In the legal cases I have consulted in, often it is claimed that children cannot be injured in motor vehicle collisions, and therefore they do not require any treatment. To escalate this perspective, I have consulted in cases where the chiropractor treating such a child is accused of committing fraud, a crime. Occasionally, these cases will even progress to courtroom trial.
Pertaining to the causes of death of our children, the following statistics were compiled from the United States Centers for Disease Control (CDC) National Center for Health Statistics (NCHS).
Most Prevalent Cause of Death
Most Prevalent Cause of Accidental Death
1 – 4
Motor Vehicle Accident
5 – 9
Motor Vehicle Accident
10 – 14
Motor Vehicle Accident
15 – 24
Motor Vehicle Accident
In addition, the second leading cause for accidental death in children < 1 year of age was motor vehicle accident.
Based upon these statistics, it seems ludicrous to claim that children cannot be injured in motor vehicle crashes.
Recently, a new-graduate chiropractor asked my advice regarding the management of an infant who had been injured in a motor vehicle collision. The insurance adjuster controlling the case stated: “our chiropractic consultant informs us that it is unlikely that an infant can be injured in a motor vehicle collision and therefore treatment of an infant after a motor vehicle collision is not likely to be reasonable or necessary.” Chiropractors that treat motor vehicle collision injuries, including those to children, are probably familiar with this attitude.
More than a decade ago, I had the opportunity to testify in a case in which a 7-year-old child and a 22-month-old toddler were injured in a motor vehicle collision. The children were treated successfully by a chiropractor. The mother of the children was adamant that the chiropractic care her children received was necessary for the improvement of their condition caused by the motor vehicle collision. Yet the case went to trial because of the attitude by the insurance company and their chiropractic paper reviewer that the children did not need the amount of care they received; or that the treating chiropractor’s records could not justify the care that he gave to the children.
One of the consequences of this trial was my generation of a chapter in a book, Pediatric Chiropractic, edited by Claudia Anrig and Greg Plaugher, Williams and Wilkins, 1998. The second edition of this book is due out later this year (2011). I did an extensive review of the literature pertaining to injuries to children from motor vehicle collisions, using more than 200 references. This article is a summary of some of the main principles of child injuries from motor vehicle collisions.
Many of the concepts that pertain to adults in motor vehicle collisions also apply to children, including the basic principles of inertial acceleration/deceleration injuries, patient preparedness prior to impact, and rotation of the head or trunk prior to impact. Overall, studies indicate that the pattern of injury among children in motor vehicle collisions is similar to those of the general population.
However, injuries to children in motor vehicle collisions can be unique as a consequence of the following reasons:
1) Child safety seats.
2) The increased size of the child’s head as a proportion of the overall body mass.
3) The child’s ability to be restrained while facing rearward.
4) The use of seat belts that are designed for adults.
5) The use of lap belts without shoulder harnesses.
6) The reduced height of the developing pediatric pelvis.
7) The underdevelopment of the pediatric anterior superior iliac spine.
8) The higher center of gravity for the pediatric body.
9) The diminished development and strength of various spinal musculoskeletal components.
10) The ability to sit on the lap of adults when traveling in a vehicle.
11) The probability that a child injured in a motor vehicle collision is unprepared for the collision, or caught by surprise.
12) The more unfavorable head diameter to neck diameter ratio, as compared to adults.
I believe that each aspect (above) of this uniqueness regarding children injury during motor vehicle collisions should be understood by the health care provider so that he/she can better explain the appropriateness of treatment given to these injured children. Specifically, I believe that the health care provider should:
1) Understand the biomechanical uniqueness of injury for each age group of children involved in a motor vehicle collision.
2) Learn how to examine and document pediatric trauma, including daily charting.
3) Become proficient at the treatment management of injuries in such small bodies.
I will briefly review these concepts below. A more detailed explanation
with graphics and references is available in the next edition of Chiropractic Pediatrics, edited by Anrig and Plaugher, 2011.
Anthropometric Variables For Children
The increased size of the pediatric head as a proportion of the overall body mass influences the location and type of injuries sustained by children involved in a motor vehicle collision. At birth the head is proportionately larger and accounts for approximately 25% of the body length as compared with 15% in the adult. Consequently in motor vehicle collisions it is the head and cervical spine of the newborn that is most likely to be injured in a motor vehicle collision.
Toddlers up to 3 years of age continue to have disproportionately large head size and higher centers of gravity, and, therefore, also tend to sustain head injuries. Rear facing child safety seats tend to restrict forward head movement and prevent young heads from striking the interior of the vehicle.
The reduced height of the developing pediatric pelvis predisposes children to unique injury. Every anatomical part of children is reduced in size as compared to the adult, including the height of their pelvis. This reduced height increases the probability for a lap belt to slip over the top of the brim of the pelvis during a motor vehicle collision, resulting in more serious abdominal visceral and lumbar spine fulcrum injuries.
Anterior Superior Iliac Spine
The underdevelopment of the pediatric anterior superior iliac spine increases the probability for unique injury for young patients. Children younger than 10 years of age have less development of the anterior superior iliac spine as compared to the adult. This increases the probability for a lap belt to slip over the top of the brim of the pelvis during a motor vehicle collision, resulting in more serious abdominal visceral and lumbar spine fulcrum injuries.
Center of Gravity
The higher center of gravity for the pediatric body changes the nature and location of injury. Children have a relatively higher center of gravity and a greater tendency for the lap belt to ride cephalad to across the abdomen as compared to adults. This elevated position allows the child to submarine forward under the belt, increasing injury to the abdomen and/or the spine.
4-9 year olds have a relatively lower center of gravity in contrast to infants and toddlers, closer to the umbilicus but still above the lap belt. Yet the iliac crests are underdeveloped in this age group and the lap belt tends to slip up over the bony pelvis and onto the abdomen. With a rapid deceleration event, with a greater proportion of body mass above the lap belt and with the lap belt already in contact with the abdomen, “jackknifing” occurs with compression and injury of abdominal viscera. The hallmark indicator of abdominal viscera and mid-lumbar spine injury is abdominal or flank ecchymosis.
The diminished development and strength of various spinal musculoskeletal components increases the probability of significant tissue injury in children. Children have less well developed muscle and connective tissue, which increases probabilities for spinal joint and neurological injury.
Primarily because of the shortness of their pelvis and under development of their anterior superior iliac spine, children, especially those between ages 4-9, have a higher probability of having their torso slip under the lap belt during a motor vehicle collision thus sustaining associated injuries. This is termed submarining. 10-14 year olds have a better developed anterior superior iliac spine, a “taller” pelvis, and consequently experience submarining less often.
Child on Adult Lap
A parent should never hold an infant or child on their lap while riding in a motor vehicle. In a front-end collision at 25 miles per hour at impact, the forces on the baby may reach 20 G. If the weight of the baby is 7.5 pounds its effective weight raises to 150 pounds (7.5 lb X 20 G = 150 lb). If the weight of the child is 25 pounds its effective weight raises to 500 pounds (25 lb X 20 G = 500 lb). It is impossible for the adult to hold the baby under those circumstances. To hold a 10-pound infant at 30 mph the adult strength required would be roughly that needed to lift 300 pounds one foot off the ground.
If the adult holder is also unrestrained, their body may crush the baby against the dashboard or the back of the front seat. When the adult is not restrained, the infant is crushed by a force equal to the mass of the adult multiplied by the square of the speed and divided by two. When the child is held in the arms of an adult and both are not using belt restraints, the weight of the adult is added to the child’s weight as they are thrown forward. The adult will crush the child with an incredible force.
Studies indicate that many infants under the age of one travel in cars while being carried on adult laps.
Careful observation of anthropomorphic video graphically shows that even though the principles of inertia apply to children, they are different, especially when the child is less than 40 lbs. When young children are unrestrained, their entire body functions as a single piece of inertial mass, and will fly through the air during motor vehicle collisions, becoming “human projectiles.” Injuries include crashing through the glass and being thrown from the vehicle, as well as colliding with the inside of the vehicle. In a moving vehicle that is stopped suddenly by an impact, an unrestrained smaller child will continue to move at the original vehicle speed until stopped by the interior of the vehicle. Even in low speed collisions an unrestrained child becomes a human projectile.
Studies indicate that children run more risk of injury or death traveling unrestrained in a vehicle than by being hit by a vehicle as a pedestrian. It is estimated that disabling to fatal injuries to these children would decrease by 78-91% if the child was using a restraint system during motor vehicle collisions. It is estimated that 49% of child passenger deaths from motor vehicle collisions could have been prevented with appropriate child restraint use. Children not in safety restraint devices are 11 times more likely to die in a motor vehicle collision than children placed in restraints. Unrestrained children are three times more likely to sustain a brain injury than restrained children.
Children in Restraints
Reduction In Injuries:
The April 2011 edition of the journal Pediatrics published the policy recommendations of the Committee on Injury, Violence, and Poison Prevention pertaining to Child Passenger Safety in motor vehicle collisions. This project used twenty-two expert collaborators. The abstract of their work project includes:
Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of children 4 years and older.
This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence:
1) Rear-facing car safety seats for most infants up to 2 years of age.