Child Passenger Safety: Update on Maryland CPS Programs Educational Conference Call February 17, 2005

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Child Passenger Safety Update on Maryland CPS
Programs Educational Conference Call February
17, 2005

• AAP Maryland Chapter Maryland Emergency
  Medical Services for Children

This conference call is sponsored by the Maryland
EMS for Childrens Partnership Grant from the
federal EMSC Program USDHHS/HRSA/MCHB
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Child Passenger Safety and Occupant
ProtectionLaws and General Overview

• Meg Miller
• Maryland Highway Safety Office at State Highway
  Administration
• 410-787-4077
• 1-888-963-0307, x4077

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Importance of Child Passenger Safety Laws

• Unintentional injury remains the leading cause of
  death among children 4-14 years of age
• 42 of those injury-related deaths are a result
  of motor vehicle crashes
• In 2003, 33,471 vehicle occupants were killed in
  traffic crashes of those nearly 8 were 0-15 YOA
  (2,570)
• 290,000 were injured (28,000 incapacitating
  injuries)
• (National Center for Statistics and Analysis)

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More Statistics

• In 2003, 291 children up to age 4 were seriously
  injured in motor vehicle crashes in Maryland 35
  were totally or improperly unrestrained.
• In Maryland, only 18 of booster-appropriate
• children actually are using boosters (according
• to a 2003 statewide observational study).

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Maryland Traffic Law

• Title 22-412.2 Child Safety Seats
• A child safety seat must be used in accordance
  with the seat and vehicle manufacturers
  instructions for a child
• younger than 6 years of age regardless of weight
  or
• who weighs 40 pounds or less regardless of age
• A person may not transport a child younger than
  16 YOA unless the child is secured in a child
  safety seat or vehicles seat belt in all seating
  positions in all vehicles

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Things to Remember About Current Law

• Applies to vehicles with MD registration class A,
  M, and E (trucks under 7000 pounds)
• Multiple violations in one vehicle at one time
  are to be considered one violation
• A child seat or seat belt may only be used by one
  person
• If there are more occupants required by this
  section to be restrained than there are positions
  for them, there is no violation as long as all
  positions are in use by someone required to use
  one.

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Applications of the Law

• In other words, if you have 5 children restrained
  appropriately in a car with 4 seating positions
  (driver excluded), there is no violation if the
  four available seating positions are being used
  by a child in a restraint system.
• However, double buckling (two kids in one belt)
  is a violation.
• If a seat is used in the US it must meet all US
  federal safety standards.

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CPS Law, Continued

• Out of State vehicles A child being transported
  in a motor vehicle registered in another state,
  DC, or another country, shall be in an approved
  child safety seat used in accordance with both
  the vehicle and the seat manufacturers
  instructions if the child
• Is under 4 years of age, regardless of weight or
  
• Weighs 40 pounds or less, regardless of the
  childs age

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Meaning of the Law

• Although not specified as a requirement of the
  law, booster seats are included as one of the
  child restraint options.
• Boosters were not specified in the law because
  some children might need other types of special
  needs restraints, and we didnt want to make
  those technically illegal by saying boosters were
  the only choice.
• If child falls into the small of children that
  are 6 YOA and less than 40 pounds, by law (and
  recommendation), s/he still needs to be using a
  child restraint system.

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Exemptions from the Law

• If a seating position does not allow the proper
  use of a booster seat (i.e., no shoulder belt
  available) there is no violation.
• Also, if only lap belts are available in the back
  seat, and are being used for children older than
  6 and weighing gt40 pounds, there is no violation.
  (Its not best practice, but its not against
  the law either.) However, there are restraints
  available to help in these situations, call KISS
  for assistance.
• Also not covered
• children who have a written medical certificate
  from their doctor

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Reminders

• This law was not meant to be punitiveif a family
  goes to court and proves that they have purchased
  or rented a safety seat, the fine is waived.
• Other requirements and applications of the law
  include
• A person may not transport a child younger than
  16 years of age unless the child is secured in a
  child safety seat or vehicles seat belt in all
  seating positions in all vehicles.
• A child younger than 16 years may not ride in an
  unenclosed cargo bed of a pickup truck.

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Related Laws

• The District of Columbia requires all children
  under 8 to be in a properly installed child
  safety seat (includes boosters). Their law
  applies to all vehicles operated in DC. 75 fine
  and 2 points.
• Virginia requires use of a child safety seat
  (including boosters) by children under age 6 with
  no weight requirements.
• PA Children up to age 8 must use approved
  restraint. Secondary law for kids over 4 years
  of age.
• DE requires children ages 6 and under and
  weighing less than 60 pounds to be properly
  restrained in an appropriate child safety seat in
  all seating positions.

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Changes in the Child Seat Industry

• LATCH (Lower Anchors and Tethers for Children)
• Uses a set of bars mounted in the seat bight
  (where seat cushions meet) to anchor child seat
  into car
• Does not use the seat belt anymore
• All passenger cars have at least two locations
• Tether anchors are the hooks on the back deck or
  the back of the seat
• The top tether on the child seat hooks to them to
  reduce head excursion

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LATCH

• In most vehicles the lower anchors are only in
  the outer seating positions and cannot have the
  two inner most points used together.
• Meaning if you have a sedan you can not use the
  LATCH system to anchor the child seat to center
  rear seat of the vehicle.
• This system was meant to make the installation of
  car seats universal and easy.
• To someone outside looking in, a LATCH-installed
  seat may not look installed, since seat belts are
  not being used!

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Car Seats with Harnesses for Higher Weight Limits

• New Car Seats with higher weight limits are now
  available
• Until recently there were no car seats made for
  general use that had weight limits above 40
  pounds with the harness system
• There are several currently available, and more
  to come!
• This is good for the kids that still like to move
  around a lot after 40 pounds and need more
  protection (i.e., kids who reach 40 pounds very
  early and who are not developmentally ready to
  use Belt Positioning Boosters).

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Resources

• There are many resources for you if you have
  questions or concerns related to transporting
  children in your vehicles or enforcement/investiga
  tive situations.
• Maryland Kids In Safety Seats (KISS) at
  410-767-6016
• MHSO 410-787-4077, MSKC 410-787-5893
• Various CPS Technicians / Instructors throughout
  the State

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Maryland Kids in Safety Seats(KISS) Maryland
Department of Health Mental Hygiene

• Tracy A. Whitman
• Coordinator

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What is Kids in Safety Seats?

• Statewide program dedicated exclusively to child
  passenger safety issues.
• KISS
• 1. Educates the public (parents and
  professionals) on all cps issues.
• 2. Promotes the proper and consistent use of
  child safety seats.
• 3. Answers questions/provides technical
  support/training to the public.

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KISS Services

• Child Safety Seat Loaner Programs
• Technical Assistance/Referral Service
• Presentations/Trainings
• Safety Seat Check-up Events
• Referral Service
• Child Passenger Safety Clearinghouse

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Loaner Programs

• Available to Maryland residents
• Not available in every county
• Some service county residents only
• Low cost (sometimes no cost)
• Education is provided
• Special needs programs (5)
• Seats vary per site

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Presentations/Trainings

• One and Two-Hour General CPS Overviews
• 16-Hour Child Care Providers Training
• 16-Hour Special Needs Training
• 16-Hour RN Training
• 16-Hour Law Enforcement Training
• 32-Hour National Standardized Certification Course

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Safety Seat Check-up Events

• Assistance provided to agencies/ organizations
  conducting events
• Organized by appointment or open to public
• SAFE KIDS Van and/or Trailer (fee)
• KISS holds regularly scheduled check-ups once a
  month
• No charge but appointments are necessary

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Referral Service

• KISS maintains a current list of Permanent
  Fitting Stations (PFS)
• PFS are sites where child transporters may take
  their vehicle and seat to have certified child
  passenger safety technician check the seat for
  correct use and installation
• Most locations are free but appointments are
  necessary
• Many locations run on a wait list

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Clearinghouse

• Requests for materials
• Answers best practice and other technical
  inquiries
• Presentation/training and health fair display
  requests

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Contact KISS

• Helpline 800-370-SEAT or 410-767-6016
• E-mail
• Kiss_at_dhmh.state.md.us
• Web site
• www.mdkiss.org

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Child Passenger Safety

• Donna J. Perlin, MD
• Allen Walker, MD
• Jean Ogborn, MD
• Ann Duggan

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Statement of Problem

• Motor vehicle collisions are the major cause of
  death for children ages 5-9 years
• Ramsey, A
• Among 5-9 year olds in fatal crashes, 48 were
  unrestrained
• CDC

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Statement of Problem

• Parents reliably restrain their infants and
  toddlers in appropriate child safety seats
  secondary to a public awareness of their
  significant protective records in motor vehicle
  crashes

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Statement of Problem

• The prevailing belief among parents of children
  ages 4-8 years is that a lap/shoulder belt is the
  appropriate form of restraint once the child has
  outgrown their toddler seat. Unfortunately, the
  studies show this belief to be false

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Booster Seats

• Decrease the risk of significant injury in a
  motor vehicle accident by a factor of 3.5
• Provide a relative risk reduction of 4.2 for
  significant head injury
• Used in only 6-10 of children in the 4-8 year
  old age range
• Decreased the risk of both lumbar and hollow
  viscus injuries
• Winston, FK, Ramsey, A

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Maryland Statistics

• In 2003, motor vehicle crashes involving Maryland
  children resulted in fatalities and serious
  injuries to
• 282 children lt5 years old
• 546 children 5-10 years old
• 923 children 11-16 years old
• Car safety seat misuse in Maryland, as of May,
  2004, is 88

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Crash Dynamics

• An object in motion remains in motion at the
  original speed until acted upon by an outside
  force
• Approximate
• Weight X Speed Restraining Force
• Example 40 lb. Child in a car going 40 mph has
  1600 lbs of crash weight

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Three Collisions
1. Vehicle 2. Human 3. Internal
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Children in Crashes Children are more
vulnerable to injury in crashes
because
Immature musculoskeletal system Cars are designed
to protect the ADULTS
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Child Safety Seats Prevent Injury

• Prevent ejection
• Spread out crash forces
• Contact strongest parts of the childs body
• Allow the child to ride down the crash
• Protect head, neck, and spinal column

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Local News Paper Articles
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Statement of Problem

• Various studies have shown that only 6-10 of
  children who are 4-8 years old are actually being
  appropriately restrained in booster seats
• Ramsey, A
• Decina, LA
• Karp,H

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Statement of Problem

• Lack of awareness of their need by parents is the
  most commonly cited barrier to their usage
• Ramsey, A
• Rivera, FP
• Kunkel, NC

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Statement of Problem

• Other barriers to booster seat usage are the cost
  of the seats, child resistance, peer pressure and
  the difficulty of fitting multiple seats into the
  car
• Rivera, FP
• Ramsey, A

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Statement of Problem

• Many parents are not aware that the seatbelts
  required by law in most states for their children
  ages 4-9 are not sufficient protection for their
  children in a crash
• Their perception is that the laws support the
  current safety recommendations

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Statement of Problem

• The state law usually ends with three or four
  year olds. The law of physics lasts a lifetime.
• (Bob Wall, Child-Passenger Safety Instructor)5.

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Statement of Problem

• Many states, including Maryland, have recently or
  are in the process of enacting legislation
  mandating booster seat usage for children over
  age 4

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Goals of This Study

• Our long-term goal is to design an effective
  intervention to optimize the transportation
  safety of children ages 4-8 through a
  multifaceted attack on the previously reported
  barriers to booster seat usage

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Goals of This Study

• In order to achieve this goal, we must determine
  the factors that directly influence the most
  commonly cited barrier to their usage, parental
  knowledge of their efficacy

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Hypothesis

• Pediatricians can play an important role in
  advocating their usage by educating families

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Hypothesis

• We hypothesize that the frequency of booster seat
  counseling is low among primary care
  pediatricians

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Hypothesis

• In the first part of our study we hope to
• assess the frequency of Pediatrician counseling
  regarding booster seats
• to delineate those factors that are associated
  with a poor rate of booster seat counseling.

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Hypothesis

• In the second part of our study we will evaluate
  the effectiveness of booster seat legislation on
  Pediatrician counseling practices by assessing
  the change counseling practices

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• We acknowledge the role of the pediatrician in
  the movement towards widespread booster seat
  utilization

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Long Term Goal

• This study hoped to delineate those factors that
  are associated with a poor rate of booster seat
  counseling.  Our long-term goal is to devise an
  intervention directed at those predictive
  variables.

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Conceptual Framework
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Study Design/Methods

• A cross sectional descriptive study
• Our sample of 992 Maryland pediatricians was
  obtained from the membership list of the Maryland
  Chapter of the American Academy of Pediatrics

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Study Design/Methods

• Data was collected via self-administered
  questionnaires distributed through the mail with
  two subsequent re-mailings for non-responders

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Study Design/Methods

• The survey included questions regarding the
  practitioners knowledge of current percentages
  of booster seat usage, practice experience with
  patients injured in motor vehicle collisions,
  awareness of AAP recommendations regarding
  booster seat counseling, and personal counseling
  practices

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Study Design/Methods

• Data was gathered regarding variables in our
  conceptual framework hypothesized to influence
  pediatrician counseling practices

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Study Design/Methods

• We opted to utilize the enactment of Maryland
  booster seat legislation on October 1, 2003 as
  the potential impetus for change in subsequent
  booster seat counseling practices among Maryland
  pediatricians

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Study Design/Methods

• Primary Care Pediatricians who responded to the
  first survey were re-sampled following the
  legislation change and we are currently in the
  process of collecting this comparison data

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Study Design/Methods

• A total of 992 surveys were mailed between July
  2003 and September 2003, prior to the enactment
  of Maryland legislation mandating booster seat
  usage, with a response rate of 45
• 104 were excluded due to non-primary care
  practice or retirement

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Results

• Only 55 of surveyed pediatricians were aware of
  the AAP recommendation to counsel families of
  children ages 4-6 about booster seats and were
  consistently counseling

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Results

• This translates into 45 of pediatricians who
  were not aware of the recommendation and not
  counseling

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Results

• Only 30 of the participants were aware of the
  then upcoming change in the Maryland legislation
  requiring booster seats

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Results

• Only 17 (5) were aware of the change and were
  able to correctly identify the preceding legal
  restraint requirement for infant/toddlers,
  children ages 4-6, and children greater than 6
  yrs of age
• Of these 17, 88 were parents themselves

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Results

• Ninety percent of participants reported that they
  usually or always counsel families regarding
  infant/toddler seats
• Only 72 report the same for booster seat
  counseling

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Significance

• The current usage of booster seats for children
  ages 4-8 years is only about 6-10
• Multiple barriers to their use have been cited
  with the most common barrier being parental
  knowledge
• A multifaceted approach to public education is
  needed

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Significance

• Pediatricians must be on the forefront of this
  process to increase the publics awareness of
  this important issue
• Failure to counsel parents about booster seats
  implies a lack of acknowledgement of their
  significance

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Best Practice Recommendations for
Practitioners/Providers

• Maryland Child Passenger Safety Advisory Board
  recommends that written guidelines on the
  dissemination of CPS information be
• developed by
• public and private hospitals
• pediatric and family clinics
• physician offices
• birthing centers

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Best Practice Recommendations for
Practitioners/Providers

• 1. Distribute a current summary of Maryland
  restraint laws pertaining to children under age
  16
• 2. Distribute a listing of Maryland Child
  Passenger Safety (CPS) programs located within
  the state including the Maryland Kids in Safety
  Seats program at 1-800-370-SEAT

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Best Practice Recommendations for
Practitioners/Providers

• 3.Distribute CPS written materials that are
  current and contain accurate information
• 4.Encourage proper seat fit by using the 5-STEP
  test for those that are atleast 6 years of age
  and weigh greater then 40 pounds

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The Five Step Test Used to determine
if a child is ready for the adult
seat belt
1. Does the child sit all the way back against
the auto seat? 2. Do the child's knees bend
comfortably at the edge of the auto seat? 3.
Does the belt cross the shoulder between the neck
and arm? 4. Is the lap belt as low as possible,
touching the thighs? 5. Can the child stay
seated like this for the whole trip?
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Best Practice Recommendations for
Practitioner/Provider

• 5.Educate patients about the risks of death or
  serious injury associated with failure to use a
  child safety seat or seat belt system appropriate
  for size

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KISS - Maryland Kids In Safety Seats
www.mdkiss.org

• What is the Appropriate Seat for Your Child?
• Guide to Using Rear-Facing Restraints
• What are Maryland Safety Laws?
• When are Upcoming Seat Safety Checks?
• When are Upcoming Seat Safety Trainings?
• KISS Newsletter New notes

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• www.miemss.org/EMSCwww/CPSHome.htm
• Hospital Resource Information Kits
• CPS Hospital Contact CPS Technician Liaison
• Transporting ChildrenSpecial Health Care Needs
• Guidelines on Best Practice for Health Care
  Facilities
• Links to CPS Resources
• Posters on safe passenger safety for all ages
• Proper Occupant Protection video/DVD order form

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Thank you for your time and your interest in
Child Passenger Safety !
The End