Injury Prevention 1997; 3: 17 - 22

High levels of incorrect use of car seat belts andchild restraints in Fife an important and under-recognised road safety issue

Harry Campbell, Sheena Macdonald, Paul Richardson

AbstractObjective-To pilot data coilection instru-ments and to make a preliminary estimateof the level of incorrect use of car seatbelts and child restraints in Fife, Scotland.

Design-Cross sectional survey of carscontaining adults and children at a num-ber of public sites across Fife in 1995 toassess use of car occupant restraints.Trained road safety officers assessedwhether seat restraints were appropriatefor the age of the passengers and whetherrestraints were used correctly. Theseassessments were based on standardspublished by the Child Accident Preven-tion Trust.

Participants-The survey gathered datafrom 596 occupants in 180 cars: 327 adultsand 269 children. Ten per cent of driverswho were approached refused to partici-pate. Car occupant restraint was assessedin 180 drivers, 151 front seat passengers,and 265 rear seat passengers.

Main results-Three hundred and sixtyone occupants wore seat belts, 68 wererestrained by a seat belt and boostercushion, 63 in toddler seats, 25 in twoway seats, and 18 in rear facing infantcarriers. Ninety seven per cent of drivers,95% of front seat passengers, and 77% ofrear seat passengers were restrained.However, in 98 (52%) vehicles at leastone passenger was restrained by a devicethat was used incorrectly. Seven per centofadults and 28% ofchildren were securedincorrectly. The commonest errors wereloose seat belts and restraint devices notadequately secured to the seat. Rates ofincorrect use were highest in child seatrestraints, reaching 60% with two wayseats and 44% with rear facing infantseats.

Conclusions-The incorrect use of caroccupant restraints is an under-recog-nised problem, both by health profes-sionals, and the general public. Incorrectuse has been shown to reduce the effec-tiveness of restraints, can itself result ininjury, and is likely to be an importantfactor in child passenger injuries. Thecorrest use of car seat restraints meritsgreater attention in strategies aiming toreduce road traffic casualties. Areas ofintervention that could be consideredinclude raising public awareness of thisproblem, improving information and in-struction given to those who purchase

child restraints, and encouraging in-creased collaboration between manufac-turers of cars and child restraints, inconsidering safety issues.(Injury Prevention 1997; 3: 17-22)

Keywords: road safety; road traffic accidents; caroccupant restraints/seat belts.

Although the number of children killed orseriously injured in road traffic accidents hasfallen in the last decade,' increasing use ofchild restraints has been found in the USA tobe associated with an increase in the misuse ofthese devices.2 In the USA rates of misuse ofchild restraints of over 60% have been docu-mented.3 It has been proposed that misuse ofcar safety seats may now be an important factorin child passenger injuries.2 One survey ofchildren presenting to a paediatric emergencydepartment found that 7% had injuries asso-ciated with misuse.4The effectiveness of seat restraints in pre-

venting injury is reduced when these are usedincorrectly.5-`0 In addition, certain injuries,such as chest and abdominal soft tissue injuriesand whiplash injuries to the neck, have beendescribed more commonly since the wide-spread use of occupant restraints. Theseinjuries are thought to be due, in part, toincorrect use.5"' Included among these arecertain serious injuries, such as high cervicalspine fractures in children and lumbar spinaldislocations ('seat belt syndrome'), which werepreviously rare but have become more com-mon in recent years.9 10 12-15 Adult seat beltshave also been associated with increasedreports of certain types of injuries, includingbowel16-'8 and lumbar spine'920 injuries withlap belt use, and aortic," pancreatic,22 andcardiac23 injuries with lap/shoulder belt use.As the level of incorrect use of car occupant

restraints was unknown in Fife and we couldidentify no relevant UK data published in themedical or public health literature, we carriedout a survey to estimate the level of incorrectuse of car seat belts and child restraints in Fife.

MethodsA literature search, contact with the Transportand Road Research Laboratory (TRRL) of theUK Departmnent of Transport, and personalcontacts within the road safety officer profes-sion, failed to identify established data collec-tion instruments or methods that could beapplied in this survey. Accordingly, consultantswith recognised expertise in in-car safety and

Department of PublicHealth Sciences,University ofEdinburgh, EdinburghEH8 9AGH Campbell

Centre for Health andSocial Research,GlenrothesS Macdonald

Fife Police, GlenrothesP Richardson

Correspondence to:Dr Campbell.

17

on Septem

ber 19, 2020 by guest. Protected by copyright.

http://injuryprevention.bmj.com

/Inj P

rev: first published as 10.1136/ip.3.1.17 on 1 March 1997. D

ownloaded from

Campbell, Macdonald, Richardson

Q a0U ,)_ 0.C"

GorQ ,a r

0

4.._

rz.e4. c

-4.Cd 0

.4Go0..) CI4

i C. 1- 4

6.Dd

a)

e4 .a ,44.o

4,. . a) a)0

Cg)aX :~4. a)* r

b.))a

30 0

0.0

a.-. cr 2

;, 8o -0

'- ,v

X'L

_b _._ ._

"0a)-

. 0a)"0

"0g

42 U

a)o a

44O o88°

"0 "0

a) a)XE oSD

y ag E

*C

4 A.

0C,.-. c.

CS ;

b. ..C.

H~~~~~~~~~"e

v od'

la-4 co C.

t=C- bi) 9) b.0lF LO trCl bib;4 Dg* -.

16. 16. C) ta2 ~0 es .2g8tf028i S;U2a;4) >.. Cr,P33 0.02a . 48o 54R RRco ad~~ 4)

co~ ~ ~ ~ ~ iId i'd

d)E; ) ;co~~~~ ~~ ~~~~~~~-Im Cd C

~~~0.) 3-ma

v 8 > = ¢ 58 g ; O .8 a 4 5 sws;gnSd >

c-a ce 4 s= .I4a * 4- 3

~~ ~ ~ ~ ~ ~

0 8"0~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~J2fi3 28U1daQa8>P3eU2

U2Wa-'8t

**.)* o0$. ho~ 0.0.

a)rA 4

-" 04

M ) 0

m F-T Ffl ETlw

a)

b

cooao

.4-~~~~~~~~ a)m

a

Cd

) 'b tV $Xa X,V

oa

g~~~~~~.a)I0 U2 rC".U2 U2

-8 baRa) a).-.-

a)) v 2zR

"0a)

I4.-a

Cd9 U)

*^~~~~~~~~~~~~~~~~~~~~~~~~~atV

4.a

+V 0

*~~~~~~~~~~~~~~~~rrU.2~~ ~U>~I

U2 rta v R dZ

4)~ ~ ~

-T-10. U,

a)

U2av0ff EXI

a...

m

I4 8. a-

S.

a..a)Ca,z2

l -1>'(..b

vET3a - I

.0 a

a) .0

r4C

a)

0 4o 4.

-.!0.A

18

0

o oago° a c,4-C;

O)vm

C0C)

44-P4*a)

PC"a.

"0

0 0.

aR)~ a)d)aeH+

_ _

_"_

.;a)..CQ

0

b00aa

a)

a)0._

.0

a. W

.a

UO0.0

ba)

a-I

._ ._

COD

. 0

aoO"0

a- 0.- o

14D

.21D

riL)Dv1)ajz 7.D.U.(1)4Z0:40

iI

b.))

o0c._

4.

Vg r

a SV

._0

N~ °Ca

0

'0S i n

biD

C4b)

. c

a U"30"a)Oa).XaS.

Xe

a)*_...

a )04. .0

80o;a~ ,V

rt r,a

&$u2zt0s1

0 e t Z

0a 02_

a)4 "0t4.1 *1 a

0_U2 0 0

a0.lCp0 E5U 0

aDC

U2*_U 004. 0"0<-

*..0°2J

R1

am.0 02

o0 0"0 a) "

OI

*"a* 0t

_ _ a)

4. 0t

R a)* . t

a).a;0V

: ,

.0S

* Za )0

"80.a

a)

4.0

tV_:

9w4

: (1

w

: 4-1-

a)

aa)00

a

a).0"00C)

0C.t.,

00:

"S)It;

rA

;Z

a)tll

0l

a)

"0

ra)

Iav0

0-8.0

a)"02aa)ri

" a)

U2C40

a)ta0a)._

a)

0

".9a)

aJ,vr°

tV

0

Sa)

-r.s

40.

aL)

._

R

Q Q p

on Septem

ber 19, 2020 by guest. Protected by copyright.

http://injuryprevention.bmj.com

/Inj P

rev: first published as 10.1136/ip.3.1.17 on 1 March 1997. D

ownloaded from

High levels of incorrect use of car seat belts and child restraints in Fife

experience in training were invited to run a twoday course at which Fife road safety staff weretrained in how to assess correct use of carrestraints. Data collection instruments basedon an established TRRL questionnaire weredeveloped and piloted by road safety officers(appendix 1). Standards adopted for theassessment of correct use and definitions forappropriate age and weight for each device arethose published by the Child Accident Preven-tion Trust (CAPT).24

Seven sites were selected across all districtsof Fife. These included car parks of super-markets, leisure and recreation facilities, oroutdoor centres. Observations took place onSaturday mornings and afternoons in Augustand September 1995. Two road safety officerscarried out the survey by approaching cars asthey entered the car park and stopping thosethat contained both adults and children. Theyinvited the occupants to take part in a survey toassess correct use of seat restraints and toreceive expert advice, as appropriate. Approxi-mately 10% of drivers declined to take part,usually because of lack of time. Vehicle checkstook between 10 and 25 minutes with the twoofficers working together. Assessment of cor-rectness of use followed CAPT guidelines,recorded on a standardised recording form.Any problems identified were discussed with

Table 1 Age categories of the drivers and passengers; results are number (%)

PassengersDriver Front Back left and right Back centre

Age (years) Age (years)17-29 60 (33) 14+ 117 (78) 28 (12) 2 (8)30-59 98 (54) 1-13 28 (18) 193 (81) 24 (92)60+ 22 (12) <1 6 (4) 18 (7) 0

Total 180 (100) Total 151 (100) 239 (100) 26 (100)

Table 2 Assessment of restraint use by position in the car; results are number (%)

PassengersBack left

Driver Front and right Back centre

Restrained- appropriately(for weight and age) andcorrectly 170 (94) 127 (84) 134 (56) 5 (19)

Restrained- appropriately(for age and weight) andincorrectly 4 (2) 16 (11) 60 (25) 5 (19)

Restrained- inappropriatelyfor weight and age - 3 (2) 9 (4) 2 (8)

Unrestrained 6 (3) 5 (3) 36 (15) 14 (54)

Total 180 (100) 151 (100) 239 (100) 26 (100)

Table 3 Assessment of restraint use by seat position and age ofpassenger; results are number(%/0)

Inappropriate Incorrect useNo Unrestrained restraint of restraint

DriversAdults 180 6 (3) 0 4 (2)

Front passengersAdults 117 5 (4) 0 12 (10)Children (0- 14 years) 34 0 3 (9) 4 (12)

Rear passengersAdults 30 5 (17) 0 2 (7)Children (0- 14 years) 235 45 (19) 11 (5) 63 (27)

TotalAdults 327 16 (5) 0 18 (6)Children (0- 14 years) 269 45 (17) 14 (5) 67 (25)

Overall total 596 61 (10) 14 (2) 85 (14)

the vehicle occupants. Once completed, thenext suitable vehicle was stopped and invited toparticipate.

Data were entered into a dBase IV database(Ashton Tate) and analysed on SPSS forWindows (SPSS Inc) to produce frequencytables.

ResultsFive hundred and ninety six occupants in 180cars were surveyed. One hundred and thirteenvehicles were registered after 1 August 1987,57 were registered before 31 July 1987, and for13 the registration year was unknown. Thefitting of rear belts became statutory in carsmanufactured on or after 1 October 1986. Theage of the car occupants, their position in thecar, and the assessment of restraint use byposition in the car and age of passenger, isshown in tables 1, 2, and 3.

DRIVERSSix drivers (3%) were unrestrained, all in the17-29 age category. On four (2%) occasionsthe drivers were recorded as being incorrectlysecured by the seat belt.

FRONT PASSENGERSOnly five (4%) passengers were unrestrained,all above 14 years of age. Three children woreadult seat belts which were inappropriate fortheir age. Sixteen passengers were wearing arestraint device that was being used incorrectly.In four instances (3%) the safety device wasnot correctly fitted to the car, and in 15 cases(10%) the passenger was not correctly securedby the seat belt or safety device.

REAR PASSENGERSFifty (19%) passengers were unrestrained; 46of these were travelling in vehicles registeredbefore 31 July 1987 in which rear seat beltswere not fitted. Only one passenger wastravelling unrestrained in a car registered after1 August 1987.Of the 50 unrestrained passengers, five were

aged 14 and over and 45 were aged between 1and 13 years. A further 1 1 children wdre adultseat belts inappropriate for their age. Fewerpassengers (26) were sitting in the centreposition than the right or left positions, but amuch higher proportion of those in centre seatswere unrestrained (54% compared with 15%).

Sixty five (25%) passengers were wearing arestraint device being used incorrectly: in 41instances the restraint device was incorrectlyfitted to the car, and in 45 cases the passengerwas not correctly secured by the seat belt orsafety device.

INCORRECT USE OF SAFETY DEVICESNinety eight occupants were incorrectly re-strained. Of these, 13 were also inappropriatelyrestrained, that is, an inappropriate age to usean adult seat belt, and the remaining 85

19

on Septem

ber 19, 2020 by guest. Protected by copyright.

http://injuryprevention.bmj.com

/Inj P

rev: first published as 10.1136/ip.3.1.17 on 1 March 1997. D

ownloaded from

Campbell, Macdonald, Richardson

Table 4 Problems identified with restraints

No No (%)Type of restraint used used failed Reasons for failing No

Adults seat belts (13 of these occupants were an 361 37 (10) Twisted such that function impaired 15inappropriate age/weight for using an adult seat Belt not tight 10belt) Diagonal strap crosses neck not shoulder 10

Lap restraint crosses stomach not pelvis 5Clip buckle not fastened 1Frayed or worn webbing 1

Booster cushion 68 16 (24) Booster cushion not attached to seat through hooks or ears 9Twisted such that function impaired 4Diagonal strap crosses stomach not pelvis IBelt not tight 1Buckle does not work correctly 1Booster cushion not sitting securely on seat 1

Two way seats (forward and backward) 25 15 (60) Safety device not secured tightly 10Retaining strap not tight 7Safety device not secured according to manufacturer's recommendations 3

Toddler seat (traditional and polystyrene) 63 22 (35) Safety device not secured tightly 9Safety device not secured according to manufacturer's recommendations 8Retaining strap not tight 6Buclde not fastened 1Buckle not clipped 1

Infant carrier-rear facing 18 8 (44) Retaining strap not tight 4Safety device not secured according to manufacturer's recommendations 3Safety device not secured tightly 1Buckle does not work correctly 1

Table S Child restraint devices: site ofpurchase and instruction given by retainer; results arenumber

Type of retainer

Motoring Baby Supermarket!Level of instruction given by retailer outlet outlet shop Total

Demonstration and fitting 1 0 0 1Demonstration 3 2 2 7Instructions 8 8 1 16No instructions 8 7 13 28No answers 4 1 1 6

Total 24 18 17 59

occupants (16% of the 535 who were re-

strained) were using the restraint incorrectly.The most frequently identified problems are

shown in table 4. The proportion of car

occupants incorrectly secured by a restraintwas much higher in children than adults (25%compared with 6%), and by restraint deviceused (60% of children in two way seatscompared with 44% of infants in rear facingcarriers, 35% of children in toddler seats, and24% of children using booster cushions). Incars where a problem had been identified, only19% of drivers were aware of these problems.Those who were aware of the problem eithercited economic reasons for not correcting themor gave no explanation.

CHILD CAR RESTRAINTS

Seventy two child car restraints (80%) were

purchased new. Details of the type of retailerand of instructions given at the time ofpurchase were asked in 59 cases and these are

recorded in table 5. The level of correct use

among those given some kind of instruction or

demonstration and those not given any in-struction is 60% and 53%, respectively. Thedegree of bias in these data due to selectiverecall of information over a period of severalyears is unknown.

DiscussionProperly used lap/shoulder seat belts are

effective in reducing the risk of fatal and

serious injuries when car occupants are in-volved in accidents.25-28 The percentage re-duction for fatalities has been estimated atbetween 18% and 45%, with the combinationof shoulder plus lap belt being more effectivethan either individually.29-3' In addition, a 60%reduction in injuries has been documented.34 35However, as car occupant restraint use reacheshigh levels it becomes increasingly importantto consider whether restraints are being usedcorrectly.

Incorrect use of restraint devices lessens theprotection they provide. Results from sled testswith belted dummies indicate the greaterpotential for serious head injury with as littleas 25 mm slack in a seat belt.4 Investigations ofsevere or fatal injuries have shown excessivebelt slack as an important contributor toinjuries.5 68 Reports are predominantly fromhospital based case studies and do not repre-sent incidence data from which statements ofrisk can be inferred. They suggest, however,that further research to estimate risks asso-ciated with incorrect use is needed, and thathealth workers should be aware of the differentpattern of injuries found among restrainedpassengers involved in accidents comparedwith those who are unrestrained.

In this study of 596 car occupants in Fife, incars with seat belts fitted, 97% of drivers and83% of passengers were travelling protected bya seat belt or other restraint device. The level ofrear seat restraint use in cars with rear beltsfitted as standard was significantly higher, at96%. We therefore expect that rear seatrestraint use will continue to rise as theproportion of cars without rear seat belts falls.The study population can be described interms of two significant populations-onebeing occupants of older vehicles without seatbelts in their rear seats, and people with newercars with seat belts in the rear of the vehicle.Impressively, the majority of individuals innewer cars with seat belts in all seatingpositions had only 12 unbelted occupants.The large proportion of unbelted children inthe study in older cars may arise from familiesin Fife having limited resources and driving

20

on Septem

ber 19, 2020 by guest. Protected by copyright.

http://injuryprevention.bmj.com

/Inj P

rev: first published as 10.1136/ip.3.1.17 on 1 March 1997. D

ownloaded from

High levels of incorrect use of car seat belts and child restraints in Fife

cheaper, less safety equipped cars. Individualsin these cars indicated that they could eithernot afford an appropriate restraint, or to getseat belts fitted would be too expensive on a car

that is old and of limited value.Approximately 3% of these passengers,

however, use a method of restraint that isinappropriate, albeit not illegal (see table 6) fortheir age and weight. Most of these are 6- 10year old children using a seat belt that crosses

their neck rather than their chest. Further-more, in 52% of all vehicles surveyed there wasat least one occupant using a restraint deviceincorrectly. The proportion of child car occu-

pants incorrectly secured by restraint deviceswas 25%. The level of incorrect use was

particularly high in children restrained in car

safety devices, where 35% were used incor-rectly. The proportions of the various devicesused incorrectly were: two way seats 60%, rear

facing infant seats 44%, toddler seats 35%, andbooster cushions 24%.A sample that only included cars containing

both adults and children, the selection ofsupermarkets and lesiure/recreation/outdoorfacilities as survey sites, and the conduct ofthe surveys on Saturday may all have biased thesample studied. Furthermore, the 10% ofdrivers who refused to participate may havebeen less likely to be wearing restraint devicesand no comparison data were gathered fromsuitable cars that were not invited to partici-pate. This, and the biased sample, may explainthe finding of higher rates of car occupantrestraint in this survey compared with those inprevious surveys in Fife that used TRRLsampling methods and studied over 3500vehicles.'6 The unusually high rates of restraintuse in this survey may suggest that this sampleis over-represented with safety conscious fa-milies. To the extent that these families alsoattend more closely to purchasing appropriaterestraints and using them correctly, the samplemay tend to underestimate the level of incorrectuse of restraints.

Nevertheless, the high rates of incorrect use

are consistent with a similar survey carried outby the British Standards Institution in 1990,"findings from vehicle safety checks carried outby the Royal Automobile Club in the UK (JohnLyus, In-Car Safety Centre, personal commu-nication), and data from the USA.' Our precisedefinition of incorrect use was closely based on

Table 6 Car occupant restraint: summary of legal requirement in the UK in 1996

Front seat Rear seat Responsibility

Driver Seat bealt must be wom - Driverif fitted

Child under 3 years Appropriate chid Appropriate child Driverrestraint must be used restraint must be used

if availableChild aged 3-11 and Appropriate child Appropriate child Driverunder 1.5m (approx restraint must be restraint must be5ft) wom if available. If wom if available. If

not an adult seat belt not an adult seat beltmust be wom must be wom if

availableChild aged 12 or 13 or Adult seat belt must be Adult seat belt must be Driveryounger child 1.5m wom if available wom if available(approx 5ft) or morein height

Adult passengers Seat belt must be wom Seat belt must be wom Passengerif available if available

accepted standards published by CAPT,24 andwe trained road safety officers in the practicalassessment of restraints in relation to thesestandards. Thus the faults we report are seriousin that they compromise the effectiveness of therestraint devices89 or may directly result inserious injury.'2 13We were unable to distinguish between

incorrect use resulting from misuse and thatdue to poor design of restraint systems. Forexample, it is considered that the increase inhigh cervical spinal injuries in children is dueto the lack of top tethering because theseinjuries are rarely seen in Australia where toptethers are mandatory. It may be, therefore,that in some situations current child seatrestraints simply cannot be tightened suffi-ciently when using an adult lap and diagonalseat belt with an inertia reel. Car manufac-turers appear to give highest priority to theeffectiveness of restraint of adults rather thanchildren. Currently, seat belt anchorage pointsare being moved further forward to place thelap strap across adult thighs rather than thestomach. This makes it more difficult to securechild seats safely. Moreover, car seats and beltsare rigorously tested to ensure adequateprotection of adult occupants. Child seats,unlike adult car seats, are not made by the carmanufacturers and thus car manufacturers donot test the performance of child restraints intheir vehicles.38The level of incorrect use of seat belts in

serious accidents that result in car occupantinjuries or fatalities is not known. Data on seatbelt use at the time of accidents has not beencollected by the police during accident investi-gations since 1994. A study of fatalities amongrestrained children in UK road traffic accidentsfrom 1979-94 carried out by Vehicle SafetyConsultants, Silverdale, Lancashire, Englandon behalf of the TRRL has shown that, whereinformation on correcmess of restraint ofchildren was recorded, 38% of these childrenwere restrained incorrectly at the time of thefatal accident (SJ Rattenbury, personal com-munication). It is not known what proportionof these deaths would have been avoided if therestraint had been used correctly.

Implications for preventionIn summary, the levels of car occupantrestraint use found in this survey in Fife arehigh in vehicles with seat belts fitted. In partthis reflects the design of the survey, whichselected vehicles in family use at weekends.Despite studying this safety conscious group,however, examples of incorrect use of re-straints were found in 52% of vehiclessurveyed. The rates of incorrect use weresubstantially higher in children and wereparticularly associated with specific types ofchild car restraints. Action to address thisproblem is required across a number of relatedareas. More attention should be given to childsafety in car and car seat belt design.5 Effortsshould be made to encourage car and car seatmanufacturers to provide information thathighlights common faults in restraint use and

21

on Septem

ber 19, 2020 by guest. Protected by copyright.

http://injuryprevention.bmj.com

/Inj P

rev: first published as 10.1136/ip.3.1.17 on 1 March 1997. D

ownloaded from

Campbell, Macdonald, Richardson

that provide proper instruction in their correctuse. 14

Health care professionals need appropriateguidelines39 40 So that they can provide up-to-date information for parents regarding their car

safety seat choices and use.4' Including discus-sion of car safety as a routine part ofchild healthpromotion programmes is an important new

initiative.42 In Fife we have also held awareness

raising seminars outside the health sector forsocial work department staff who deal withyoung children and their families, nursery staff,childminders and nannies, as well as vehicleregistration and inspection service staff.Community initiatives such as the establish-

ment of infant car seat loan schemes have beenshown to be effective and should be exploredfurther.43 Since it has been shown that lack ofparental knowledge about child restraint deviceuse contributes to improper use of thesedevices,44 efforts should be made to raise publicawareness and knowledge of this issue.4445

In the UK, the 'In-Car Safety' initiative hasorganised public displays and open access In-Car Safety clinics at which the public can

receive a free car restraint safety check. It isimportant that priority is given to theseinitiatives and that this is coupled with on-

going evaluation so that the most effectiveinitiatives in any setting are identified. Withoutsuch activity the potential for reducing roadtraffic accident injuries and fatalities will not befully achieved.

We would like to thank the Fife Police Force road safety team(Bob Blues, Roy Harley, Don Yard) for carrying out the surveywork and all others who helped to make this survey possible,and Sandra MacDonald and Cheryl Armstrong for expertassistance in preparation of the manuscript.

1 Staples B, Pharoah POD. Child health statistical review.Arch Dis Child 1994; 71: 548 - 54.

2 Williams AF. Observed child restraint use in automobiles.Am Dis Child 1976; 130: 1310- 7.

3 Marplis LH, Wagenaar AC, Molnar Recognising thecommon problem of child automobile restraints misuse.Pediatrics 1988; 81: 717-9.

4 Graham CJ, Kittredge D, Stuemky JH. Injuries associatedwith child safety seat misuse. Pediatr Emerg Care 1992; 8:351-3.

5 Johnston C, Rivara FP, Soderberg R. Children in carcrashes: analysis of data for injury and use of restraints.Pediatrics 1994; 93: 960-5.

6 Ruta D, Beattie T, Narayan V. A prospective study of non-fatal childhood road traffic accidents: what can seatrestraint achieve? Jf Public Health Med 1993; 15: 88 - 92.

7 Still A, Roberts I, Koelmeyer T, Vuletic J, Norton R. Childpassenger fatalities and restraint use in Auckland. NZMedJf 1992; 105: 449-50.

8 Esser RC. Restraint model validation tests, phase I. Washing-ton DC: National Highway Traffic Safety Administration,US Department of Tranportation, 1983.

9 States JD, Huelke DF, Dance M, Green RN. Fatal injuriescaused by underarm use of shoulder belts. Trauma1987; 27: 740.

10 Niederer P, Walz F, Zollinger U. Adverse effects of seatbelts and causes of belt failures in severe car accidents inSwitzerland during 1976. Proceedings of twenty-first stappcar crash conference. Warrandale PA: Society of Auto-motive Engineers, 1976; 53-9.

11 Chorba TL, Klein TM. Increases in crash involvement andfatalities among motor vehicle occupants younger than 5years old. Pediatics 1993; 91: 897-901.

12 Fuchs S, Barthel MJ, Flannery AM, Christoffel KK.Cervical spine fractures sustained by young children inforward-facing car seats. Pediatrics 1989; 84: 348-54.

13 Taylor TKF, Nade S, Bannister JH. Seat belt fractures ofthe cervical spine. J Bone joint Surg Br 1976; 58: 328.

14 Bull MJ, Stroup KB, Gerhart S. Misuse of car safety belts.Pediatrics 1988; 81: 98.

15 Lane JC. The seat belt syndrome in children. Accid AnalPrev 1994; 26: 813-20.

16 Tolins SH. An unusual injury due to the seat belt. J Trauma1964; 4: 397-9.

17 Williams JS, Kirkpatrick JR. The nature of seat belt injuries.J Trauma 1971; 11: 207-18.

18 Arajavi S, Santavirta S, Tolonen J. Abdominal injuriessustained in severe traffic accidents by seatbelt wearers. JTrauma 1987; 27: 393-6.

19 Huelke DF. Seatbelt injuries. J Trauma 1975; 15: 20.20 Moskowitz A. Lumbar seatbelt injury in a child: case report.

J Trauma 1989; 29: 1279-2.21 Clyne CAC, Ashbrooke EA. Seat belt aorta: isolated

abdominal aortic injury following blunt trauma. BrJ Surg1985; 72: 239.

22 Freeman CP. Isolated pancreactic damage following seatbelt injury. Injury 1985; 16: 478- 80.

23 Muwanga CL, Cole RP, Sloan JP, et al. Cardiac contusionin patients wearing seat belts. Injury 1986; 17: 37-9.

24 Child Accident Prevention Trust. Every ride a safe ride: aguide for advice-givers on in-car safety for children. London:CAPT. 1992.

25 Anderson PA, Rivara FP, Maier RV, Drake C. Theepidemiology of seatbelt-associated injuries. Y Trauma1991; 31: 60.

26 Christian MS. Non-fatal injuries sustained by seatbeltwearers: a comparative study. BMJ 1976; ii: 1310 - 1.

27 Avery JG, Hayes HRM. Death and injury to children in carsin Britain. BMJ 1985; 291: 515.

28 Teret SP, Jones AL, Williams AF, et al. Child restraint laws:an analysis of gaps in coverage. Am Y Public Health 1986;76: 31-4.

29 Evans L. Rear seat restraint system effectiveness inpreventing fatalities. Accid Anal Prev 1988; 20: 129-36.

30 Evans L. Motorized two-point safety belt effectiveness inpreventing fatalities. Accid Anal Prev 1991; 23: 165-74.

31 Henderson M, Wood R. Compulsory wearing of seat beltsin New South Wales, Australia. An evaluation of its effecton vehicle occupant deaths in the first year. Med J Aust1973; ii: 797-801.

32 Huelke DF, Sherman HW. Seat belt effectiveness: caseexamples from real-world crash investigations. Y Trauma1987; 27: 750-3.

33 Evans L. Restraint effectiveness, occupant ejection fromcars and fatality reductions. Accid Anal Prey 1990; 22:167-75.

34 Braustein PW. Medical aspects of automotive crash injuryresearch. JAMA 1957; 163: 249.

35 Lindgren S, Warg E. Seat belts and accident prevention.Practitioner 1962; 188: 467-73.

36 Campbell H, Gorman D, Richardson P. An observationalstudy of car occupant restraint in Fife: impact of recentlegislation. Public Health 1993; 107: 429- 35.

37 British Standards Institution, Education Section. Tighteningtheir belts-an essay on the misuse of children's restraints incars. Education occasional paper. London: BSI, 5 June1991.

38 Green G. Are they belted up in the back? Independent 13May 1995.

39 Committee on Injury and Poison Prevention. Selecting andusing the most appropriate car safety seats for growingchildren: guidelines for counseling parents. Pediatrics1996; 97: 761-2.

40 American Academy of Peditrics, Committee on Injury andPoison Prevention, Committee on Fetus and Newborn.Safe transportation of premature and low birth weightinfants. Pediatrics 1996; 97: 758-60.

41 Gunnip A, Roberson C, Meredith J, Bull MJ, Stroup KB,Branson MK. Car seats: helping parents do it right.Journal of Pediatric Health Care 1987; 1: 190- 5.

42 Hall DMB. Health for all children. Oxford: Oxford MedicalPublishers, 1996.

43 Lindqvist KS. Does the use of child safety seats increase as aresult of loan schemes? AccidAnal Prev 1993; 25: 421 - 9.

44 Ruffin MT, Kantor R. Adults' knowledge about the use ofchild restraint devices. Fam Med 1992; 24: 382- 5.

45 Foss RD. Evaluation of a community-wide incentiveprogram to promote safety restraint use. Am J PublicHealth 1989; 79: 304-6.

22

on Septem

ber 19, 2020 by guest. Protected by copyright.

http://injuryprevention.bmj.com

/Inj P

rev: first published as 10.1136/ip.3.1.17 on 1 March 1997. D

ownloaded from