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Children's Height and Injury Risk With Child Restraint Systems
Hsuan-Fan Tung1, Jen-Fu Huang2,3,4, Jhih-Ming Tang2
1Division of Pediatric Surgery, Jen-Ai Hospital, Dali Branch, Taichung, Taiwan.
Insights
Child restraint systems (CRSs) may increase head and neck injuries in children compared to seat belts (SBs). Injury patterns vary non-linearly with height, suggesting current transition thresholds may be inadequate.
Area of Science:
- Pediatric trauma
- Occupant protection
- Injury biomechanics
Background:
- Child restraint systems (CRSs) and seat belts (SBs) transition is based on fixed age/height.
- Height-specific injury patterns in children using CRSs vs. SBs are not well-characterized.
Purpose of the Study:
- Examine height-associated regional injury patterns in children from motor vehicle crashes.
- Assess injury pattern variations between CRS and SB users based on height.
Main Methods:
- Retrospective cohort study of 6503 children (6-11 years) from the Trauma Quality Improvement Program (2017-2020).
- Used inverse probability of treatment weighting and restricted cubic spline modeling for height-dependent analysis.
- Evaluated severe regional injuries (Abbreviated Injury Scale score ≥3).
Main Results:
- CRS use was linked to higher severe head/neck and spinal cord injuries compared to SBs.
- A nonlinear, height-dependent association between restraint type and injury patterns was observed.
- Children 110-140 cm using CRSs had more severe spinal/thoracic injuries but fewer abdominal injuries.
Conclusions:
- The association between child restraint devices and injury patterns is height-dependent and nonlinear.
- A shift in injury anatomy occurs across the 110-140 cm height range.
- Uniform age/height thresholds may not fully capture growth-specific vulnerabilities in child occupant protection.
Importance:
The transition from child restraint systems (CRSs) to seat belts (SBs) is often based on fixed age or height thresholds. However, the association between height and injury patterns among injured children remains insufficiently characterized within clinical trauma settings.
Objectives:
To examine the association between height and regional injury patterns among children involved in motor vehicle crashes evaluated at trauma centers and to assess how these patterns vary between CRS and SB users.
Design, Setting, And Participants:
This retrospective cohort study of children 6 to 11 years old who were involved in motor vehicle crashes evaluated at trauma centers used inverse probability of treatment weighting with gradient boosting machine-derived propensity scores and restricted cubic spline modeling to evaluate height-dependent associations between protective device and injury pattern. Data from the American College of Surgeons-Trauma Quality Improvement Program (2017-2020) were used. Statistical analyses were conducted between June 1, and August 31, 2025.
Main Outcomes And Measures:
Prevalence of severe regional injuries (Abbreviated Injury Scale score ≥3).
Results:
A total of 6503 children aged 6 to 11 years (mean [SD] age, 8.48 [1.69] years; 3251 male [50.0%], 3252 female [50.0%]) were identified from the database; 1066 (16.4%) had used a CRS. After weighting, CRS use was associated with a higher prevalence of severe head and neck injury (13.9% vs 10.5%; odds ratio, 1.41; 95% CI, 1.06-1.88, P = .02) and severe spinal cord injury (2.9% vs 1.8%; odds ratio, 1.70; 95% CI, 1.02-2.84, P = .04) compared with SB use. Height-dependent analysis revealed a nonlinear association between restraint type and injury patterns. Among children measuring 110 to 140 cm, CRS use was associated with a higher prevalence of severe spinal and thoracic injuries, whereas the prevalence of abdominal injury was lower within the same height range.
Conclusions And Relevance:
In this cohort study, the association between protective devices and injury patterns was height dependent and nonlinear. A shift in regional injury anatomy was observed across the 110- to 140-cm spectrum, suggesting that a uniform threshold may not adequately characterize growth-specific vulnerabilities.
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