Prevention
This webinar is made possible by
CPS POLICY REDEFINED
•
The American Academy of Pediatrics
(AAP) Child Passenger Safety Policy
Statement
∼ First issued in 2002, reaffirmed in 2007
•
Dynamic change in Child Passenger
Safety over the past decade:
∼ Scientific evidence has grown
∼ Legislation and regulation has expanded
∼ Restraint use has dramatically increased
∼ Automotive & restraint system design has
changed
•
AAP released revised CPS Policy
Statement in April 2011 issue of Pediatrics
•
Policy statement and Technical Report
authors:
∼ AAP’s Committee on Injury, Violence, and
Poison Prevention
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©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
WHAT YOU WILL LEARN TODAY
3|
•
The evidence behind the revised
recommendations
•
What is different
•
Why they changed
©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
TOO MANY AFFECTED
Leading Causes of Death
Age (years)
The burden of motor vehicle
crashes is great.
•
Leading cause of death for
children ages 4 and above
•
Result in more than 5,000
deaths each year to those
under age 21
∼ This number comprises 15
percent of all crash fatalities.
•
For each fatality, 400 more
children and youth receive
medical treatment for injuries.
Source: Centers for Disease Control and Prevention, 2007
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©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
THE MODERN ERA OF CPS
•
July 8, 1996: USA Today
publishes article describing
how children are killed by
passenger air bags
•
Education and laws
increase
∼ Rear seating for children
∼ Use of age-appropriate
restraints
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©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
THE MODERN ERA OF CPS
•
•
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The number of crashrelated deaths declines 45
percent between 1997
and 2009 for those under
age 16.
The lives of approximately
4,800 children have been
saved since 1997 due to
improvements in child
passenger safety.
Number of Pediatric Motor
Vehicle Fatalities
2500
2000
1500
1000
500
0
©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
THE MODERN ERA OF CPS
•
Children under age 16
spend nearly as much time
in motor vehicles as adults.
•
∼ Average: 3.4 trips / 45-50
minutes per day
The more time spent in motor
vehicles corresponds to
increased crash exposure.
∼ Age-appropriate restraint use on
all trips is so important.
Number of person
trips per day
Exposure of Children to Motor Vehicle Travel
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
5-14
15-19
20-24
25-54
Age group (years)
Source: National Household Transportation Survey, 2009
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©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
55-64
65+
RESTRAINTS – HOW THEY WORK
•
Restraints are designed to:
∼ Reduce the risk of being ejected during a crash
∼ Distribute energy load to bones rather than soft tissue
∼ Limit crash forces by prolonging deceleration
6-year-old children in 35 mph frontal impact crash
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©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
RESTRAINTS – HOW THEY WORK
•
Types of Restraints
∼ Vehicle restraints: air bags, seat belts
∼ Add-on restraints: child restraint systems (CRS)
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©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
PREVALENCE OF USE BY AGE
Child restraint use has significantly increased over the past decade
100%
1999
75%
•
From 1999 to 2007, restraint
use for 6- to 8-year-olds in
crashes increased
significantly; however, in
2007, 57% were still
improperly restrained.
•
In 2009, 89% of children in
the United States under age
13 were restrained.
2007
50%
25%
0%
<1
1
2
3
4
5
6
7
8
Age in Years
Source: PCPS Fact and Trend Report, 2008
∼
Source: 2009 National Survey of the Use of Booster Seats. DOT HS 811-377. NHTSA, 2010
10 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
55% of 4- to 7-year-olds
were in child restraint
systems.
BEST PRACTICE
RECOMMENDATIONS
New Algorithm for Pediatricians
to Use with Families
11 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
CHILDREN WITH SPECIAL HEALTH NEEDS
•
Children with certain physical and
behavioral conditions may require
specialized restraint systems.
∼ These include premature infants,
those with cerebral palsy, skeletal or
muscle tone abnormalities,
tracheostomy, or fractures needing
spica casts, as well as those in
wheelchairs
•
The AAP has a separate policy
statement for transport of children
with special health needs. It is
available at:
∼ aappolicy.aappublications.org
12 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
RECOMMENDATION 1
Rear Facing Car Safety Seats
“All infants and toddlers
should ride in a Rear
Facing Car Safety Seat
until they are 2 years of
age or until they reach
the highest weight or
height allowed by their
car safety seat’s
manufacturer.”
13 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
REAR FACING CAR SAFETY SEATS
Situation
•
Because infants’ spines are
developing and their heads
are proportionally large for
their bodies, injury to their
head or spine may occur if
not properly restrained.
•
21% of U.S. infants less
than age 1 or 20 lbs are
incorrectly seated in forward
facing seats.
14 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
REAR FACING CAR SAFETY SEATS
Confirmatory Evidence
•
Children up to age 2 placed in
forward facing car safety seats
(FFCSS) are 1.8 times more
likely to be seriously injured
than children up to age 2 in
RFCSS.
∼ Applies for all crash types
(frontal, side) and age groups (0
to 23 months)
•
This safety benefit from
RFCSS applies up to age 2.
∼ Forward facing children ages 12
to 23 months were over five
times as likely to be injured
when compared to rear facing
children of the same age.
15 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
PEDIATRIC OBESITY
& CHILD PASSENGER
SAFETY
•
34% of U.S. children are
“obese” (BMI >=95th%) or
“overweight”
(BMI >=85th% to <95th%).
•
To accommodate this
changing population, more
child restraints with higher
weight and height limits are
available.
∼ 30 of the 35 convertible seats
now available can
accommodate up to 35 lbs
rear facing
(BMI >95th% for 24 months).
Source: Centers for Disease Control and Prevention, 2000
16 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
RECOMMENDATION 2
Forward Facing Car Safety Seats
“All children 2 years or
older, or those younger
than 2 who have outgrown
the rear facing weight or
height limit of their car
safety seat should use a
Forward Facing Car Safety
Seat with a harness for as
long as possible, up to the
highest weight or height
allowed by their car safety
seat’s manufacturer.”
17 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
FORWARD FACING CAR SAFETY SEATS
Confirmatory Evidence
Prevention of Deaths
•
FFCSS vs. unrestrained
children
∼ Over a 6-year period (19881994), 1- to 4-year-olds placed in
forward facing restraints reduced
their risk of dying in a crash
54%.
•
FFCSS vs. seat belt-restrained
children
∼ 2- to 6-year-olds placed in
forward facing restraints reduced
their fatality risk by 22%.
– 17% reduced risk even with
gross CRS misuse
18 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
FORWARD FACING CAR SAFETY SEATS
Confirmatory Evidence
12 to 47 months old
Prevention of Injuries
When correctly placed in a
FFCSS vs. a seat belt
alone, children ages 1 to 4
have a 71% reduction in
serious injury risk.
3%
Risk of Injury
•
2%
71%
1%
0%
Seat Belt
Forward facing CSS
Source: Accident Analysis and Prevention, 2004
19 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
RECOMMENDATION 3
Belt-Positioning Booster Seats
“All children whose
weight or height is above
the forward-facing limit
for their car safety seat
should use a BeltPositioning Booster Seat
until the vehicle seat belt
fits properly, typically
when they have reached
4 feet 9 inches in height
and are between 8 and 12
years of age.”
20 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
BELT-POSITIONING BOOSTER SEATS
Situation
•
Most vehicle seat belts do not
fit children until they are 4’ 9”
tall and 8 to 12 years old.
•
For the lap and shoulder belt to
fit correctly:
∼ The shoulder belt should lie
across the center of the chest
and shoulder, not the neck or
face.
∼ The lap belt should sit low
across the hips and pelvis, not
on the abdomen.
∼ A child should be tall enough to
sit against the seatback with
knees bent and not slouching.
21 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
6-YEAR-OLD CHILD IN 35 MPH CRASH
Correct restraint:
Belt-positioning booster
with lap/shoulder belt
Incorrect restraint:
Adult lap/shoulder belt
22 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
SEAT BELT SYNDROME
•
During serious crashes,
incorrect belt fit is
associated with injuries to
the spine and abdomen.
•
This occurs because:
∼ The developing pediatric
pelvis cannot hold the lap
belt in place.
∼ Children tend to slouch, with
their knees bending
comfortably at the edge of
the seat, causing the lap belt
to ride up.
∼ The belt compresses the
abdominal organs directly
against the spinal column,
causing high tension forces
in the lumber spine.
23 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
BELT-POSITIONING BOOSTER SEATS
Confirmatory Evidence
Prevention of Deaths
•
Booster seats vs.
unrestrained children:
∼ 67% reduced fatality risk for
ages 4 to 5
∼ 55% reduced fatality risk for
ages 6 to 8
•
Booster seats vs. seat
belts alone
∼ Booster seats do not appear to
offer additional protection
against fatal injuries in severe
crashes as compared to seat
belts alone. They do, however,
provide additional protection
against non-fatal injuries.
Source: Rice et al 2009
24 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
BELT-POSITIONING BOOSTER SEATS
Confirmatory Evidence
Prevention of Injuries
Children ages 4 to 8 placed in
belt-positioning booster seats
are 45% less likely to sustain
non-fatal injuries than those
placed in seat belts alone.
∼ No significant difference between
highback and backless boosters
•
4- to 8-year-olds
1.4
Injury Risk (%)
•
1.6
1.2
1
45%
0.8
0.6
0.4
0.2
Only 1% of children ages 4 to 7
are injured in crashes when
placed in booster seats, as
compared to 1.5% placed in
lap/shoulder belts and 7% for
unrestrained children.
25 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
0
Belt vs. Booster
Highback vs. Backless
Source: Pediatrics, 2009
RECOMMENDATION 4
Lap and Shoulder Belts
“When children are old
enough and large enough to
use the vehicle seat belt
alone, they should always use
Lap and Shoulder Seat Belts
for optimal protection.”
26 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
LAP AND SHOULDER BELTS
Situation
•
Since 1989, lap and
shoulder belts are required
in rear outboard seating
positions.
•
Since 2005, lap and
shoulder belts are required
in center rear seating
positions.
27 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
LAP AND SHOULDER BELTS
Confirmatory Evidence
Lap and shoulder belt vs. unrestrained
•
Seat belts reduce the risk of serious injury or death by 40% for
4- to 14-year-olds.
•
If all passengers ages 8 to 15 were restrained by lap and
shoulder belts (vs. 72% currently):
∼ 45% less deaths would occur
∼ 32% less hospitalizations would occur
Lap and shoulder belt vs. lap only belt
•
For children placed in the center rear, 81% less risk of injury
with lap and shoulder belt vs. lap belt only
∼ The greatest reduction is seen in abdominal injuries.
28 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
RECOMMENDATION 5
Children in the Rear Seats of Vehicles
“All children younger than
13 years should be restrained
in the rear seats of vehicles for
optimal protection.”
29 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
CHILDREN IN THE REAR SEATS OF VEHICLES
Situation
•
Since the mid-90s there has
been a significant increase in
placing children in the rear seat.
•
Children are more likely to ride in
front if the driver is male, not a
parent, or if there is no frontal air
bag.
Source: Occupant Restraint Use in 2009—Results From the National Occupant Protection Use Survey Controlled
Intersection Study
30 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
CHILDREN IN THE REAR SEATS OF VEHICLES
Confirmatory Evidence
•
Children riding in the front
seat are 40 to 70% more
likely to be injured than
children riding in the rear.
•
This rear seat benefit
extends to side impact
crashes:
Injury Risk for 0 to 12-year-olds
by Row and Restraint Type
∼ 62% less likely to be
injured in rear seat
Source: Pediatrics, 2005
31 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
SPECIAL CONSIDERATIONS
Children & Air Bags
•
Air bags were originally installed in the late 80s to prevent serious injuries
to unrestrained adults when crashes occur.
•
Air bags have saved thousands of lives; but, in certain cases involving
young children seated in front of them, they can be extremely dangerous:
∼ First report: 8 children died due to contact with deploying air bags in otherwise
survivable crashes. (Nov. 1995, MMWR)
•
Mechanism of injury resulting in these deaths:
∼ Rear-facing infant: Air bag contact with rear surface of restraint (posterior skull and
brain injuries)
∼ Belt-restrained or unrestrained child: Vehicle deceleration places child’s head in path
of air bag during deployment (Atlanto-occipital fracture, brain stem injury, diffuse
axonal injury)
•
How the National Highway Traffic Safety Administration (NHTSA)
responded to child fatalities:
∼ Recommended all children, from birth to age 13, sit in the rear
∼ Changed regulation FMVSS 208 to encourage development of air bags that deploy
with lesser force (2nd generation)
32 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
SPECIAL CONSIDERATIONS
Frontal Air Bags
•
Second generation air bags (vehicle year 1998+):
∼ Reduce crash fatality risk 29% in children ages 6 to 12 vs. no air bag
Risk of serious injury
∼ Serious injury rate of 14.9% for seat belt restrained children ages 3 to 15 involved in
crashes with first generation air bags; injury rate drops to 9.9% with second
generation air bags
1st generation AB
2nd generation AB
25%
20%
15%
10%
5%
0%
3-8
9-12
Age (years)
Source: Archives of Pediatric & Adolescent Medicine, 2005
33 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
13-15
SPECIAL CONSIDERATIONS
Side Air Bags
•
92% of 2011 model cars,
94% of SUVs, and 56% of
pickups have standard head and
torso side air bags.
•
Side air bags reduce
struck-side fatalities by 18%
for all occupants and also protect
the thorax in adults.
•
2.7% of children in side impact
crashes were exposed to side air
bag deployment.
∼ 10.6% sustained AIS 2+ injury to
the head or upper extremities.
•
There is no evidence that side air
bags increase the risk of significant
injury or death.
34 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
WHAT YOU SHOULD KNOW ABOUT
Child Restraint Laws
•
Although all states instituted some
form of child restraint law by 1984,
most state laws do not comply with
Best Practice recommendations.
•
Older children (ages 5 to 15) are
not covered by the gap between
child and adult restraint laws in
several states.
•
Passage of booster seat laws
increased child restraint use 39%
among 4- to 7-year-olds.
•
Restraint use among 13- to
15-year-olds is 7.2% higher
in states with primary
enforcement laws.
35 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
WHAT ELSE YOU SHOULD KNOW ABOUT
Other Considerations
•
Children left in or around vehicles have an elevated risk of injury/death
from back-overs, hyperthermia, or power window entrapment.
∼ Children should never be left unattended in or around parked cars.
•
Children in compact extended cab pickup trucks are four times as likely
to be injured than in other vehicles.
∼ Children should never ride in the cargo area of a pickup truck.
•
Although children less than 2 are not required to have their own airplane
seat, it is recommended that they use their car safety seat when flying.
•
Consult the AAP’s Child Passenger Safety Technical Report for more
details at aappolicy.aappublications.org.
36 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
WRAP-UP
•
Please type questions in Q&A text box
•
Tape of webinar, copy of slides available from
www.chop.edu/carseat
∼ Wait about 2 weeks
∼ Full citation of sources available from printed
version
•
Questions about AAP recommendations
∼ Bonnie Kozial, [email protected]
37 | ©2011 The Children's Hospital of Philadelphia Research Institute. All rights reserved.
REFERENCES
Background of Child Passenger Safety (Slides 4-10)
Injury Prevention and Control: Web-Based Injury Statistics Query and Reporting System (WISQARS). Centers
for Disease Control and Prevention. Available at: http://www.cdc.gov/injury/wisqars/index.html. Accessed
August 17, 2010.
Fatality Analysis Reporting System (FARS) Encyclopedia. National Highway Traffic Safety Administration.
Available at: http://www-fars.nhtsa.dot.gov/. Accessed August 17, 2010.
National Household Travel Survey. U.S. Department of Transportation, Federal Highway Administration.
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Partners for Child Passenger Safety Fact and Trend Report. The Children's Hospital of Philadelphia, September
2008. Available at: http://stokes.chop.edu/programs/injury/files/PCPS_Reports/2008_FT.pdf. Accessed
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Pickrell TM, Ye TJ. The 2009 National Survey of the Use of Booster Seats. DOT HS 811 377. U.S. Department
of Transportation, National Highway Traffic Safety Administration, September 2010. Available at: http://wwwnrd.nhtsa.dot.gov/Pubs/811377.pdf. Accessed February 21, 2011.
Arbogast KB, Jermakian JS, Kallan MJ, Durbin DR. Effectiveness of Belt Positioning Booster Seats: An Updated
Assessment. Pediatrics 2009; 124 (5): 1281-1286.
Rear Facing Car Safety Seats (Slides 13-16)
Traffic Safety Facts: Child Restraint Use in 2008 -- Demographic Results. DOT HS 811 148. U.S. Department of
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in the United States, 1999-2004. JAMA 2006; 295 (13): 1549-1555.
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Forward Facing Car Safety Seats (Slides 17-19)
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Children in the Rear Seat of Vehicles (Slides 29-31)
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Children and Air Bags (Slides 32-34)
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Arbogast KB, Durbin DR, Kallan MJ, Winston FK. Effect of Vehicle Type on the Performance of Second
Generation Air Bags for Child Occupants. Annu Proc Assoc Adv Automot Med 2003; 47: 85-99.
Arbogast KB, Durbin DR, Kallan MJ, Elliott MR, Winston FK. Injury Risk to Restrained Children Exposed to
Deployed First- and Second-Generation Air Bags in Frontal Crashes. Arch Pediatr Adolesc Med 2005; 159
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Arbogast KB, Kallan MJ. The Exposure of Children to Deploying Side Air Bags: An Initial Field Assessment.
Annu Proc Assoc Adv Automot Med 2007; 51: 245-259.
Child Restraint Laws (Slide 35)
Staunton C, Davidson S, Kegler S, Dawson L, Powell K, Dellinger A. Critical Gaps in Child Passenger Safety
Practices, Surveillance, and Legislation: Georgia, 2001. Pediatrics 2005; 115 (2): 372-379.
Winston FK, Kallan MJ, Elliott MR, Xie D, Durbin DR. Effect of Booster Seat Laws on Appropriate Restraint Use
by Children 4 to 7 Years Old Involved in Crashes. Arch Pediatr Adolesc Med 2007; 161 (3): 270-275.
Durbin DR, Smith R, Kallan MJ, Elliott MR, Winston FK. Seat Belt Use among 13-15 Year Olds in Primary and
Secondary Enforcement Law States. Accid Anal Prev 2007; 39 (3): 524-529.
Other Considerations
Kids and Cars. Available at: http://www.kidsandcars.org. Accessed August 17, 2010.
Winston FK, Durbin DR, Kallan MJ, Elliott MR. Rear Seating and Risk of Injury to Child Occupants by Vehicle
Type. Annu Proc Assoc Adv Automot Med 2001; 45: 51-60.
Use of Safety Belts and Child Restraint Systems. Part 135, No. 128. In: Federal Aviation Regulations, U.S.
Department of Transportation, Federal Aviation Administration, 2003.
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