Increasing Child Passenger SafetyResearch and Impact

Michelle L. Macy, MD, MSWilliam G. Barsan

Emergency Medicine Research ForumApril 27, 2016

Disclosures

• No financial relationships or conflicts of interest to resolve.

A newborn and an NPR story

Booster Seat Laws – by Age, 2016

From the Insurance Institute for Highway Safety website: http://www.iihs.org/laws/childrestraint.aspx

Trends in Child Passenger Deaths per Million Children; 1975-2013

Insurance Institute for Highway Safety analysis of Dept. of Transportation Fatality Reporting System. http://www.iihs.org/iihs/topics/t/child-safety/fatalityfacts/child-safety accessed April 21, 2015

Toward Zero Deaths

Passenger Safety Needs and Child Development

5 pounds

20 pounds

30 pounds

40 pounds

50 pounds

60 pounds

70 pounds

80 pounds

Infant-only seat, rear-facing, never in front seat with passenger-side airbag

Convertible safety seat, rear-facing until child is at least 1 year of age and 20 lbs, then forward-facing to max weight/height allowed by seat

Combination seat with internal harness that transitions to a belt-positioning booster seat, forward-facing only, weight varies

Forward-facing seat with internal harness, weight varies Integrated child seat; toddler seat with harness (20-40 lb) or some as belt-positioning

booster seat with lap/shoulder belt (>35-40 lb) as long as child fits Belt-positioning booster seat with lap/shoulder belt as long as child fits 2002 AAP Guidelines – Selecting and using the most appropriate car safety seats for growing children.

The safest place in a vehicle for all children is in the rear seat.

Retired Guidelines – American Academy of Pediatrics 2002

Rear-Facing Car Seat to 1 year and 20 pounds

Forward-Facing Car Seat to 4 years and 40 pounds

Booster Seat to 8 years and 80 pounds

5 pounds

20 pounds

30 pounds

40 pounds

50 pounds

60 pounds

70 pounds

80 pounds

Infant-only seat, rear-facing, never in front seat with passenger-side airbag

Convertible safety seat, rear-facing until child is at least 1 year of age and 20 lbs, then forward-facing to max weight/height allowed by seat

Combination seat with internal harness that transitions to a belt-positioning booster seat, forward-facing only, weight varies

Forward-facing seat with internal harness, weight varies Integrated child seat; toddler seat with harness (20-40 lb) or some as belt-positioning

booster seat with lap/shoulder belt (>35-40 lb) as long as child fits Belt-positioning booster seat with lap/shoulder belt as long as child fits

The safest place in a vehicle for all children is in the rear seat.

Updated Guidelines – American Academy of Pediatrics 2011

Infant-only or convertible child safety seat used rear-facing until 2 years of age or until they reach the highest weight or height limit allowed by the seat manufacturer

Convertible or combination child safety seat used forward-facing for as long as possible [children 2 years of age and older (or those less than 2 years old who have outgrown their seat’s rear-facing weight or height limit)]

Booster seat for all children whose weight or height is above the forward-facing limit for their child safety seat until the vehicle lap and shoulder belt fits properly

2011 AAP Guidelines for Child Passenger Safety – Policy Statement originally published online March 21, 2011

Images for child safety seats used with permission fromthe Children’s Hospital of PhiladelphiaCenter for Injury Research and Prevention

The safest place in a vehicle for all children is in the rear seat.

Disparities Continue

Results: Restraint Use 1-3 Year OldsMichigan Law Requires Car Seat

Rear-Fa

cing C

ar Se

at

Forw

ard-Fa

cing C

ar Se

at

Booster S

eat

Seat

Belt or U

nrestrain

ed0%

20%

40%

60%

80%

100%

White Nonwhite

Results: Restraint Use 4-7 Year OldsMichigan Law Requires Booster Seat

Car Seat Booster Seat Seat Belt Unrestrained0%

10%20%30%40%50%60%70%80%90%

100%

White Nonwhite

Results: Restraint Use 8-12 Year OldsMichigan Law Requires Seat Belt

Booster Seat Seat Belt Unrestrained0%

10%20%30%40%50%60%70%80%90%

100%

White Nonwhite

Variation in Appropriateness CriteriaAppropriate by

Restraint Type

Michigan Law

National Guidelines*

Typical Seat Weight Limit

Typical Seat Height Limit

<4 years <2 years <36 pounds <37 inches

<4 years 2-4 years 36-65 pounds 37-50 inches

4-7 years 5-11 years 66-100 pounds 51-56 inches

≥8 years ≥12 years >100 pounds >56 inches

*Parents encouraged to follow manufacturer specified weight/height limits of child safety seats

Room for ImprovementAppropriate by

Restraint Type

Michigan Law

National Guidelines*

Typical Seat Weight Limit

Typical Seat Height Limit

100% 100% 100% 100%

98% 100% 98% 9% 14%

84% 42% 13% 16%

78% N/A 13% N/A

*Parents encouraged to follow manufacturer specified weight/height limits of child safety seats

Appropriateness across Criteria

Michigan Law

National Guidelines

Typical Seat Weight Limits

Typical Seat Height Limits

Size

90% 58% 23% 29% 34%

• Michigan Law X Size, kappa = 0.10

• National Guidelines X Size, kappa = 0.53

• Typical Seat Weight X Height Limits, kappa = 0.58

Focus Group DataParent’s Advice for the Experts on Car Seat Safety

• “Don’t do it by age. Do it by height and weight. And then once you get to this height and this weight, they need to go to this type of car seat… because it gets confusing. You don’t know what’s recommended and what’s the law.”

• “Be more clear on the car seat laws vs. what's recommended. Better access to research studies so we can see what went into changing the laws.”

Weight Limits for Child Safety Seats U.S. Market in 2012

Op-Eds: Local Impact

Michigan Child Passenger Safety Law

Acknowledgements• Grants from the NICHD K23 HD070913 and The Michigan Center for

Advancing Safe Transportation Throughout the Lifespan (MCASTL)

• Mentors: C. Raymond Bingham, Ken Resnicow, Gary L. Freed, Rebecca M. Cunningham

• Collaborators: Mary L. Smiley, Peter D. Jacobson

• Research Team: Brigitte McCool, Deepika Kandasamy, Tricia Jacobson, Amy Teddy, Amber Kroeker, Aaron Cheek, Bethany Buschmann, Genevieve Davis, Randy Dowding, Chelsea Kittridge, Lynn Massey, Laura Spera, Julie Weber

Questions?

Contact InformationMichelle L. Macy, MD, MSAssistant ProfessorDepartments of Emergency Medicine and Pediatrics, Child Health Evaluation and Research (CHEAR) UnitUniversity of MichiganEmail: mlmacy@umich.eduPhone: 734.936.8338www.chear.org

Leaving More Protected than They Came

On DepartureOn Arrival Rear-

FacingForward-

FacingBooster Belt Missing

Rear-Facing n=630

95% 4% 0 <1% 1%

Forward-Facing n=273

9% 84% 5% 0 1%

Booster n=150

1% 26% 72% 0 1%

Belt n=52

0 11% 40% 48% 0

Missing n=224

59% 11% 21% 4.0% 4%

Focus Group DataViews on ED for Receipt of Child Passenger Safety Information

• “So there’s always a lot of downtime. So I think that parents would be receptive to getting information on child safety.”

• “I think if you say something like we care about your children, we care about you. You know?”

• “If it’s a pamphlet or some kind of literature, ‘Here, I’m handing this about car seats.’ then, I guess that’s fine.

• “Even if you did it at the end of the service, it’s like, ‘OK, I’ve been here for however long. I’m ready to go.”

• “I honestly can’t imagine any scenario where I would not find that annoying.”

• “But if I’m at emergency I don’t want to sit down and talk to you. I want to find out what’s wrong with my kid…”

• 1 in 3 emergency doctors did not know if a car seat inspection program was available in their area

Percent STRONGLY AGREE/AGREE PEM EM p-value

It is my role to educate parents about child passenger safety

95% 82% <0.001

Parents in the ED should be made aware of child passenger restraint laws

89% 79% <0.001

Results – Behaviors PEM vs. EM

RARELY/NEVER Responses PEM EM p-value

Recommend this family replace the car seat even if no signs of damage

12% 46% <0.001

Recommend the family purchase a booster seat for their 3-year-old child

59% 65% 0.157

• Scenario 1: A 3-year-old was restrained in a forward-facing car seat during a roll-over MVC.

Results – Behaviors PEM vs. EM

RARELY/NEVER ResponsesPEM EM p-value

Inform the parent a 6-year-old child is too young to sit in the front seat

4% 12% <0.001

Recommend this child use a booster seat

6% 16% <0.001

• Scenario 2: A 6-year-old front seat passenger is brought into the ED by their parent after a minor MVC.