Removing barriers to booster seat use in Canada

Canadian children between four and nine years old would be much safer car passengers if booster seats were routinely used, but unfortunately they are not. This paper examines the barriers to booster seat use and the role of paediatricians and their organizations in removing these barriers. Road traffic injury is the leading single cause of death for Canadian children (1). In 2001, it was responsible for 139 fatalities and approximately 17,000 injuries among children aged zero to 14 years in Canada (2). Booster seats reduce the odds of injury to a child passenger by 59% compared with seat belts alone for children four to seven years old (3). Among 4243 children in this age group involved in crashes in the United States between December 1998 and May 2002, the injury rate was 1.95% among those using seat belts compared with 0.77% among those using belt positioning boosters (3). Importantly, children in booster seats did not have injuries to the abdomen, the spine, or the lower extremities whereas children in seat belts had injuries to all body regions. This American study strongly suggests that booster seats correct the biomechanical vulnerability that children in seat belts have for lap belt injuries – a far too common cause of traumatic paraplegia among children (4,5). Since 2000, a total of 31 children (ages two through 12) have been admitted to The Hospital for Sick Children in Toronto or The Children's Hospital of Eastern Ontario in Ottawa, following frontal crashes in which seat belts were used for restraints. Of these 31 children, 16 had abdominal organ, spinal column or spinal cord injury. No such injury has been seen in a child restrained in a booster seat in either hospital (data on file, Crash Protection for Children Study, Hospital for Sick Children, Toronto [lead investigator Andrew Howard]). The Canadian Paediatric Society has recently undertaken a national surveillance of lap belt injuries because of the important and preventable morbidity associated with this condition (6). Despite being highly effective devices, booster seats are underused in Canada. The most recent Canadian national data are from 1997, when only 4.5% of children five to nine years old were using booster seats, whereas 78.9% of children in the same age group were using seat belts (7). Observational studies in Seattle in 1999 and 2000 showed that only 10% to 16% of children who should have been using booster seats did so regularly (8,9). There is some evidence that booster seat use increased for four- and five-year-olds in the United States between 1999 and 2002 (10). Booster seat rates as high as 29% have been reported in Canada, although this survey was performed in an automobile manufacturing community and the majority of respondents had incomes above $80,000. Accordingly, this may represent a ‘best case’ scenario (11). It is possible that booster seat rates are increasing in Canada, but at present most children are probably not protected. The main reason that booster seats are not used is because parents do not believe that they are necessary. This is the explanation given by 56% of parents in one study (9) and 45% of respondents in another (8). A focus group study found that additional barriers included cost, difficulty and child acceptance. This study also showed that most parents incorrectly identified the age at which it becomes safe to use a lap-shoulder belt (12). If parents are confused, they may get little help from their equally confused doctors. Only 33% of Toronto community paediatricians correctly identified the recommended weight (27 kg or 60 lb) for transition from a booster seat to a lap shoulder seat belt, and only 25% could identify the recommended age (eight years old) (13). However, 92% could identify the correct weight for placing a child in a forward-facing car seat. Parental knowledge can be increased by anticipatory guidance during paediatrician office visits. Parents look to health care providers, emergency medical services, or law enforcement personnel as the source of the most accurate messages about child safety seat use (12). It has been shown that counselling can increase short term seat restraint use rates (14). Motor vehicle occupant protection was ranked as the highest priority for office-based injury prevention counselling by a delphi process among injury prevention experts (15). Many resources are available in Canada and online to support such counselling (Table 1). Useful web sites to support anticipatory guidance about booster seats Useful web sites to support anticipatory guidance about booster seats Creative means of providing this counselling might include providing a prescription for a booster seat, or using a colour-coded height or weight chart that displays restraint recommendations (Figure 1). Children arriving at the office incorrectly restrained in an adult seat belt without a booster (Figure 2) might become paraplegic on the way home (Figure 3). The Canadian Paediatric Society could coordinate research to determine effective, efficient tools to improve parents' knowledge. A shaded growth chart for determining appropriate type of child restraint after weighing and measuring in the office. Where height and weight disagree, height is generally a better indicator of seat belt fit and should be followed A shaded growth chart for determining appropriate type of child restraint after weighing and measuring in the office. Where height and weight disagree, height is generally a better indicator of seat belt fit and should be followed A seven-year-old male in a stationary car demonstrates the lack of fit of an adult lap shoulder belt. The lap portion is very high on the abdomen and the shoulder sash has been placed behind the body. This is dangerous and will lead to the injury shown in Figure 3 A seven-year-old male in a stationary car demonstrates the lack of fit of an adult lap shoulder belt. The lap portion is very high on the abdomen and the shoulder sash has been placed behind the body. This is dangerous and will lead to the injury shown in Figure 3 Lap belt injury – The magnetic resonance imaging shows gross disruption at L2–L3 and signal changes in the spinal cord proximally. The child was paraplegic with a T11 level spinal cord injury Lap belt injury – The magnetic resonance imaging shows gross disruption at L2–L3 and signal changes in the spinal cord proximally. The child was paraplegic with a T11 level spinal cord injury Community interventions are also known to be effective in increasing booster seat use. A multi-faceted campaign involving community coalitions and citizen advisory groups, including a newspaper and newsletter, Web site, brochures, telephone information line, resource kit, radio and television public service announcements, educational program discounts and car seat training programs was carried out in four communities in Washington state along with the introduction of booster seat legislation. Booster use increased from 13% to 26% in the intervention communities and from 17% to 20% in control communities (16). Canadian media campaigns have also increased observed child restraint use among infants and toddlers in the past, but have not been evaluated specifically for booster seats (17). Safe Kids Week 2004, a national media campaign run by Safe Kids Canada, will focus on booster seats this year. Further information is available via . Booster seat legislation is currently in place in only one Canadian province, Quebec. Sixteen states in the United States now have such legislation and it is pending in 16 other states. Parents report that legislation is an important factor in achieving booster seat use (12). Safety legislation has been shown to reduce child injury rates; for example, provinces with mandatory bicycle helmet legislation had a 45% reduction in bicycle related head injuries compared with the 27% reduction in provinces that did not adopt this legislation (18). Canada needs booster seat laws in every province and physicians should be credible advocates for such laws, both individually and collectively through the Canadian Paediatric Society. Physicians can address the low booster seat use in Canada at the office, community and provincial levels. At the office level, the resources listed can help to educate you and the parents in your practice. At the community level, the paediatrician can support and endorse safety campaigns. The World Health Organization has declared Safe Roads the theme for World Health Day 2004 (April 7, 2004). This is an excellent year to start community campaigns for booster seat safety. Safe Kids Week 2004 is focused on booster seat promotion across Canada and will take place from May 31, 2004 onwards. Further information is available from Safe Kids Canada. At the provincial level, advocacy by the individual or through professional organizations will help Canadian legislatures to pass the booster seat laws that our children deserve. Drs Howard and Snowdon are supported by the Auto21 Network of Centres of Excellence.

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