What would be the best restraint to use on an infant during care for a head wound?

Annu Proc Assoc Adv Automot Med. 1998; 42: 15–27.

Abstract

In 1983, the Insurance Corporation of British Columbia became involved in advocating the use of child restraints. A study was undertaken in 1997, using existing insurance claim data, to better define the problem of child restraint use. Data was collected on a total of 188 injured child passengers aged 0–10 years. The majority of the children were restrained at the time of the crash. Over 90% of the children aged three years or older were restrained by the adult seat belt only. Greater emphasis needs to be given to the simple message to restrain the child using the appropriate restraint system.

INSURANCE CORPORATION OF BRITISH COLUMBIA

The Insurance Corporation of British Columbia (ICBC) is a provincial Crown Corporation in Canada established in 1973 to provide universal auto insurance to BC motorists. All motorists in BC are required to buy a basic package of ICBC Autoplan insurance that includes “accident” benefits (which cover costs of medical and wage loss, no matter who is at fault), third-party legal liability protection and underinsured motorist protection. In 1997, ICBC completed a merger with the former provincial government Motor Vehicle Branch and assumed responsibility for almost all driver licensing and related services. ICBC’s mission is “Helping British Columbians take the Risk out of Road Transportation”. For more than two million drivers in BC, ICBC is a public agency committed to preventing crashes and auto crime, providing effective loss-protection products and services and helping people recover from loss.

At ICBC the best opportunity of cost control is injury prevention. ICBC has recently joined forces with the BC government for an extensive road safety campaign, the Six-Point Plan which is targeted at changing driver behaviour. Under the Six-Point Plan such programs as intersection safety cameras, graduated driver licensing and speed cameras are being implemented. More information on these programs is posted on the ICBC web-site, www.icbc.com. Where primary emphasis has been given to the Six-Point Plan, there is ongoing work at ICBC to maximise the protection of vehicle occupants during a crash. This work includes child restraint educational activities.

CHILD RESTRAINT REQUIREMENTS IN BC

Provincial legislation requiring drivers to properly restrain children under the age of 6 years in a motor vehicle was proclaimed in 1985 [BC Reg. 3/85]. This legislation remains in effect and in summary requires that:

• all infants, less than 9 kg shall be restrained in a rear-facing restraint system which complies with CMVSS 213.1;

• toddlers weighing 9 to 18 kg shall be restrained in a child restraint which complies with CMVSS 213;

• all other children under the age of 6 years shall be restrained by the pelvic restraint of a seat belt assembly.

These laws do not yet recognise the availability of booster seats [CMVSS 213.2] for improved seat belt geometry and the need to encourage parents to secure the older child in a booster with a lap/torso seat belt system.

PUBLISHED STATISTICS

The population of the province of British Columbia was almost 3.9 million in 1996, of whom 492,000 were children aged 0–9 years [BCSTATS, 1998]. In 1996, there were 45,883 live births to BC residents in the province [Vital Statistics Agency, 1998]. The pattern of child transportation in motor vehicles in BC is not known, however provisional published official traffic collision statistics indicate that a total of 1,481 child passengers aged 0–10 years were injured in motor vehicle crashes in 1995, ten of whom were fatally injured. This represents about 3% of the total number of people injured or killed that same year in officially reported road crashes in BC [ICBC, 1997a]. Motor vehicle collisions are police “reportable” in BC if they result in personal injury or death or aggregate property damage in excess of $1,000 ($600 for a motorcycle). In reality, not all reportable collisions are reported due to a variety of reasons including the reduced scene attendance by the police.

STUDY OBJECTIVE

In an attempt to better define the scope of child restraint use and to provide a better estimate of the real incidence of child passengers injured in motor vehicle crashes, a study was initiated at ICBC using the insurance claims data base.

STUDY METHODOLOGY

SELECTION CRITERIA

Children aged 0–10 years and identified as “injured” when the claim was first reported were included in the sample. All ICBC insurance claims are initiated through a telephone claims representative who also categorises whether or not it is a bodily injury claim. As a precautionary measure, children who have complained of pain or have been taken to a doctor after the crash may also be recorded as “injured” at this time. To include all children for whom there may have been an insurance injury claim, the following “injury” selection criteria were applied in this study:

• a medical practitioner diagnosed a physical injury or a “psychological” problem resulting from the crash;

• an adjuster or parent stated injuries were sustained in the crash;

• complaint of pain resulting from the crash;

• “bodily injury” insurance dollars were paid out; and/or

• a doctor examined the child.

AVAILABLE DATA BASES

Insurance claims are processed throughout BC at one of 54 ICBC Claim Centres. A paper file is established at the Claim Centre handling the claim and information on the crash circumstances, any injuries and vehicle damage are routinely recorded. Basic information on the nature of the claim and insurance cost data are entered into a central computer data base. At present, the primary purpose of the data base is to support the financial management and monitoring of vehicle and injury claims costs.

SAMPLING PROCEDURES

The study was conducted at three Claim Centres in the Vancouver area for a given 12-month period. The 12-month period was selected by each Claim Centre in order to maximise the number of files which were still in-house. (Older closed files are stored at a central location and are less easily retrieved). At two of the Claim Centres pertinent files were retrieved for motor vehicle crashes which occurred during 1994 and at the third Claim Centre, the selected study period was 1 August 1995–31 July 1996. Cases which met the study criteria were identified through case listings maintained at each Claim Centre as well as a search of the central ICBC data base.

RESULTS OF THE STUDY

THE SAMPLE

Insurance files for a total sample of 188 injured child passengers aged 0–10 years were studied. These passengers were injured in 139 motor vehicle crashes which occurred during the 12-month study period and were processed at the three selected Claim Centres. There were 91 (48.9%) females and 95 (51.1%) males. This information was not available for the remaining two children. The age of the children is given in Table 1.

Table 1

Age in Years - Injured Child Passengers 0–10 Years

The seating position of the children in the vehicle was reported for 134 (71.3%) of the 188 injured children. In light of current air bag related educational efforts to encourage care-givers to restrain children 12 years and under in the back seat, it is interesting to note that during this study period (1994–1995), at least one-third of this sample of children (aged 0–10 years), were sitting in the front seat.

CRASH CIRCUMSTANCES

Over half (55.1%) of the vehicles in which the children were travelling, were sedans. The next most common mode of transportation was vans, in 26 (18.8%) of crashes. The majority of children were involved in multi-vehicle collisions. In 133 (95.7%) crashes, there was another vehicle involved. Rear and frontal collisions were the most frequent, 56 (43.4%) of the case vehicles were struck at the rear and there were 46 (35.7%) vehicles involved in frontal impacts. In 24 (18.6%) of the crashes the vehicle in which the child was travelling was struck on the side. Of the remaining crashes, six were single vehicle crashes, four of which were roll-overs.

CRASH SEVERITY

The extent of vehicle damage was used as an indication of the severity of the crash. Damage was classified as minor if it was cosmetic or confined to the bumper and breakage of the lighting units or, in the case of side impacts, there was only fender or door panel damage without intrusion. Using this criteria, there was minor damage to 49 (36.8%) of the vehicles. There was moderate damage to 54 (40.6%) of the vehicles which included structural body damage forward (or rearward) of the wheel arch. In 18 (13.5%) cases the damage to the case vehicle extended to or beyond the wheel arch. In a further 12 (9.0%) cases there was intrusion into the occupant compartment, 11 of these vehicles were impacted on the side and the remaining vehicle was involved in a rollover. In all cases “survivable” space remained. Vehicle damage was not determined for seven case vehicles.

INJURIES SUSTAINED BY THE CHILD PASSENGERS

The primary body area reported to have been injured is given in Table 2.

Table 2

Primary Body Area Injured

The most frequently reported injury was in the region of the neck and upper back. Of the 168 children for whom clear injury information was available, 69 (41.1%) sustained neck and upper back injuries, variously described in medical notes as soft tissue injuries, muscle spasms or sprains or just complaints of pain. An additional four (2.4%) children were reported to have suffered lumbar sprain or lower back pain. Psychological problems following the crash, were reported for 24 (14.3%) of the children. The psychological problems were variously described as nightmares, other sleeping problems and post-traumatic stress. Injuries to the face or head were noted as the primary injury for 47 (28.0%) children. Only 44 (26.2%) children sustained injuries to more than one body region. Soft tissue injuries and complaint of pain in the region of the back and upper back again prevail. Only three children sustained injuries to more than two distinct body regions, in all cases of a minor nature.

INJURY SEVERITY

The severity of the injuries were rated using the Abbreviated Injury Scale, AIS [AAAM, 1990]. The AIS is a standardised universal system for ranking and comparing injuries by severity. Injuries are classified by body region on a discrete six point scale from AIS 1 (minor) to AIS 6 (maximum, currently untreatable). As noted above, 57.7% of the reported injuries were soft tissue injuries, complaints of pain or psychological problems. In addition, the reported injuries of eight other children were confined to minor scratches or complaints of pain. These “injuries” are not covered by the 1990 AIS, even at the AIS 1 level. Of the remaining children, 53 (31.6%) sustained injuries rated AIS 1, nine (5.4%) children each suffered an injury rated AIS 2 and there was one fatality (AIS 5).

Although the majority of children sustained only minor injuries, it is of note, that 141 (83.9%) children received formal treatment or care. They visited a medical practitioner, usually a family doctor or were taken to see a psychologist or physical therapist. Only two children were hospitalised as in-patients, for treatment of their injuries.

RESTRAINT USE

The reported restraint used by the injured child passenger is given in Table 3. There was no information in the insurance file on restraint use for 52 (27.7%) of the children. A summary of the restraint use data by the age of the injured child is given in Table 4. Of the 27 children aged two years or younger, 85.2% were restrained in an infant or child restraint. However, only three (15.0%) children who were aged three years were in a child restraint. Of the 109 children aged three years and older (for whom restraint use was reported) only seven (6.4%) were restrained in a child restraint, booster or integrated seat. No child older than five years was restrained in such systems. It was also reported that eight children were sharing the seat belt, with either an adult or another child, at the time of the crash. Only six of the children were reported to be unrestrained. Four of these children were in parked vehicles, that were impacted from the rear.

Table 3

Type of Restraint Use by Age of Child

Table 4

Summary of Restraint Use by Age of Injured Child

RESTRAINT EFFECTIVENESS

Restraint effectiveness was analysed from a review of the vehicle damage, the crash configuration, the child’s seating position, reported restraint use and the injuries sustained by all occupants. The analysis was confined to the 136 children for whom restraint use was reported and in three of these cases, restraint effectiveness was not assessed due to inadequate data.

It was considered that for at least 46 (34.6%) children, restraint use was effective in preventing injuries in moderate to severe crashes and for at least another 65 (48.9%) children, restraint use probably provided some protection in less severe crashes. With the available data it was difficult to identify whether or not restraint misuse was a contributing source of injury, however in at least 14 (10.5%) cases, it was determined that the child’s injuries would probably have been prevented if the child had been secured in a restraint system appropriate for their age. In a further eight (6.0%) cases, children restrained in available lap belt only systems sustained head or face injuries rated AIS 1 which were considered avoidable if the child had been in a three-point seat belt system.

COMPARISON WITH PUBLISHED STATISTICS

In BC, information on all traffic collisions is routinely compiled. Although it is recognised that some collisions are not reported, this data base is used to determine and monitor collision trends as well as identify and develop new road safety programs. The central ICBC insurance claims data base was used to estimate the incidence of under-reporting in official statistics. The number of child passengers aged 0–10 years, included in the ICBC injury claims data base for the 12-month period from 1 August 1995 to 31 July 1996, was 30% greater than that reported in 1995 published statistics [ICBC, 1997a]. From available official statistics, the number of crashes involving children during the first half of 1996 was comparable to 1995. Based on these calculations, published BC statistics under-estimate the incidence of injured child passengers (0–10 years) by approximately one-third.

STUDY OUTCOMES

CHILD RESTRAINT USE

In this insurance based sample of children injured in motor vehicle crashes, 85.2% of the children aged two years and under were in an appropriate restraint for their age level, infant or child restraint. Only 6.4% of the children aged 3–10 years were restrained in a child restraint, booster or integrated seat. With the exception of four unrestrained children, the majority of children aged 3–10 were restrained only in the adult seat belt. Most children up to at least seven years are likely to be too “small” to be restrained in the vehicle seat belt alone. The results of the study indicate that in Vancouver, parents are failing to keep their children in the appropriate restraint system beyond the age of two years. By law, all children less than 18 kg are required to be restrained in infant or child restraint systems. Based on available anthropometric data, most children up to at least the age of 3–4 years are likely to fit in this category. The failure of parents to restrain their younger children at 18 kg and over in booster seats is within the law, given these children were restrained by the adult seat belt. It is, however, contrary to local educational efforts which promote the use of booster seats to raise the child so the lap belt fits over his or her pelvic structure [ICBC, 1997b].

The results indicate that in most cases, the children are at least restrained in some manner. Only two children in moving vehicles were not restrained, one of whom sustained fatal injuries when he was ejected from the vehicle during a roll-over.

BENEFITS OF RESTRAINT

The results of the study indicate that simply restraining a child during a crash can reduce the risk of injuries, even in moderate to severe crashes. On the basis of past studies [Gardner, Pedder and Legault, 1993; Wilson, Grant and Hurley, 1994] it is reasonable to assume that there was a high incidence of misuse of child restraints used by the injured children in the present study. The problem of misuse is also observed locally, with a reported misuse of 80% of children checked at BCAA clinics [BCAA, 1998]. The reality, however, is that the injurious consequences of improper use varies depending on the nature and extent of the misuse. There is an obvious need to identify which types of misuse most compromise the protective benefit of restraint systems. This would enable the identification of critical features for improved design to reduce the opportunity for gross misuse.

EDUCATIONAL DIRECTIVES

The study findings that the majority of young children had been removed from child restraints too soon highlights the need to promote the prolonged use of appropriate restraints. Recent efforts have concentrated more on the detailed instruction on how to use child restraint systems properly. There is an obvious need to ensure extended use of child restraints by children over two years of age. The following guidelines in Table 5 are recommended to clarify and encourage the use of appropriate child restraint systems. With the increasing number of vehicles fitted with front passenger-side air bags, it is also recommended that provincial road safety programs encourage parents to keep all children, 12 years and under, restrained in the back seat [Transport Canada, 1997].

Table 5

Guidelines on Appropriate Child Restraint Use

CURRENT DATA BASE

The retrospective file examination was successful in identifying a road safety priority to encourage parents to keep children in the proper restraint system. The study also highlighted the limits of using existing insurance files for the collection of detailed data on child restraint use. The routine collection of detailed child restraint data by claims adjusters is probably unrealistic. The collection of more detailed data would be labour intensive and depend on qualified observers to determine the manner in which the restraint was used (and installed).

There is considerable benefit, however, in the use of a standard check list or form to encourage the documentation of basic restraint information to monitor restraint use. It is recommended that the following information could usefully be routinely recorded for all child passengers:

• type of child restraint used

• orientation of infant or child restraint (rear-facing or forward-facing)

• seat belt system available and used

• age, weight and height of child

• child’s seating position in vehicle

Simple pictograms of the different types of restraint systems would facilitate the reliable identification and documentation of the restraint used.

OFFICIAL STATISTICS

Published BC Traffic Collision Statistics significantly under-estimate the incidence of motor vehicle related injuries to children. Resource planning or assessment of legislative changes based solely on these official statistics are likely to be invalid unless recognition is taken of this finding.

CONCLUSIONS

1. It is possible to obtain basic information on the pattern of restraint use by children using existing insurance files.

2. The available data clearly indicates that many children, injured in motor vehicle crashes, have been removed from the child restraint too soon.

3. The current pattern of restraint use is contrary to local educational efforts which promote the use of child restraints and then booster seats for younger children until they have reached at least 27.2 kg (60 lb.).

4. The finding that young children were inappropriately restrained, the majority over two years using only the adult seat belt, needs to be addressed through the promotion of prolonged use of proper restraints for children.

5. One obvious way to encourage proper use of restraints is to make them easy to use and to reduce the opportunity for misuse through improved design. The current market offers a wide variety of options and styles. All efforts to avoid confusion in the selection and use of the proper restraint should be considered. For example, dedicated child restraint systems designed for older children could be expected to reduce the relocation of the child too soon in a seat belt.

6. Insurance based data could be an effective means of monitoring child restraint use and their effectiveness in the full range of collision types and severities. This would require the routine and standardised collection of information on the size of the child, type of restraint used and seating position.

7. The need to link official motor vehicle statistics with medical care attendance registers is indicated to provide more reliable incidence data.

8. The majority of the study sample of injured child passengers sustained relatively minor injuries. It is of note, however, that 83.9% sought treatment and the costs of such care should not be overlooked.

FUTURE INITIATIVES

Although the problem definition is not complete, plans for future child restraint programs at ICBC include:

• Focusing primary efforts to raise and prolong the use of infant and child restraint systems through a combination of law enforcement and targeted education;

• Increasing the booster seat use rate through targeted education campaigns; and

• Training public enquiry staff to handle telephone enquiries regarding child restraints in an informed and straight-forward manner.

ACKNOWLEDGEMENTS

The work was possible through the co-operation and assistance of the managers and records personnel of the Coquitlam, Kitsilano, and North Shore West Claim Centres of ICBC and the help of Carol Reimer of Claims Operational Systems. Thanks also to Hugh Venables of ICBC Public Affairs & Corporate Marketing for his input.

The conclusions reached and the opinions expressed in this paper are the authors and do not necessarily reflect those of ICBC.

REFERENCES

• AAAM The Abbreviated Injury Scale 1990 RevisionsAssociation for the Advancement of Automotive MedicineDes PlainesIllinois; 1990 [Google Scholar]
• BCAA. Personal communication, Technical Services, British Columbia Automobile Association, 1998.
• BC Reg. 3/85. Motor Vehicle Act, section 217, BC Gazette, Part 2, January 22, 1998.
• BCSTATS. Personal communication Ministry of Finance and Corporate Relations, BC Government, www.bcstats.gov.bc.ca 1998.
• CMVSS 213. Child Restraint Systems, Canadian Motor Vehicle Safety Standards.
• CMVSS 213.1. Infant Restraint Systems, Canadian Motor Vehicle Safety Standards.
• CMVSS 213.2. Booster Cushions, Canadian Motor Vehicle Safety Standards.
• Gardner, W.T., Pedder, J.B. and Legault, F. Potential Improvements to the Canadian Child Restraint Regulations, SAE Paper 933088, Child Occupant Protection, SAE Publication SP-986, 1993.
• ICBC. British Columbia 1995 Traffic Collision Statistics, Insurance Corporation of British Columbia publication RS17 (0597), 1997a.
• ICBC. Infant and Child Restraint Systems for Motor Vehicles - Doing It Up Right, Insurance Corporation of British Columbia TS244A (1097), 1997b.
• Transport Canada. Car Time: A New Attitude on Board, video, 1997.
• Wilson, R.J., Grant, G. and Hurley, J. 1992 Observational and Telephone Survey of Restraint Use by Children in Motor Vehicles. Road Safety and Motor Vehicle Regulation Directorate of Transport Canada, Publication No. TP11943 (E), 1994.
• Vital Statistics Agency Personal communication, Ministry of Health and Ministry Responsible for Seniors, BC Government, www.hlth.gov.bc.ca:80\vs\, 1998.

Articles from Annual Proceedings / Association for the Advancement of Automotive Medicine are provided here courtesy of Association for the Advancement of Automotive Medicine