PHILADELPHIA-Buckling up is not enough to protect children from serious injuries in automobile accidents; safety restraints such as child safety seats and seat belts must also be used properly. "The number of child passengers dying in auto crashes has dramatically declined in the past 20 years," said Flaura K. Winston, M.D., Ph.D., of The Children's Hospital of Philadelphia. "Far more children now ride in seat belts and child safety seats. But the next level of protection is to concentrate on the correct fit and most appropriate use of child restraint devices." Dr. Winston and Dennis R. Durbin, M.D., of The Children's Hospital of Philadelphia, wrote about child passenger safety in the July 9 Journal of the American Medical Association.

While the majority of children who die in motor vehicle crashes are not using car seats or restraint devices, 37% of children killed in 1997 were restrained, according to the National Highway Traffic Safety Administration. Misusing child safety restraints reduces their effectiveness, said the authors, who stress that the best safety practices take a child's age and weight into account.

For instance, infants should ride in a rear-facing child safety seat until they reach one year and 20 pounds. Children aged one to four, between 20 and 40 pounds, should ride in a forward-facing car seat, not in a seat belt. "Premature graduation to safety belts raises the risk of 'seat belt syndrome,' injuries to the abdomen and spinal cord from an improperly positioned seat belt," said Dr. Durbin. Children over 4 years and 40 pounds should use a booster seat until about age 8, when they can properly use a seat belt without a booster seat. And for all children 12 years old and younger, "the safest place is in a vehicle's rear seat," added Dr. Winston.

Although the fatality rate for child passengers in motor vehicle accidents dropped by 25% from 1977 to 1997, "fatality and injury rates have remained largely unchanged since 1990," say the authors. "We need to address 'second generation' problems of child passenger safety, such as the best usage of safety restraints for each child's age and weight," said Dr. Winston.

Recommendations for current child safety practice draw on extensive research into motor vehicle accidents, including work by Partners for Child Passenger Safety, a joint project of The Children's Hospital of Philadelphia and the State Farm Insurance Companies. Drs. Winston and Durbin are research leaders of the project, which has gathered information on thousands of injuries to children in motor vehicle accidents since June 1998. Although more than 90% of the children in accidents reported to the project were restrained, the safety restraints did not conform to best current practice in nearly half the cases. "The most serious injuries to children in car crashes are head injuries," said Dr. Winston, "and these are the most important injuries to prevent."

The Children's Hospital of Philadelphia, the nation's first children's hospital, is a leader in patient care, education and research. This 406-bed multispecialty hospital provides comprehensive pediatric services to children from before birth through age 19.

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