Discussion
We sought to describe variations in the use of child/adolescent motor vehicle safety restraints among patients presenting to our trauma center following MVCs. The results of our study demonstrate a large number of children/adolescents who are not appropriately restrained at time of MVC. Additionally, safety restraint use is not limited to only families from neighborhoods with low resources, as indicated by different neighborhood COIs. Our study is also one of the first to use neighborhood COI based on home zip codes to identify potential disparities in motor vehicle safety restraint use.
Child safety restraints are known to reduce morbidity and mortality risk in children.1 6–8 Improper child motor vehicle restraint use is associated with greater need for trauma activations on arrival to the ED, injury severity, and mortality risk.6–8 Compared with seat belts, age-appropriate child safety restraints have been reported to reduce risk of injury by up to 82% and reduce risk of death by almost 30%.17 23 24 The AAP strongly supports routine assessment and education for families with children regarding proper child safety in motor vehicles.17
Disparities exist in child safety restraint use and outcomes of children in MVCs. According to the Centers for Disease Control and Prevention, rates of unrestrained child passenger deaths after MVC are higher in black and Hispanic children compared with white children.5 In a large study of over 1200 children in Cincinnati, Rangel et al demonstrated that black children compared with white children were less likely to be restrained or properly restrained, with the greatest difference observed in use of car seats.11 They also reported that children with public insurance were less likely to be in proper child safety restraints than those privately insured.12 In contrast, Sylvester et al did not identify significant differences in sex, race, or low-income status between non-restrained, improperly restrained, and properly restrained children in Florida.9 A plausible reason for the discrepancies between these studies may be that they represent two different geographic regions with differing patient populations, public health resources, and state car seat laws. Our study is unique in that it represents a different population of patients from Los Angeles. Furthermore, rather than focusing on limited variables of race, ethnicity, or insurance type, we describe disparities in safety restraint use among children in MVCs using a more comprehensive metric of the COI.18 25–27 The COI has been mostly used in the context of general pediatrics such as childhood obesity and pediatric emergency care utilization.19 28 29 Few studies exist using the COI to investigate disparities in pediatric surgery. Recently, Bouchard et al linked data from the Pediatric Health Information Systems database to the COI 2.0 database to demonstrate differences in risk of complicated appendicitis.15 To our knowledge, our study is one of the first to use the COI to investigate variations in social determinants of health in pediatric trauma patients.
Our study demonstrates differences in motor vehicle child safety restraint use among children/adolescents from neighborhoods with different levels of childhood opportunity, although the analysis did not demonstrate any significant associations between COI and appropriate safety restraint use. The broad range in CIs suggests lack of precision, which may be due to a small sample size. Contrary to our hypothesis, most appropriately restrained children/adolescents were from neighborhoods with very low COI, while not appropriately restrained children/adolescents were mostly from low-COI and moderate-COI neighborhoods. Additionally, there were more patients from high-COI and very high-COI neighborhoods in the not appropriately restrained group than appropriately restrained group. One possible explanation is that private vehicles may be more readily available to families and children from higher COI neighborhoods, including older children, adolescents, and teenagers who may have been driving at the time of the MVC. These findings can also be supported by previous work from Shinar et al where income and level of education did not accurately predict adherence to safe motor vehicle practices such as safety belt use.30 Although an at-risk population based on COI was not identified, our study suggests that children with private insurance are more likely to be appropriately restrained (table 3), thus suggesting that perhaps publicly insured children/families may benefit from targeted injury prevention initiatives.
Despite current education and counseling of parents on child safety restraint use, an alarmingly high number of children continue to be non-restrained or improperly restrained in motor vehicles.9 12 31 Injury prevention programs are crucial aspects of pediatric trauma systems and encompass both education and intervention. Muller et al previously demonstrated that car seat classes at our institution improve parent knowledge and awareness through a comprehensive, multifaceted curriculum including hands-on practice.32 In settings where in-person resources are limited, virtual classes also improve caregiver proficiency in child safety restraints.33 However, education alone may not be sufficient to increase appropriate motor vehicle child safety restraint use. A prospective study by Gittelman et al found that parents provided with booster seat education prior to discharge from the ED were less likely to purchase and use booster seats, while the majority of families who were provided both teaching and free booster seat installation reported consistent use of booster seats for their children.34 Similarly, Apsler et al improved child safety restraint use by providing education and free booster seats to day care families, while financial initiatives and policy changes did not result in meaningful change.35 These studies highlight the importance of resources in improving child safety restraint use, regardless of neighborhood COI. Within our institution, the Injury Prevention Program provides education and resources as well as free inpatient and outpatient services to families in the community including, but not limited to, hands-on, personalized car seat classes with installations and inspections, special needs evaluations, and permanent car seats to families receiving state or county public assistance. Potential methods to improve adherence to safety restraint guidelines by families include providing education and resources in the families’ primary language, offering follow-up appointments following the initial intervention (bedside education, car seat class attendance), and providing appropriate car seats. Interventions should also be offered to families presenting to the ED or inpatient setting for any reason, rather than only those who present following MVCs.36
This study is not without limitations. Car seat orientation, whether forward facing or rear facing, was unable to be determined for every case based on the information in the trauma database and the lack of specificity in medical provider documentation. While car seat placement is specified in safety restraint guidelines, we based our criteria of appropriateness of car seat use on age and weight or height, when available.17 Use of restraint was determined based on information gathered from law enforcement and EMS responders, patients, or patients’ caregivers. Due to the retrospective nature of the study, it was impossible for us to physically verify the specific restraint types, and thus non-differential misclassification may have contributed to the results of this study.37 However, any error in EMS, ED, or caregiver reports would not be systematic and thus would not favor a specific outcome. Additionally, it is not the usual practice for medical staff to physically assess patient restraint types when they present to the hospital or ED. Hospital staff are not the first point of contact with children involved in MVCs and are reliant on those reporting from the scene of the collision. For example, although a car seat is present and use is reported, technical use may be inappropriate such that the harness height adjustment may be incorrect or may have not been buckled properly. Thus, it is possible that more patients were improperly restrained than reported. Although some patients were noted in the documentation to have been using the appropriate restraint in an improper manner (and thus were categorized as not appropriately restrained), it is possible that patients in this category were missed because it was not elucidated during patient assessment or documented in patient records. Additionally, because several patients in our study resided in neighborhoods with zip codes outside of Los Angeles County, our analysis of COI is not exclusive to Los Angeles neighborhoods. Lastly, the findings of this study represent a sample of patients at a single institution and thus may be biased and not reflect national trends from random sampling.
Despite its limitations, our study provides evidence that lack of proper safety restraint use is not exclusive to families from low-COI neighborhoods and that disparities exist between children/adolescents with varying levels of access to resources. Neighborhood COI may be helpful in identifying patient populations that should be targeted by safety restraint education and injury prevention initiatives. Furthermore, this is the first study in pediatric surgical literature that specifically attempts to describe disparities among pediatric trauma patients using the COI. The COI may represent an interesting and valuable tool for future studies in pediatric trauma.
In conclusion, appropriate child motor vehicle safety restraint use varies among children and adolescents from neighborhoods with different resources, as indicated by COI. This study introduces populations of families who may benefit from targeted education and interventions to reduce injury and death from MVCs.
