New study examines child death rates in motor vehicle crashes by state

Boston, MA-- Unintentional injury is the leading cause of pediatric death in the U.S. and motor vehicle crashes (MVCs) are the most common cause of injury. A new paper published in the Journal of Pediatrics by researchers at Center for Surgery and Public Health (CSPH) at Brigham and Women's Hospital (BWH) and UT Southwestern Medical Center in Dallas, is the first to examine state-level factors contributing to variation in pediatric mortality in motor vehicle crashes and to identify trends across states.

On average across all states, researchers found that 20 percent of children involved in a fatal crash were unrestrained or inappropriately restrained at the time of the crash. Thirteen percent were inappropriately seated in the front seat, and nearly 9 percent of drivers transporting a child passenger were under the influence of alcohol. The study's authors estimate that a 10 percent absolute improvement in child restraint use--decreasing the average number of unrestrained or inappropriately restrained children from 20 percent to 10 percent nationally--would avert approximately 232 pediatric deaths per year, or more than 1,100 over five years. These findings highlight the importance of child restraint use and reinforce guidelines on child restraints published by the American Academy of Pediatrics (AAP) in 2011.

"In order to prevent children from being killed in motor vehicle crashes, we must understand the effects of state-level regulations, their implementation and enforcement," said Lindsey Wolf, MD, MPH, general surgery resident at BWH, research fellow at CSPH and lead author of the study. "Since laws governing child traffic safety are made at the state level, we formulated a study design that would produce state-by-state geographic results, which could easily be utilized by policy makers aiming to reduce pediatric mortality and save children's lives in their states."

The authors found substantial state-level variation, and concluded overall that the percentage of children who were unrestrained or inappropriately restrained was a leading predictor of mortality. The percentage of children involved in a fatal crash who were unrestrained or inappropriately restrained varied from 2 percent in New Hampshire to 38 percent in Mississippi.

Crashes were most likely to occur on state highways (35 percent) and on roads classified as rural by the Federal Highway Authority (62 percent). Characteristics of the crashes also varied: the percentage of those that occurred on a rural road varied from 17 percent in Massachusetts and Rhode Island to 100 percent in Maine and Vermont; the percentage of those that occurred on state highways varied from 11 percent in Iowa to 84 percent in Hawaii; and the percentage of those that occurred on a road with a speed limit 65 to 80 miles per hour varied from 0 percent in Hawaii, Maine, and Rhode Island to 80 percent in Wyoming.

The number of fatal crashes over 2010-2014 ranged from 18 in Rhode Island to 2,017 in Texas, while the number of deaths ranged from 3 in Rhode Island to 346 in Texas. Age-adjusted, mean MVC-related pediatric mortality per 100,000 children varied from 0.25 in Massachusetts to 3.23 in Mississippi. The percentage of children that died of those involved in a fatal crash varied from 8 percent in New Hampshire to 30 percent in Nebraska.

The first-of-its-kind analysis included data from 18,116 children, ages 15 and younger, riding in a passenger vehicle involved in a fatal crash occurring from 2010-2014, as reported in the Fatality Analysis Reporting System (FARS) dataset. FARS is a nationwide census providing publicly-available data on fatalities associated with MVCs, compiled from various documents in each state, including police accident reports, death certificates, state vehicle registration files, medical examiner reports, state driver licensing files, state highway department data, emergency medical service reports and vital statistics. These data were used in conjunction with annual U.S. Census data to create population size estimates by age, state and region, and the percentage of households with a vehicle, in examining two outcomes: state-based, age-adjusted, mean MVC-related pediatric mortality per 100,000 children; and percentage of children involved in a fatal crash who died ("fatal crashes" were defined as crashes that occurred on a public road and resulted in at least one death, adult or pediatric, within 30 days). Both of these outcomes were calculated by region (Midwest, Northeast, South, West) and nationally.

An extensive list of factors potentially affecting MVC-related pediatric mortality were examined, including restraint use, road type, vehicle type, speed limit, red light camera policy and more. In order to understand the effects of individual factors on the desired outcomes, the study's authors leveraged an ecological study design, first employing multivariable linear regression to identify state characteristics associated with each outcome.

"The American Academy of Pediatrics has issued clear guidelines regarding child restraints and other factors in order to save children's lives in the event of motor vehicle crashes, and many states have implemented them in part, but no state has implemented them fully," said Faisal Qureshi, MD, MBA, associate professor of surgery at UT Southwestern Medical Center, and senior author of the study. "The significant state-level variation evident in our findings emphasizes the need for close collaboration between the injury prevention community and those enacting and enforcing legislation, and suggests the potential for a federal intervention in the area of child traffic safety."

The authors note that further research is required to understand how factors like vehicle type, roadway characteristics, speed limits, and red light camera use may contribute to the overall risk of death.

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This work was supported by the American College of Surgeons Resident Research Scholarship to Lindsey L. Wolf, MD. Elena Losina, PhD is supported by a grant from the U.S. National Institute of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases (K24AR057827-02). The study sponsors had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit for publication. No honorarium, grant, or other form of payment was given to anyone to produce the manuscript.

A portion of this work was presented as an oral presentation at the American Academy of Pediatrics National Conference & Exhibition in San Francisco, October 21-25, 2016.

The Center for Surgery and Public Health (CSPH) at Brigham and Women's Hospital was established in 2005 as a joint program of Harvard Medical School and the Harvard T. H. Chan School of Public Health. Its mission is to advance the science of surgical care delivery by studying effectiveness, quality, equity, and value at the population level, and developing surgeon-scientists committed to excellence in these areas. CSPH works with a diverse set of collaborators, including academic institutions, non-profit and for-profit organizations nationally and internationally, in order to eliminate disparities and foster patient-centered care through policy and practice.

Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 4.2 million annual patient visits and nearly 46,000 inpatient stays, is the largest birthing center in Massachusetts and employs nearly 16,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $600 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups. For more information, resources and to follow us on social media, please visit BWH's online newsroom.

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