Reducing childhood pedestrian injuries.

EPIDEMIOLOGY Motor vehicles are responsible for one of every five deaths among children 1–14 years of age in the United States, and pedestrian injuries account for one fourth of them. Compared with occupant injuries, pedestrian injuries are more severe, with a fivefold higher likelihood of death among those injured. In 1998, 726 child pedestrians were killed, and at least 30 000 children were nonfatally injured in traffic, which excludes those struck while in driveways, parking lots, or other non-traffic areas. Traumatic brain injury accounts for more than half the fatalities. The child pedestrian death rate has declined during the past several decades in the United States. This may be related more to reduced exposure than to a safer environment or better pedestrian skills. Since walking is a major form of exercise for children, less walking may be partly responsible for the epidemic of obesity among American children. Much research has been conducted concerning risk factors for child pedestrian injury. Overall, children are more likely to be struck in an urban area on a residential street in the late afternoon or early evening. Walking at night or while drunk are risk factors for adult, but not child, pedestrians. Children put themselves at risk during midblock dart-outs, dashes across intersections, and while alighting from buses. How and where a child is struck greatly depends on the child’s gender and age. Boys are more likely than girls to be injured, a matter that may be due more to differences in exposure to traffic than to any intrinsic factor. Age is a major determinant, since it largely determines a child’s degree of mobility and independence. Accordingly, solutions are also age dependent. For example, infants (less than 1 year old) are considered pedestrians when they are carried in arms or transported in a stroller, so that their risk is closely related to that of the caregiver, the locus of control. Toddlers (ages 1–2 years) sustain the highest overall number of pedestrian injuries. Their small size and limited traffic experience appear to be factors. Also, they are the most likely group to be injured in a non-traffic location, especially during driveway backovers. However, fatality statistics that are traffic based may under-report these events by as much as 50% in this age group, since driveways and parking lots are not classified as traffic areas. Preschool age children (ages 3–4 years) and younger elementary schoolchildren (ages 5–9 years) are most often struck as they enter the roadway at midblock, particularly if cars parked along the side of the road shield them from the view of drivers. According to some, they are at higher risk because their knowledge and key perceptual skills concerning traffic are not yet fully developed. 10 As a child’s age increases, he becomes more mobile, has less supervision, and travels further from home independently. Play may divert his focus from traffic. As children mature into preadolescents and young adolescents (ages 10–14 years), they acquire more experience in traffic. A disproportionately greater number of such youth are injured on relatively busy streets, further from home. Some key risk factors are known. Parents of elementary schoolchildren often have unrealistic expectations of the street crossing ability of their children. Other risk factors include the time when school ends, the proximity of school to home, family income, highest parental educational level achieved, employment status, crowding, ethnicity, family stress, and the child’s road environment. Among these, high traffic volume, lower income, and younger age are most strongly related to child pedestrian injury. Driver based risk factors include inattention, speed, risky driving habits, and the use of alcohol and illegal drugs. However, because the focus of this conference was on child pedestrian behaviors and the environment, rather than driver related behaviors, these aspects were not explored in detail. Surveillance systems that are crash based differ notably from those that are injury based, particularly with respect to case ascertainment and the environmental circumstances of a crash. Crash based surveillance systems of fatal and non-fatal injuries are reported to the United States Department of Transportation by the Fatal Analysis Reporting System and the General Estimates System, respectively. Unfortunately, neither of these two datasets captures children killed in non-traffic areas, such as driveways and parking lots, which account for many such injuries among toddlers and preschoolers. On the other hand, injury based surveillance systems (such as the vital statistics system of the National Center for Health Statistics and the National Electronic Injury Surveillance System) do tally the number of children killed or injured in both non-traffic as well as traffic areas. However, these systems do not capture many details concerning the cause or nature of the crash event. No surveillance system currently reports enough details of the crash or environment to suggest road engineering improvements at crash sites. Surveillance information is sorely needed that describes for each child injured the precise location and circumstances of the crash; the volume, complexity,