CASE STUDY

Background

Car travel which was a luxury in our country in the last century, has now become a way of life for our children of this century. Cars have become better; we are able to travel faster on good roads. Hence it is essential for us to know the safety aspects when travelling with our children. The literature shows benefits of reducing fatal injuries [1,2]. The non-compliance of these child safety aspects in developed countries and lack of awareness in developing countries are also quoted [3,4]. This article is written to improve the awareness of child safe-ty during car travel. We illustrate this with a case report of a pediatric trauma patient without following recommended child safety recommendations.

Case Presentation

An 8-years-old male child admitted following a road traffic accident. He was travelling a car seated in front passenger seat with his sister aged. Both of them were not using any restraints (seat belt). Father was driving the car when unfortunately, the front right-side tyre burst out and the car control was lost when it hit road median strip. This resulted in the child thrown forward due to sudden deceleration. He hit the front dashboard and sustained injury as described below.

At the time of presentation to the emergency department, child was conscious, oriented. He was found to be hypoxic with 90% saturation. He was treated with 5 l of oxygen. He had respiratory alkalosis on the day of admission. He was tachycardia with no evidence of hypo-tension.

He complained of left sided chest pain. He was not able to life his left upper limb. He was resuscitated with ATLS protocol. His investigations showed lung contusion on the left side. He had fracture of left clavicle (Fig. 1).

Fig. 1. Chest X ray.

He had no obvious head injury and his CT brain was normal. His Chest CT showed lung contusion affecting the left side (Fig. 2).

Fig. 2. CT Chest.

His CT brain was normal and MRI brain showed subarachnoid hemorrhage. Spine was screened with MRI which ruled out SCIWORA.

He was observed in Pediatric intensive care with review of his saturation, vital signs and lung expansion with periodic lung scans. He received antibiotics to prevent secondary infec-tion, analgesics and chest physiotherapy. He received neuroprotective medication and sub-arachnoid hemorrhage was treated conservatively. His clavicle fracture was treated conser-vatively with bracing and sling. His oxygen requirement gradually improved over four days. He was transferred to step down care and discharged on sixth day.

Discussion

Road traffic accidents constitute a major cause of deaths and morbidity in India. According to the Ministry of Road Transport and Highways, around 1.5 lakh people were killed in 2018 alone. The state of Tamil Nadu ranks very high in India when analyzing the deaths per lakh population.

In the year 2018 alone, as many as ten thousand deaths are in age group of less than 18 years. This calls for special review of child safety we the parents and adults should be their guardians in this aspect too.

Road traffic rules and regulations should be followed to avoid the children being hit as pe-destrians. There are enough resources in the open access resources in the web. More im-portantly the Ministry of Road Transport and Highways have published safety rules and pol-icy, question bank and data for the public to see and learn from Garces et al [5].

This article will highlight the safety of children when travelling in a car, as it has become common for this mode of travel for the present generation of children. The United States department of transportation has published information on child safety.

The following are recommended for keeping the kids safe, for the adults to refer to as a guide.

1. The safest place for children aged 12 and less in properly buckled in the back seat.
2. Proper buckling refers to use of appropriate car seats.
3. The appropriate car seats for infants and small children are in rear facing car seat placed

on the back seat and appropriate seat belt restraint for that car seat (Fig. 3).

Fig. 3. Rear facing seat placed on the car back seat for infants and small children.

4. The appropriate car seats for children grown larger is forward facing car seat placed on

the back seat with appropriate seat belt restrain for that car seat (Fig. 4).

Fig. 4. Forward facing seat placed on the car back seat for children grown larger.

5. The children aged 4 to 12 should have a raised car seat called booster seat placed on the

back seat and the seat belt worn over across the child (Fig. 5).

Fig. 5. Booster seat placed on the car back seat for the children aged 4 to 12.

6. The children over 12 should have a seat belt worn like an adult either in the front or the rear seat.

The rationale of the recommendations is as described below

1. Why should we not seat the children less than 12 in the front seat?

Children seated in the front seat are likely to be thrown forwards due to sudden deceleration. While the conventional seat belts work for adults, they are not as effective for children below the age of 12 years.

The children are thrown forwards in an accident resulting in chest injury. The airbag fitted in modern cars deploy hitting the forward thrown child, resulting in serious injuries and some-times death.

2. Why should the young children be seated in a rear facing seat?

Small children have fragile necks and spinal cords. Any flexion injury due to sudden decel-eration can result in spinal cord injury called SCIWORA, meaning Spinal Cord Injury With Out Radiological Abnormality. Infants when facing backwards, are less likely to sustain this dreaded injury.

3. Why the special seats for children aged 4 to 7 and booster seat for the older child?

The conventional seat belts are designed for adult stature and most cars do not have adjusta-ble seat belt position for small stature of children.

4. What are the other safety considerations in a modern car one should consider when trav-elling with a child?

• Side impact air bags can potentially injure young children
• Advanced frontal air bags can be held friendly to adult passengers and also the chil-dren who had to be taken in the front seat
• Rear seat belt warning systems can help the driver to be aware of belt wearing by rear seat passengers
• Auto pinch and auto reverse windows which can protect children from being pinched by the closing windows.
• Child safety locks for all the doors by the driver
• Interior trunk release and cameras to monitor the path while reversing a car.

Conclusion

The article described a serious injury to an eight-year-old boy while travelling in the front seat of a fast-moving car, unrestrained. This was a potentially a fatal injury. Hence this arti-cle has used this case scenario to bring awareness on child safety whilst travelling in a car. As adults, it is our responsibility to follow these recommendations such as the one from American College of Pediatricians [5] and American academy of orthopedic surgeons even though they are not enforceable by law at the moment.

Child car seats: the law

https://www.gov.uk/child-car-seats-the-rules
https://www.forbes.com/sites/tarahaelle/2015/12/18/putting-your-newborn-in-a-car-seat-95-of-people-do-it-wrong/?sh=6632758446d3

References

1. Howard AW. Children, automobile restraints and injuries. Paediatr Child Health. 2000;5(1):24–29.
2. Elliott MR, Kallan MJ, Durbin DR, Winston FK. Effectiveness of child safety seats vs seat belts in reducing risk of death in children in passenger vehicle crashes. Arch Pediatr Adolesc Med. 2006;160(6):617–21
3. Jones AT, Hoffman BD, Gallardo AR, Gilbert TA, Carlson KF. Rear facing car safety seat use for children 18 months of age: prevalence and determinants. J Pediatr. 2017;189:189–95.
4. Moradi M, Khanjani N, Nabipour AR. Determinants of child safety seat use among parents in an International safe Community, Tehran, Iran. Traffic Inj Prev. 2019;20(8):844–48.
5. Quadros-Garcês A, Andrade-Coimbra IB, Muniz da Silva DS. Transporting children in cars and the use of child safety restraint systems. Acta Ortop Bras. 2016;24(5):275–78.
6. Durbin DR. Child passenger safety. Paediatrics 2018;142(5):e1050–e1066.