31st May 2013, Volume 126 Number 1375

Maria KR Wilson, Julie L Chambers, James K Hamill

Trauma while travelling as a passenger in a motor vehicle is a leading cause of mortality and hospitalisation for children in New Zealand.1–3

Much of the serious trauma suffered by children in motor vehicle crashes is associated with poor seat belt fit.4,5 Booster seats help to position the seat belt over the bony pelvis and chest wall, in order to evenly distribute forces in a crash and protect the internal organs from damage.6

The use of booster seats for children who have outgrown their child car seats but are not yet big enough to fit an adult seat belt alone, significantly reduces the risk of serious and fatal injuries in children involved in motor vehicle crashes.4–9

The continued use of child car restraints until a child reaches a height of 148 cm is recommended best practice to prevent such trauma.10 The approximate age children reach this height is 11 years.

Despite best practice guidelines, children are often prematurely graduated to being restrained in the adult seat belt alone.2,5,8,11 To combat this issue many countries have updated their legislation to bring it more in line with best practice guidelines. For example, in the United Kingdom children must continue to use a child restraint or booster seat until they are 135 centimetres tall, or their 12th birthday. 2,12

In New Zealand, however, legislation only requires the use of child car restraints for children under the age of 5 years (6 years less than best practice recommendations). New Zealand law also allows the transport of children in taxis without a child car restraint; regardless of the child’s age.13 These laws legitimise the suboptimal restraint of children in cars in New Zealand.

Little is known about the transport of patients to and from hospital. By interviewing parents and caregivers of paediatric inpatients we sought to determine car restraint use and knowledge, and to gauge the need for a hospital-based car seating service.

Method

The Northern X Regional Ethics Committee granted expedited ethics approval for information to be gathered in the form of short interviews from a convenience sample of parents and caregivers of 200 child inpatients. Inclusion criteria included age 0–13 years and inpatient in a surgical or medical ward at Starship Children’s Hospital (wards 23B, 24A, 24B, 25A and 25B). Exclusion criteria were: no parent or caregiver present with the patient; the family was suffering social distress; or the patient was undergoing palliative care.
Participants were selected daily from the ward inpatient lists. Families considered suitable for interviewing were approached by investigators, provided with an information sheet, and verbal consent obtained.
We conducted interviews over a total of 15 working days using two structured interview sheets: one for children 0–4 years and the other for children aged 5 years and over. Participants were asked to provide information regarding the usual restraint used by their child; how the child was transported to hospital; their plans for transporting the child home; and their knowledge of current New Zealand legislation and best practice recommendations regarding child car restraints.
At the completion of each interview participants were offered a ‘Booster Rooster’ height chart and/or a leaflet about child restraints.14
Formulae proposed by Cochran were used to calculate the representativeness of the convenience sample. Specifically, demographic and economic characteristics of the study population were compared with all other inpatients in all Starship Hospital wards over the study period. Data was sorted into tables with totals converted to percentages for presentation.15,16

Results

Demographics—Demographic information on our study participants was collected and compared with the demographics of all 520 inpatients in all wards at Starship over the data collection period. This information is shown in Table 1.

Table 1. Demographic details of sample and inpatient population
Variables
Interview sample
n=200 (%)
Starship inpatients
n=520 (%)
Age
0–4
5–9
10–14
15–19
127 (63)
53 (26)
20 (10)
0
257 (49)
116 (22)
128 (25)
19 (4)
Gender
M
F
108 (54)
92 (46)
284 (55)
236 (45)
NZDep06
Decile 1(least deprived) 
Decile 2
Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10 (most deprived)
N/A (Overseas)
11 (5)
20 (10)
15 (7)
15 (7)
22 (11)
30 (15)
11 (5)
26 (13)
15 (7)
31 (15)
4 (2)
28 (5)
46 (9)
42 (8)
41 (8)
63 (12)
59 (11)
34 (6)
61 (12)
50 (10)
80 (15)
16 (3)
Ethnicity
NZ European
Māori
Pacific
Asian
Other
88 (44)
37 (18)
44 (22)
23 (11)
8 (4)
224 (43)
103 (20)
105 (20)
47 (9)
41 (8)

The sample was representative in terms of gender, ethnicity and socioeconomic status (as defined by the NZDep2006 scores).17 Our sample was representative of the 5–9 years age group, but over-represented the 0–4 years age group and under-represented the 10–14 years age group.

Usual car seating and restraint use—In this initial section of the interview we asked how children are usually restrained when they travel in a car, how consistently restraints are used, what type of seat belt is used, where they sit in the car and whether or not they own a car seat or booster seat. The results are shown in Table 2.

Compliance with child car seat legislation was reported to be high, with 98% of children required to be in a car seat said to be using one. When asked to be more specific about the consistency of their child’s car seat use, seven families of children younger than 5 years (5%) admitted not using the car seat all the time, with one family reporting they did not use a car seat at all.

There was a marked drop off in car restraint use (34%) in children aged 5 years and over, compared to those aged 0–4 years (98%). All participants restrained their child in at least a seat belt. Most respondents said they used a lap/sash belt, with two (4%) regularly using a lap only belt and a further four (8%) using a lap belt sometimes.

Table 2. How child is usually restrained when travelling in a car
Variables
Age 0–4 years
n=127 (%)
Age 5–9 years
n=53 (%)
Age 10–14 years
n=20 (%)
Uses car seat or booster seat
Yes
Sometimes
No
124 (98)
2 (2)
1 (1)
18 (34)
9 (17)
26 (49)
2 (10)
0
18 (90)
Consistency of use of car seat or booster seat
All the time
Usually
Just now and then
Don’t use
120 (95)
5 (4)
1 (1)
1 (1)
18 (34)
4 (8)
6 (11)
25 (47)
2 (10)
0
0
18 (90)
Type of seat belt used
None
Car seat/Booster
Lap/sash
Lap only
Combination
0
124 (98)
3 (2)
0
0
0
17 (32)
30 (57)
2 (4)
4 (8)
0
2 (10)
18 (90)
0
0
Usual seating location in car
Back (side)
Back (centre)
Front
Combination
Unsure or N/A
109 (86)
9 (7
3 (2)
5 (4)
1 (1)
32 (60)
3 (6)
0
17 (32)
1 (2)
10 (50)
0
1 (5)
9 (45)
0
Ownership of car seat or booster seat
Own
Rented 
Borrowed
Don’t use
111 (87)
12 (9)
3 (2)
1 (1)
27 (51)
0
1 (2)
25 (47)
2 (10)
0
0
18 (90)

Most children, in all age groups, were placed on the side in the back seat. However, sitting in the front seat, at least sometimes, became more common as children got older (6% in 0–4 years; 32% in 5–9 years; 50% in 10–14 years), indicating a possible change in parental attitudes to car restraint safety.

Child restraint ownership was not shown to have any apparent impact on patterns of use, but this was not tested as part of the research design and the result may have been due to the sample size.

Trip to hospital—We asked participants to provide information about how they had transported their child to hospital for this visit. Their answers are shown in Table 3.

Table 3. How families had transported their child to hospital for this visit
Variables
Age 0–4 years
n=123* (%)
*4 born in hospital
Age 5–9 years
n=53 (%)
Age 10–14 years
n=20 (%)
Car
(n=147)
Car seat
Seat belt
Held in lap
Not restrained
84 (92)
2 (2)
5 (6)
0
15 (38)
18 (46)
3 (8)
3 (8)
2 (12)
14 (82)
0
1 (6)
TOTAL
91
39
17
Taxi
(n=15)
Car seat
Seat belt
Held in lap
Not restrained
8 (73)
2 (18)
1 (9)
0
0
2 (100)
0
0
0
2 (100)
0
0
TOTAL
11
2
2
Ambulance
(n=33)
Car seat
Seat belt
Held in lap
Not restrained
6 (30)
12 (60)
2 (10)
0
1 (8)
10 (83)
1 (8)
0
0
1 (100)
0
0
TOTAL
20
12
1
Helicopter
(n=1)
Car seat
Seat belt
Held in lap
Not restrained
0
0
1 (100)
0
0
0
0
0
0
0
0
0
TOTAL
1
0
0
Table 4. Trip home from hospital
Variables
Age 0–4 years
n=127 (%)
Age 5–9 years
n=53 (%)
Age 10–14 years
n=20 (%)
Car
(n=168)
Own car seat
Rented
Borrowed
Seat belt only
90 (87)
8 (8)
4 (4)
1 (1)
20 (42)
0
1 (2)
27 (56)
2 (12)
0
0
15 (88)
TOTAL
103
48
17
Taxi
(n=15)
Own car seat
Rented
Borrowed
Seat belt only
7 (58)
1 (8)
0
4 (33)
0
0
0
0
0
0
0
3 (100)
TOTAL
12
0
3
Ambulance
(n=7)
Own car seat
Rented
Borrowed
Seat belt only
0
0
2 (50)
2 (50)
0
0
0
3 (100)
0
0
0
0
TOTAL
4
3
0
Unsure
(n=10)
Own car seat
Rented
Borrowed
Seat belt only
4 (50)
0
0
4 (50)
0
0
0
2 (100)
0
0
0
0
TOTAL
8
2
0

The use of car seats for the 0–4 year age group reduced slightly from usual patterns of use (98%). Only 92% of those brought to hospital in a car used a car seat. This total drops further (82%) if those brought in a taxi are included. It was noted that 8% (16/196) of children driven to hospital in vehicles, were unrestrained.

Plans for trip home—Parents and caregivers were asked to provide information about their plans for transporting their child home. The results of this are displayed in Table 4 below.

Nine (7%) children in the 0–4 year age group were at immediate risk of being transported home in an unsafe way, without a child car restraint.

Seven (3%) children required ambulance transfer. Three of these children required this due to lack of access to an appropriate car seat, as two were too small to be transported in a normal baby capsule and another had a hip spica cast fitted.

Booster seat use and awareness—Finally, we discussed the current child car restraint laws and best practice guidelines with parents and caregivers and asked them how much information they had previously known. We also showed them how tall 148 cm is and asked them to estimate whether or not their child was taller or shorter than this. We then used their estimates of their child’s height to calculate how many of those children who should be in booster seats reported using one. These findings are shown in Table 5.

Table 5. Information families knew about child restraint use
Variables
0–4 years
n=127 (%)
5–9 years
n=53 (%)
10–14 years
n=20 (%)
Aware of height recommendation
Yes
No
54 (43)
73 (58)
17 (32)
36 (68)
10 (50)
10 (50)
Estimated height
<148cm
>148cm
Unsure
127 (100)
0
0
51 (96)
2 (4)
0
4 (20)
13 (65)
3 (15)
Uses car seat or booster if <148cm
Yes
Sometimes
No
124 (98)
2 (2)
1 (1)
18 (35)
9 (18)
24 (47)
1 (25)
0
3 (75)

Parents and caregivers report a substantial lack of knowledge with regards to best practice guidelines for child car restraint use. Overall, 60% of families interviewed were not previously aware that it is recommended for children to be restrained in a booster seat until they reach a height of 148 cm.

The group that reported the least knowledge were those with children in the 5–9 years age group, with only 32% of parents and care givers being aware.

When these results were cross referenced with those of reported booster seat use, it was found that 67% of parents and caregivers, whose children do not use or only sometimes use a booster seat, were unaware of this recommendation. However, this also implies that 33% of parents and caregivers of this age group are aware but are choosing to transport their child in suboptimal restraints.

Over 47% of 5–9 year olds who are shorter than 148 cm reportedly never use a booster seat.

Discussion

From interviews of 200 families we have demonstrated that approximately half of children over the age of 5 years are inappropriately restrained both in their travel to and from hospital and in their usual practice. A smaller, but significant proportion, of children aged younger than 5 years old were reported as being inappropriately restrained. Many children will travel home from a hospital in an unsafe fashion.

Many families would have benefited from access to a car seat service while they were at the hospital. In the group of children older than 5 years of age, these were mainly families that came from outside Auckland who had travelled to hospital by means other than a car. These families often did not have access to car seats whilst in Auckland and were more likely to transport their child in a taxi without a car seat.

Pre-admission and inter-hospital transfer processes might include advice notes for families about child restraints. Providing seats on short term rental would make child restraints available for use in vehicles travelling to and from airports. We found that families who brought their car seats with them into hospital often had nowhere to store them and were forced to store the bulky seats in the patients’ rooms. A hospital-based carseat service would help troubleshoot in such situations.

Although most parents and caregivers are compliant with legislative requirements for restraining their children up to the age of 5 years, a significant number of children 5 years and over may not be using optimal restraints when travelling in the car, putting them at increased risk for serious or fatal injuries in a crash. It is apparent that the main reason for this is a widespread lack of knowledge in parents and caregivers of children of all ages, but particularly those families of children aged between 5 and 9 years. This finding is consistent with other studies looking at the use and non-use of booster seats.2,4,6,18,19

We found, similarly to Simpson,18 that once we had offered information about best practice guidelines, many parents and caregivers appeared shocked to find out that they had not been doing their best by their child. A number of parents and caregivers expressed an immediate desire to change their current practice, while most others seemed open to the idea of change, especially once they had an understanding of why booster seats are recommended. Only one family expressed strong opposition to the recommendation, stating they thought it was ‘unreasonably tall’.

Other reasons parents and caregivers gave for not using a booster seat were child resistance and the challenge of having enough space for more than two car seats or booster seats in the back of the family car. Cost was only mentioned as a factor by three families.19

Lack of knowledge appears to be the biggest barrier to appropriate child car restraint use. There is evidence to show that education alone will not adequately improve compliance with best practice guidelines.

Our study showed that at least a third of parents who do not use a booster seat for their booster eligible child are aware of the guidelines, but have chosen not to follow them. Updates to legislation regarding the use of booster seats would be expected to remedy this, and bring New Zealand in line with best practice recommendations.9,20,21

Many participants in our study expressed surprise that the law differs so much from safety recommendations. This difference is particularly concerning as parents are known to look to the law to guide their decisions around car seat safety.4,18,19

Parents and caregivers may be particularly receptive to receiving child safety information at a time when the health of a child has been threatened.23 Health professionals are able to take the opportunity of the families’ presence in hospital to encourage appropriate child car restraint use and encourage the utilisation of child car seat services to find out correct advice.

Car seat services have been shown to be effective for improving travel safety practices but literature is sparse, the provision of advice and child restraints within health services offers the opportunity to more carefully monitor responses to advice.2,4,21,24

A limitation of this study is that we relied on parents’ and caregivers’ reports of child restraint use and we were unable to verify whether these reports accurately corresponded to their actual practices. This could be relevant due to the tendency of self-reported data to overestimate use when compared to observational studies, which could be explained by people’s desire to conform to socially acceptable norms.5,19,22

Another limitation to our study was that we were unable to verify the height of the children and therefore relied on parent and caregivers’ estimates when judging whether or not they were taller or shorter than 148cm. We minimised the impact of this however, by only asking for an estimate after showing the parent or caregiver exactly how tall 148 cm was, either with a height chart14 or a point previously identified by the interviewer.

Despite the potential issues with this method, most answered confidently, with only three parents and caregivers unable to estimate whether their child was taller or shorter than 148 cm.

Conclusion

There is a need for improved child car restraint practices for children being transported to and from hospital. Hospital-based car seat services provided in collaboration with community based services and qualified child restraint technicians would facilitate safer transport of children leaving hospital, and provide education to a receptive audience.

Booster seat legislation is recommended to improve restraint use by children older than 5 years of age (see Table 6).

Table 6. Suggestions for best-practice hospital-based child restraint services

Child health services collaborating with community based child restraint rental schemes so child car seats (on short and long term rental) and expert technical advice about car seats are accessible to families and clinical staff

Child restraint advice provided for families by qualified staff as routine part of pre-admission and discharge; and before transfer and transport between hospitals and health services

District Health Board vehicles are all fitted with anchor bolts for securing child restraints

Children’s wards providing storage space for child car seats

Alignment of legislation to best practice advice for the transportation of older children

Abstract

Aim

The purpose of this study is to determine how children are transported to and from hospital, and to understand caregivers’ car restraint knowledge base.

Method

A convenience sample of 200 inpatients in five wards at Starship Children’s Hospital. Parents or caregivers underwent a short interview, asking: the usual restraint used by their child; how the child was transported to hospital; their plans for transporting the child home; their knowledge of current New Zealand legislation and best practice recommendations regarding child car restraints.

Results

In their normal car travel, 95% children younger than 5 years were reported to be using a car seat all the time, versus 34% children aged 5 to 9 years. In their journey to hospital, 8% (7/91) of children younger than 5 years were not in a child car seat; 27% (3/11) of children younger than 5 years transported to hospital in a taxi, were not in car seats (one was held in the parent’s lap). Responses about the planned trip home showed nine children (7%) were at immediate risk of being transported in an unsafe way, without a child restraint. Questions about awareness of correct child restraint use showed 68% of the families with children aged 5 to 9 were unaware that it was important to continue to use a child restraint for their child.

Conclusion

There is an opportunity for child health professionals to provide support to families with children in hospital by collaborating with established child restraint rental agencies and making best practice child restraint advice and products more readily available. New Zealand law should be updated to require the use of child car restraints beyond a child’s fifth birthday.

Author Information

Maria KR Wilson, MBChB 4 Medical Student, Faculty of Medical and Health Science, University of Auckland, Auckland; Julie L Chambers, Trauma Coordinator, Starship Children’s Health, Auckland; James K Hamill, Paediatric Surgeon, Starship Children's Hospital—and Department of Surgery, University of Auckland

Acknowledgements

This study was funded by Faculty of Medical and Health Science, University of Auckland. We also thank Peter Reed, Elizabeth Segedin, Gail Gillies and Ronald Ma for their support and help; Kiffin NZ Ltd for helping format the questionnaires; and Elizabeth Keeling and Jennifer Currigan for helping with data collection.

Correspondence

Julie Chambers, Starship Children’s Hospital, Level 4, Surgical Service Support Office, PO Box 92024, Auckland 1142, New Zealand.

Correspondence Email

juliech@adhb.govt.nz

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