Pediatric Obesity in Motor Vehicle Collisions

PEDIATRIC OBESITY IN MOTOR

VEHICLE COLLISIONS

Authors: Rockan Sayegh, BS, MA, Darlene Bradley, RN, PhD(c), MSN, CEN, MICN, FAEN,and Federico E. Vaca, MD, MPH, FACEP

Section Editors: Donna Ojanen Thomas, RN, MSN, Joyce Foresman-Capuzzi, RN, BSN, CEN,CTRN, CPN, CCRN, SANE-A, EMT-P, and Michelle Tracy, RN, MA, CEN, CPN

Earn Up to 9.5 CE Hours. See page 514.

Introduction

In the United States, with the exception of infants, mostfatal injuries in children are the result of motor vehicle col-lisions (MVCs).1 The National Highway Traffic SafetyAdministration (NHTSA) estimates that in 2008, 968children aged 14 years or younger died as occupants inmotor vehicle crashes and approximately 168,000 wereinjured.2 It has been well documented that child restraintsappropriate for age and weight can significantly reduce ser-ious injury and death.3,4 However, appropriate restraintsmust be installed and used correctly to provide optimalprotection. In support of ENA’s position statements onmotor vehicle occupant protection and motor vehiclesafety, this article will focus on the consequences of child-hood obesity as it relates to MVCs using the most currentmedical literature available.

Motor Vehicle Collisions

According to NHTSA, nearly half of the child occupantsaged 4 to 15 years who were fatally injured in a collisionwere unrestrained.5 A study conducted by Rangel et al6

recently found that of the 1,268 children injured in anMVC, 45% were restrained but only 20% were in appro-priate age-specific restraints. When worn properly, seatbelts

effectively transfer most of the force of a collision to thechest and bony pelvis, areas that can generally withstandmuch of the resulting forces.

The use of adult seatbelts in small children who do notmeet safety recommendations for height and weight poses sig-nificant risks for serious injury and death in the event of a colli-sion. Adult seatbelts, too large for the small child, invariably willrest anatomically against the child’s abdomen, increasing therisk for serious intra-abdominal injury and “seatbelt syn-drome.” Seatbelt syndrome in an MVC encompasses suchinjuries as hip and abdominal contusions, lumbar vertebraand spinal cord injuries, intra-abdominal injuries, and injuriesto the head and face.7

Both NHTSA and the Centers for Disease Controland Prevention recommend that children less than 80pounds or shorter than 4 feet 9 inches not be restrainedusing adult seatbelts.8 Instead, booster seats provide anincreased elevation so that the adult seatbelts have a correctanatomic fit for children who have outgrown child safetyseats yet remain too short in stature for just the vehicle seat-belts. When compared with seatbelt use alone, belts posi-tioned correctly with the aid of booster seats were 59%more effective in reducing injury to children aged 4 to 7years.9 The Insurance Institute for Highway Safety reportsthat restrained children have an 80% lower risk of fatalinjury than unrestrained children.10

Within the past 20 years, lawmakers have becomeincreasingly aware of the benefits of age- and weight-appro-priate child restraint use. Similarly, best practice guidelineshave evolved as traffic safety and injury prevention researchhas advanced. NHTSA and the American Academy of Pedia-trics recommend that all children aged less than 13 years beseated in the rear of the vehicle with age- and weight-appro-priate restraints.11 To date, states continue to enact andenhance vehicle occupant safety codes and laws that mirrorthe best practice guidelines, and as a result, more children arebeing properly restrained. The inclusion of booster seats instate vehicle safety codes has resulted in increased use amongchildren aged 4 to 7 years.12 Today, Safe Kids Worldwidereports that all 50 states and the District of Columbia have

Rockan Sayegh, Researcher, Center for Trauma and Injury Prevention Re-search, University of California, Irvine Medical Center, Orange, CA.

Darlene Bradley, Member, ENA Orange Coast Chapter, Director Emergency/Trauma Services, University of California Irvine Medical Center, Orange, CA.

Federico E. Vaca, Professor of Emergency Medicine, Department of Emer-gency Medicine, Yale University School of Medicine, New Haven, CT.

For correspondence, write: Darlene Bradley, RN, PhD(c), MSN, CEN,MICN, FAEN, Director Emergency/Trauma Services, University of Califor-nia Irvine Medical Center, 101 The City Dr, Orange, CA 92868; E-mail:Strgzzr3@yahoo.com.

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child occupant laws. However, it should be noted that thereis considerable state-by-state variation in age-specificrestraint policies and penalties, with several remaining sub-standard to best practice recommendations.

There is no question that child age- and weight-appropri-ate restraints are effective in reducing fatal or serious injuriesto children in MVCs. However, child occupant safetyrestraints must be properly installed and used correctly to pro-vide optimal protection. How many children, however, areactually restrained correctly? Although the trend toward prop-er seatbelt use increased from 1998 to 2002, NHTSAreported in 2005 that booster seat use declined for childrenaged 4 to 7 years.13 Studies have shown that many youngstersare moving prematurely from booster seats to adult seatbeltsalone.14 In addition, the incorrect use of child safety seats hasplaced children at greater risk for injury in a motor vehiclecrash.15 Safe Kids Worldwide estimates that 82% of childsafety seats are installed or used incorrectly.16 Factors thatinfluence proper child occupant restraint use include seatbeltuse by the parent and age, gender, ethnicity, and socioeco-nomic status of the parent.17-19

Obesity Implications in MVCs

With the national epidemic of childhood obesity, it is impor-tant to take into account how obesity in this group affects theuse and efficacy of child occupant restraint systems. In adultsthere appears to be a linear decrease in seatbelt use with increas-ing body mass index, suggesting that seatbelts may not be largeenough to accommodate larger sizes or are simply too uncom-fortable for overweight adults to use regularly.20 This can haveserious implications on child passengers in cars driven by obeseadults because those who do not use safety belts themselves areless likely to properly restrain their children.21-23 Although thesafety implications regarding obese adults and seatbelt use areclear, there remains a paucity of similar medical literature withrespect to obese children and restraint use.

If obese children are not properly restrained, they maybe at greater risk for injury in anMVC. A study by Pollack etal24 at the Johns Hopkins Bloomberg School of PublicHealth, Baltimore,Maryland, found that as bodymass indexincreased in children aged 9 to 15 years, injuries to the lowerand upper extremities increased as well. Obese children maybe physically too large for their respective occupantrestraints, causing them to be too uncomfortable. Safetyand booster seats do exist, however, only for limitedweight/height variations. Conflict arises because some obesechildren do not fit the required height and weight specifica-tions. In addition, child safety seats that accommodate over-weight children are commonly more costly. Safety seats for3-year-old children weighing greater than 41 pounds begin

at $240.25 Because of these limited variations and theincreased cost of obese-specific safety restraint mechanisms,many obese children are not properly restrained. The parentsof an overweight child who outgrows his or her child safetyseat or booster seat may resort to restraining their child usingadult seatbelts. Although the weight of the child would beconsidered adequate in this case, the more importantrequirement of height may not exist and could result inincorrect positioning of the lap belt, ultimately leading togreater risk of serious injury.7,26-28

Outcomes

Research in adults has identified a correlation with obesityand degree of injury.29-31 In a population of obese andnonobese adults, Neville et al30 found that obese patientswere 5 times more likely to die from blunt trauma injuriescompared with their nonobese counterparts. It is suspectedthat obese children may have similar results.

Physical harm may not be the only outcome of MVCs.Psychological harm from the trauma of the collision or injurymay also be evident. A Swedish study in June 2008 showed thatone-third of children met diagnostic criteria for post-traumaticstress disorder/syndrome 1 month after an MVC.32 Althoughtreatment for physical injuries, both short and long term, is read-ily available and efficient, frequently, there are limited treatmentresources for the long-term psychological harm associated withtrauma from an MVC. Speculation exists that psychologicalimplications for injured obese children, who are already copingwith the social consequences of obesity, such as depression, poorself-confidence, and peer-related issues, may be more seriouscompared with nonobese children. Currently, it appears thatno studies have been done to determine whether obese childrenare at greater risk for the development of post-traumatic stressdisorder/syndrome from traumatic experiences.

Conclusion

The medical literature suggests that obesity negatively influ-ences injury outcomes in children.29,33 However, limitedinformation exists with regard to types and mechanisms ofinjury that carry a prognosis detrimental to the child’s healthand well-being. Questions yet to be fully understood includethe following: (1) Compared with their nonobese counter-parts, are obese children at greater risk for serious injury inthe event of an MVC? (2) How do obese children fare inMVC injury outcomes compared with their nonobese coun-terparts in terms of injury severity, length of hospital stay,mental health, and residual disability? (3) After a traumaticinjury, are obese children at greater risk for post-traumaticstress syndrome? Further study on the relationships of injuryand childhood obesity is necessary.

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In the meantime, emergency nurses must educate par-ents about the dangers of childhood obesity. The educationmust include the correct use of child safety seats and restraintsto ultimately reduce the risk of injury in an MVC. ENA’sposition statements and injury prevention and education pro-grams are excellent resources to develop this process.

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19. Braver ER. Race, Hispanic origin, and socioeconomic status in relationto motor vehicle occupant death rates and risk factors among adults.Accid Anal Prev. 2003;35(3):295-309.

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27. Slavin RE, Borzotta PA. The seromuscular tear and other intestinallesions in the seatbelt syndrome: a clinical and pathologic study of 29cases. Am J Forensic Med Pathol. 2007;23(3):214-22.

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29. Brown CV, Neville AL, Rhee P, Salim A, Velmahos GC, DemetriadesD. The impact of obesity on the outcomes of 1,153 critically injuredblunt trauma patients. J Trauma. 2005;59(5):1048-51.

30. Neville AL, Brown CV, Weng J, Demetriades D, Velmahos GC. Obe-sity is an independent risk factor of mortality in severely injured blunttrauma patients. Arch Surg. 2004;139(9):983-7.

31. Ciesla DJ, Moore EE, Johnson JL, Burch JM, Cothren CC, Sauaia A.Obesity increases risk of organ failure after severe trauma. J Am CollSurg. 2006;203(4):539-45.

32. Olofsson E, Bunketorp O, Andersson AL. Children and adolescentsinjured in traffic—associated psychological consequences: a literaturereview. Acta Pediatr. 2008;98(1):17-22.

33. Brown CVR, Neville AL, Salim A, Rhee P, Cologne K, Demetriades D.The impact of obesity on severely injured children and adolescents.J Pediatr Surg. 2006;41(1):88-91.

Submissions to this column are encouraged and may be sent toDonna Ojanen Thomas, RN, MSNdonna.thomas@imail.orgorJoyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN,SANE-A, EMT-Pjoyceforesmancapuzzi@rcn.comorMichelle Tracy, RN, MA, CEN, CPNjmtracy2001@yahoo.com

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