Evidence to support changes to child restraint legislation.
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ABSTRACT: To assess the success of recent outreach activities to promote appropriate child restraint in motor vehicles by examining trends in restraint types used by children under age 9 in 3 large regions of the United States. Cross-sectional study was conducted of children who were under age 9 and in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 8730 crashes involving 10,195 children, representing 128 291 crashes involving 149,820 children, was collected between December 1, 1998, and November 30, 2002. Parent report was used to determine restraint type used in the crash. Logistic regression models were used to analyze the secular trend of restraint type use. Overall, for children under age 9, seat belt use decreased significantly from 49% to 36% between 1998 and 2002; for 7- and 8-year-olds, from 97% to 92%; and for 3- to 6-year-olds, from 63% to 34%. Concurrently, gains were achieved in overall child restraint use from 49% to 63%, for 7- and 8-year-olds, from 2% to 5%; and for 3- to 6-year-olds, from 35% to 65%. Child restraint use remains stable for children from birth to 2 years of age (from 97% in 1998 to 98% in 2002). Both the use of child safety seat and belt positioning booster seat increased significantly, whereas shield booster seat use decreased significantly. Although considerable achievements have been realized over a short period of time, substantial inappropriate restraint still remains: 62% of children aged 4 to 8 remain inappropriately restrained in adult seat belts. Parents hear safety messages when they are relevant to their children. As a result, sustained efforts about appropriate restraint must continue to maintain and improve the gains achieved in appropriate child restraint use. The additional benefits realized by recent changes in child restraint laws remain to be evaluated.PEDIATRICS 06/2004; 113(5):e458-64. · 5.30 Impact Factor
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ABSTRACT: The efficacy of seat belts in reducing deaths from motor vehicle crashes is well documented. A unique association of injuries has emerged in adults and children with the use of seat belts. The "seat-belt syndrome" refers to the spectrum of injuries associated with lap-belt restraints, particularly flexion-distraction injuries to the spine (Chance fractures). We describe the injuries sustained by 8 children, including 2 sets of twins, in 3 different motor vehicle crashes. All children were rear seat passengers wearing lap or 3-point restraints. All had abdominal lap-belt ecchymosis and multiple abdominal injuries due to the common mechanism of seat-belt compression with hyperflexion and distraction during deceleration. Five of the children had lumbar spine fractures and 4 remained permanently paraplegic. These incidents illustrate the need for acute awareness of the complete spectrum of intra-abdominal and spinal injuries in restrained pediatric passengers in motor vehicle crashes and for rear seat restraints that include shoulder belts with the ability to adjust them to fit smaller passengers, including older children.Canadian journal of surgery. Journal canadien de chirurgie 11/2005; 48(5):373-6. · 1.27 Impact Factor
- The Medical journal of Australia 09/2008; 189(3):183. · 3.79 Impact Factor
598 MJA • Volume 189 Number 10 • 17 November 2008
from 14–26kg”, and that they are not to be
used if the child’s eye level is above the top
of the booster back, or above the top of the
car seat back or headrest when restrained in
the booster seat.3
The matter of children exceeding the
maximum weight threshold of 26kg while
failing to meet the transition height to adult
seatbelts is far from trivial. Previous
research published in the Journal found
that about 50% of 7-year-olds whose
height fell between 100cm (the upper rec-
ommended height for child car seats) and
145cm (the recommended seatbelt transi-
tion height) exceeded 26kg, with only
27% having an age- and sex-adjusted body
mass index >25kg/m2.4 Consequently, due
to the current range of approved booster
seats available in Australia, children may be
placed at some unquantified risk in the
event of a crash, as optimal protection
above this weight threshold cannot be
guaranteed. Further compounding this
scenario is that pursuant to r266 of the
Australian Road Rules, if a child “cannot
safely be restrained as required . . . because
of his or her height or weight”, the use of a
seatbelt may be deemed acceptable.1 To
avoid this scenario, it is essential that
booster seats with a higher maximum
weight threshold be made available in Aus-
tralia as soon as practicable.
Michael P Fitzharris, Senior Research
Diana M Bowman, Postdoctoral Research
1 Accident Research Centre, Monash University,
2 Injury Prevention and Safety Promotion,
Monash South Africa, Johannesburg, South
3 Monash Centre for Regulatory Studies,
Faculty of Law, Monash University, Melbourne,
1 National Transport Commission. Australian
Road Rules. As approved by the Australian
Transport Council. Canberra: National Road
Transport Commission, Feb 2008. http://
RoadRules February2008.pdf (accessed Sep
2 Zurynski YA, Bilston L, Elliott EJ. Booster seat
use by children aged 4–11 years: evidence of
the need to revise current Australasian stand-
ards to accommodate overweight children [let-
ter]. Med J Aust 2008; 189: 183.
3 Standards Australia and Standards New Zea-
land. Child restraint systems for use in motor
vehicles, AS/NZS 1754: 2004 (incorporating
Amendment No. 1). Sydney: Standards Aus-
tralia and Standards New Zealand, 2004. http://
4 Fitzharris MP, Charlton J, Bohensky M, et al.
Booster seat use by children aged 4–11 years:
evidence of the need to revise current Australa-
sian standards to accommodate overweight
children. Med J Aust 2008; 188: 328-331.
Evidence to support changes
to child restraint legislation
Wei Du, Caroline F Finch and
Lynne E Bilston
TO THE EDITOR: Despite expert recom-
mendation, Australian states have yet to enact
legislation requiring use of child restraints
beyond the age of 12 months.
Our analysis of police crash records and
linked hospital separation data for the period
July 2000 to June 2001 in New South Wales
found that a large proportion of children who
were hospitalised following motor vehicle
accidents were reported by police as having
used adult (standard) seatbelts at the time of
It is of particular concern that over 80%
of 5–8-year-olds in this cohort were using
standard seatbelts rather than child
restraints (eg, booster seats). This pattern of
premature “graduation” to seatbelts has also
been reported in general populations of
child motor vehicle passengers both
overseas1 and in Australia,2 and also in
presentations of child motor vehicle passen-
gers after a crash to a NSW hospital’s emer-
Child restraints are specifically designed to
provide crash protection for children’s
anthropometrical dimensions. Standard seat-
belts are not designed to accommodate chil-
dren, so they are unlikely to achieve the good
fit to rigid body parts required for safety.
Consequently, use of standard seatbelts by
young children allows more head excursion
during a crash, thereby negating their pri-
mary goal of protecting against central nerv-
ous system injury, and potentially causing
Chance fractures and abdominal injuries.4
Our results provide further evidence that
such seatbelt use may not protect, or may
even cause injuries, during a crash.
Child road trauma is largely preventable or
controllable with the use of appropriate child
restraints, including booster seats. A cost–
benefit analysis showed that the use of
booster seats produced a benefit–cost ratio
for road trauma prevention of 9.4 (US$1854/
US$197).5 To prevent child road trauma in
Australia, all child motor vehicle passengers
should use appropriate child restraints.
Australian child road safety stakeholders
recommend that child motor vehicle passen-
gers use appropriate restraint systems accord-
ing to their height, weight and age when
travelling on road. Our findings provide fur-
ther justification for proposed legislative
changes that would require the compulsory
use of appropriate child restraints for child
motor vehicle passengers.
Wei Du, PhD Student1
Caroline F Finch, NHMRC Principal Research
Fellow and Research Professor in Human
Movement Science and Injury Epidemiology2
Lynne E Bilston, NHMRC Senior Research
Fellow and Associate Professor3
1 NSW Injury Risk Management Research
Centre, University of New South Wales,
2 University of Ballarat, Ballarat, VIC.
3 Prince of Wales Medical Research Institute,
University of New South Wales, Sydney, NSW.
1 Winston FK, Chen IG, Elliott MR, et al. Recent
trends in child restraint practices in the United
States. Pediatrics 2004; 113: e458-e464.
2 Charlton J, Koppel S, Fitzharris M, et al. Factors that
influence children’s booster seat use. Report No.
250. Melbourne: Monash University Accident
Research Centre, 2006.
Child restraint use among children (0–8 years) hospitalised for injury after a motor
vehicle accident, compared with that of the general population, New South Wales
*Linked hospital and police data from July 2000 – June 2001 were accessed from the NSW Injury Risk
Management Research Centre. Case selection is based on corresponding codes in the International
Classification of Diseases, 10th revision, Australian modification, 2nd edition.
†Based on a telephone survey conducted in NSW during 2005–2006.
Hospitalised children* General population†
Restraint use 0–4 years 5–8 yearsTotal 0–4 years5–8 years Total
Child restraint9 (22%)09 (10%) 295 (94%)70 (31%) 365 (68%)
Adult seatbelt 11 (27%)42 (82%)53 (58%)12 (4%)153 (67%)165 (31%)
21 (51%) 9 (18%) 30 (33%) 6 (2%)4 (2%)10 (2%)
41 (100%)51 (100%)92 (100%)313 (100%) 227 (100%)540 (100%)
MJA • Volume 189 Number 10 • 17 November 2008
3 Brown J, McCaskill ME, Henderson M, Bilston LE.
Serious injury is associated with suboptimal
restraint use in child motor vehicle occupants. J
Paediatr Child Health 2006; 42: 345-349.
4 Santschi M, Echave V, Laflamme S, et al. Seat-belt
injuries in children involved in motor vehicle
crashes. Can J Surg 2005; 48: 373-376.
5 Miller TR, Zaloshnja E, Hendrie D. Cost-outcome
analysis of booster seats for auto occupants aged 4
to 7 years. Pediatrics 2006; 118: 1994-1998.
Umbilical cord blood banking:
public good or private benefit?
David E Roberts
TO THE EDITOR: Samuel and colleagues’
article on the ethics of umbilical cord blood
(UCB) banking1 reflects much of the misinfor-
mation and bias that bedevil this debate. They
argue against storage of autologous stem cells
from UCB for a variety of contradictory, pater-
nalistic or ideologically driven reasons.
The indication for autologous UCB storage
is in anticipation of developments in regener-
ative medicine, an exciting field that holds
great promise; it is not in anticipation of
transplantation for malignancy, which is
unlikely to occur. Samuel et al acknowledge
these points, yet base their criticism of auto-
logous storage on the latter indication.
Next, they state that autologous stem cells
can be easily harvested at any time in life.
Perhaps, for use in transplantation; but cells
obtained later in life are likely to be of little
use in regenerative medicine. Capacity for in-
vitro manipulation declines with age.
Third, they argue that the two alternatives
of public and private UCB storage are mutu-
ally incompatible — “public good or private
benefit” (my emphasis). Australia’s three pub-
lic banks are close to achieving the desired
number of cords (about 20000) needed for
transplantation medicine in the non-Indigen-
ous population.2 There is no shortage, and
certainly no shortage of potential donors.
Why argue against autologous storage as if
Fourth, the authors disapprove of the for-
profit motive in private-sector medicine. That
may be their ideological position, but it is
paternalistic to impose that view on the rest of
us. Can parents not make up their own minds
on the value of autologous storage? At $2000
upfront and $150 a year, storage is not so
expensive that “only a small proportion of the
population are able to afford [it]”. I remind
readers of media reports that the Australian
Government’s Baby Bonus (now $5000) was
often used to purchase luxury items such as
flat-screen televisions rather than being spent
on the baby’s needs.3
The authors are correct in one respect: some
(but not all) private UCB banks have been
deliberately deceptive and misleading in their
marketing, and, in so doing, have been pred-
atory and exploitative. However, it does not
then follow that parents cannot access sound
and sober health advice in the marketplace.
The public versus private UCB storage
debate does have an ethical dimension, but
not this one. This debate is really just a turf
Competing interests: I have worked as an advisor
(unpaid) to Cryosite, 2002–2006, and as Alternative
Medical Director (remunerated) to Biocell, 2006–
07. I hold shares in Cryosite and Biocell, purchased
at market value.
David E Roberts, Paediatrician
Joondalup Health Campus, Perth, WA.
1 Samuel GN, Kerridge IH, O’Brien TA. Umbilical cord
blood banking: public good or private benefit?
Med J Aust 2008; 188: 533-535.
2 Bone Marrow Donors Worldwide. Number of
donors/CBU’s per registry in BMDW. http://
(accessed Oct 2008).
3 Dunlevy S. Rudd’s baby bonus crackdown. The Daily
Telegraph (Sydney) 2008; 19 Mar. http://
49,23398368-5001021,00.html (accessed Oct 2008). ❏
Gabrielle N Samuel, Ian H Kerridge and
Tracey A O’Brien
IN REPLY: Roberts asserts that we are
biased, paternalistic and driven by an
ideological objection to private umbilical
cord blood (UCB) storage. While this is
impressive rhetoric, it bears little resem-
blance to the points made in our article.1
Contrary to Roberts’ assertion, we do not
object to private UCB storage. Our primary
concern is that marketing campaigns make
misleading or grandiose claims about the
possible application of privately stored UCB
in cancer care and regenerative medicine.
For, although stem cell research does have
great promise, it remains clinically unproven
in the management of degenerative condi-
tions. Offering hope of cure or amelioration
of illness based on scientific speculation is
enormously problematic, especially when
directed at vulnerable parents concerned
about their unborn child. While some pri-
vate UCB banks take great care to avoid
deliberate deception, many do not.2,3 We
agree that parents should be able to decide
for themselves how and if to store their
child’s UCB, but they need accurate infor-
mation to do so.
Finally, Roberts asserts that there is no
shortage of public UCB units or donors. In
reality, there is a vast shortage of UCB units
available to ethnic minority and Indigenous
patients.4 North Caucasian donation also
needs to be maintained, particularly as the
impact of double-cord transplantation