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| Journal of the New Zealand Medical Association,
23-August-2002, Vol 115 No 1160
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Driveway-related motor vehicle injuries in the paediatric
population: a preventable tragedy
Feilim Murphy, Sarah White and Philip Morreau
Vehicles striking children on driveways are a predominant
cause of non-traffic-related injuries and account for one quarter of all
reported paediatric pedestrian injuries requiring admission to hospital in the
Auckland region. These accidents occur most commonly to children less than four
years old, who are reversed over in their own driveway by a car driven by their
parent. Although driveway-related injuries had previously been studied in
Auckland, we believed that there was still limited public awareness and that
overall incidence had remained
unchanged.1–3 We also suspected that the
children involved belonged to a clearly defined demographic group not previously
described. Our objectives were to assess the incidence of the events, describe
the nature of the injuries, identify at-risk groups and develop definitive
methods of prevention.
MethodsA retrospective review was
performed of all patients less than 15 years old, who were admitted to Starship
Children’s Hospital due to a driveway injury over a 45-month period from
January 1998 to October 2001. Starship Children’s Hospital is the tertiary
referral centre for all paediatric patients in Auckland and receives all
children requiring paediatric surgical care. Only children from the Greater
Auckland region (a population of approximately 250 000 children less than 15
years old) were included.4
Cases were identified via an admission and discharge trauma monitoring system. Fatalities at the scene were reviewed along with mortality information from the coroner’s office. Data were collected on the: gender, age and ethnicity of the child; date, time and site of the accident; vehicle type and driver; events leading up to and including the accident; description of the accident site; the number of children in the household; the initial medical assessment; injuries sustained; intensive care admission; length of stay; operative procedures; medical management; discharge; complications; and the resulting outcome. Outpatient review and telephone consultations were performed. The accident site was visited in 43 cases to ensure accuracy of the collected data. All other cases were investigated by telephone interview and 10 of these cases were inspected to ensure accuracy. ResultsA total of 77 separate driveway
accidents occurred, involving 76 patients. Two children were involved in more
than one accident. One was reversed over twice on two separate occasions during
the period and another was struck by a car driven by his other parent prior to
the commencement of the study in January 1998. One accident involved two
children being reversed over. Patient demographics and characteristics are
summarised in Table 1.
Table 1. Characteristics of driveway
accidents
* Land Transport Safety Authority
A number of key factors are evident. The median age for the
studied group was 23 months, ranging from 12 to 138 months. The majority 45
(58%) of the children were male.
The family home was the most common site for the accidents
55 (71 %). The second most common site was the home of the daytime child carer,
whose role is often held by the extended family in the study population. In
total, 16 accidents occurred at relatives’ homes, with 12 vehicles being
driven by a relative. Only six accidents occurred while the child was playing in
neighbouring driveways, three of which involved commercial vehicles. In the
eight children older than five years, the incident most often occurred (n=6)
while they were playing at a neighbour’s or relative’s
home.
The driver of the vehicle was usually a parent (39%) or
close relative (30%). Friends and neighbours were driving in only 18% of cases.
Two separate incidents were reported in which boys had released the car’s
handbrake and then escaped the vehicle only to be rolled over further down the
driveway. One 15-month old was struck by a car whose handbrake had been released
by an older sibling. In all other cases the child was reversed over.
Although the accidents occurred from 0700 to 2330 hours, the
majority occurred in the afternoon, predominantly between 1600 and 1900 (n=36).
A second peak (n=14), occurred in the morning between 1000 and 1200 hours. We
found no evidence that improved lighting could prevent the accidents. A
preponderance of events, 30 (39%), occurred during the summer months of December
to February. The frequency of the events was lowest, 10 (13%), during the spring
months of August to October.
Certain ethnic groups, such as Maori and Pacific Island
children, were over represented at 66%, as compared with their population size
of 34%. The mean number of children in households where these accidents occurred
was 3.4, as compared with the mean of 2.4 children in the average Auckland
household.4 Nineteen drivers reported seeing
the child in a safe position either in the house, at the front door, or in the
garden away from the rear of the vehicle, prior to them reversing. Despite
anecdotal evidence, we could find no correlation between multiple residences
using a single driveway and increased frequency of the
accidents.1 Only 16 (21%) events occurred on
shared-access driveways.
None of the properties had a driveway fenced or separate
from the main house. Forty three (56%) of the accident sites were inspected to
reveal the driveway was frequently easily accessible from both the front and
back of the house. Since the accident, none of the driveways had been
fenced.
The residences involved were analysed using the New Zealand
deprivation index, which divides the New Zealand population into 10 equal
groups. Group 1 represents the wealthiest 10% of the population, and group 10
the poorest 10%. In our study, the higher socioeconomic groups 1 to 3 were all
under represented. 47% of the cases occurred in groups 9 and 10, instead of the
expected 20%.
The ownership of the property was identified for 50 of the
residences where the accident occurred in the home driveway. Forty two (84%) of
fifty residences were rented properties, compared with the mean of 38% in
Auckland.4 Although the government agency
Housing New Zealand owns only 8% of rented properties in the Auckland, it owns
38% (n=19) of the homes in our study.
Thirty seven patients (48%) attended Starship
Children’s Hospital directly and 38 (49%) were transferred from other
hospitals. The median length of stay was two days. Seventeen patients (22 %)
required admission to paediatric intensive care with a median length of stay of
one day, ranging from one to nine days. Seventy patients were discharged home
and two went to rehabilitation centres.
Driveway accidents produce a distinct pattern of injury,
typically involving the head, chest and lower limbs. Thirty seven (48%) children
sustained a minor head trauma while 17 (22%) sustained a major injury such as
base of skull fracture and intracranial haemorrhage. Twenty three (29%) suffered
major thorax injuries and 9 (12%) suffered lower limb fractures. Lower limb
abrasions and lacerations were associated with a head injury in 21 (28%)
patients. The severity of the injury increased with the size of the vehicle, the
weight of the vehicle and the effect of reversing and then driving forward
again. Upper limb fractures, 3 (4%), and intra-abdominal injuries, 9 (12%), were
relatively less common.
Long-term complications were identified at follow up at a
median of 12 months, ranging from 6 to 30 months, occurred in 8 (11%) of
survivors, and ranged from mental handicap, hemiparesis, ataxia and third nerve
palsy, to marked speech and learning difficulties. There were 6 (8%) fatalities
over the 45-month period. Four children who died at the scene were identified
via the coroner’s office. Within the fatalities, both genders were equally
represented, the mean age was 30 months and the majority of the accidents (n=5)
occurred at home. Vans or trunks struck three of the six fatally injured
children. Four sustained massive basal skull fractures. One died from multiple
injuries, including pulmonary lacerations and a ruptured inferior vena cava.
Only one boy aged 32 months survived longer than 24 hours. He sustained a closed
head injury, bilateral pulmonary contusions and a left-sided first rib fracture.
Echocardiography on day two was normal. Thirteen days after discharge a fatal
left ventricular aneurysm rupture occurred.
DiscussionThe most common paediatric
pedestrian injury occurs when a child is struck by a vehicle while crossing the
road.5 However, from 1986 to 1995 throughout
all New Zealand, there were 39 non-traffic pedestrian deaths. The majority of
these were driveway-related events, occurring in children less than four
years,6 and in domestic driveways in urban
centres.7
A total of 71 non-fatal driveway related accidents occurred
during our study period, producing a non-traffic pedestrian injury rate of
7.6/100 000 children per year. There were six fatalities over the 45-month
period, resulting in a fatality rate of 0.64/100 000 children per
year.4 The overall incidence has remained
significantly unchanged over the last 15
years.2 A review of the literature reveals that
driveway-related injuries are uncommon in Europe and have a much high incidence
in New Zealand, Australia and North
America.7–9 We believe this is due to the
longer driveways and the frequency of subdivided properties in these
countries.
The mean number of children in affected households was 3.4,
while the average for the Greater Auckland region is 2.4. However, the mean
number of children per household varies markedly between ethnic groups in
Auckland, with Maori and Cook Islanders having larger families – 2.7 and
3.06 children per family respectively.4 Their
over representation within the study may reflect the perceived increased risk
for larger families.
Driveway-related injuries have a distinct injury pattern.
The short stature of the child relative to the bumper explains the predominance
of injuries to the head and chest. Lower limb injuries occur as the child falls
to the ground or is driven over. Driveway-related accidents have a higher
incidence of closed head injury and a higher mortality than traffic-related
injuries.10 Major abdominal and upper limb
injuries are uncommon. Since the majority of the fatalities sustained
untreatable injuries at the scene, the appropriate medical response is to focus
on primary prevention.11 Interventions must
involve the driveway environment, the driver, the vehicle and the behaviour and
supervision of all children.12
Vans, four wheel drive vehicles and light trucks account for
only 6% of all domestic vehicles in Auckland registered by the Land Transport
Safety Authority. However, they were involved in 28% of the accidents reviewed,
and the majority were owned and driven by a parent. These vehicles are
associated with a higher rate of accidents and more complex injuries than cars.
The large size of these vehicles produce a visibility problem that can prevent
the child from being seen during
reversing.7,11
Larger rear view and “rounded” mirrors have been
recommended in order to decrease the “blind spots” in which a child
may be missed during reversing.10 Proximity
detectors and warning reversal alerts have also been
proposed.11 However, they are expensive and not
a standard feature in most family cars and are unlikely to be purchased as a
preventive method by parents.13
Parental supervision is another key element in the
prevention of trauma in the under five age group. Younger children must be
discouraged from using the driveway as a safe extension of the house and garden
for play. The risks of releasing the handbrake and cycling behind reversing cars
must be reiterated for older children. Children should not be allowed to remain
unsupervised in any vehicle.14
The erection and maintenance of fencing and physical
barriers have proven successful in preventing accidents. The reduction of child
drowning in home swimming pools since the introduction of compulsory fencing is
an excellent example. Since the introduction of the uniform pool fencing
legislation in New South Wales, Queensland, there has been a reduction of at
least 50% in the drowning rate in private swimming
pools.15,16 Denmark has experienced major
decreases in pedestrian mortality by placing greater emphasis on
environmentally-based prevention strategies, rather than pedestrian skill
courses.17 Fencing with self-closing gates,
which isolate the driveway from the garden and the residence, would prevent
children from accessing the area while the vehicle is being reversed. It would
also allow the area around the vehicle to be safely inspected for children prior
to reversing. The absence of a definitive barrier between the play area and the
driveway has been shown to increase the risk of a driveway-related injury by a
factor of 3.5.1 In many instances, children
were clearly seen in a perceived safe area of the garden or house prior to the
movement of the vehicle. The ability of the child to get from there to the rear
of the vehicle demonstrates dramatically the need for definitive separation of
the driveway from the house.
The majority, 43 (56%), of the accidents occur in the south
of the city within clearly-defined lower socioeconomic
areas.1,3 In Auckland, 38% of all residential
dwellings are rented properties.4
Owner-occupiers accounted for only 16% of the residents in the study; a
percentage noticeable lower than the mean of 62% in Auckland. Although the
number of households involved are small, the high incidence of rental property
(84%), and particularly the 38% that were government owned, is a cause for
concern.3 Fencing is an expensive preventive
method and those in poorer socioeconomic areas are unlikely to have the finances
to build fences in order to separate the play area from the driveway. It must be
the landlord’s responsibility to provide a safe environment and to build
and maintain a fenced driveway.
Imposing compulsory driveway fencing for all properties is
undoubtedly difficult. However, in new subdivisions provision must be made for
the driveway to be fenced and separated from the house. The possibilities and
benefits of fencing should be explained and the building of suitable fences
supported.
In order to decrease the incidence of driveway-related
injuries we need to raise public awareness and create safer driveways. The
public health message needs to be correctly targeted at those most at risk,
particularly those in lower socioeconomic areas with larger families and those
driving four wheel drive vehicles and vans. Future residential building should
aim to make both driveways and properties safer. Although an expensive solution,
we recommend that all rental properties be required to have a fenced driveway
provided by the owner in order to separate it from the garden and the house.
Together, these measures would lower the incidence of driveway injuries and
thereby significantly reduce paediatric pedestrian trauma in New
Zealand.
Author information:
Felim Murphy, Senior Registrar in Paediatric Surgery; Sarah While, Registrar in
Paediatric Surgery; Philip Morreau, Consultant Paediatric Surgeon, Department of
Paediatric Surgery, The Starship Children’s Hospital, Auckland
Correspondence:
Philip Morreau, Department of Paediatric Surgery, The Starship Children’s
Hospital, Grafton Road, P O Box 92189, Auckland. Fax: (09) 307 8952; email: pmorreau@adhb.govt.nz
References:
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