Vehicle Occupant Safety: The Pediatrician's Responsibility

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* Reading of the tuberculin test should be done by the physician

or by one of his employees who has been trained to do so.

Interpretation of the test by the parents is not satisfactory.

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PEDIATRICS Vol. 64 No. 6 December 1979

positive tuberculin reactions is less than 1%’; this

recommendation is based on the assumption that

discovery of cases at this low rate will not have

epidemiologic impact (italics added). On the other

hand, in a joint statement by the Section on

Dis-eases of the Chest and the Committee on Infectious

Diseases, the American Academy of Pediatrics points out that

Since the disease (tuberculosis) may cause serious dis-ability or even death any yield is important. For the

pediatrician’s office or out-patient clinic, an annual or

bienniel tuberculin test, unless local circumstances clearly

indicate otherwise is appropriate. The importance of the

tuberculin test properly done measured and recorded

represents a major diagnostic tool in the recognition of tuberculosis.

Furthermore, as indicated in a statement by the

Section on Diseases of the Chest, the American

Academy of Pediatrics3 asserts that

It (tuberculin test) is, of course, always indicated when

there has been known contact with a tuberculous adult.

In the latter instance, if the tuberculin reaction is negative the test should be repeated eight to ten weeks after removal of the contact. If the child remains in contact with a tuberculous adult the tuberculin test should be repeated at three-month intervals.

Why is routine use of the tuberculin skin test so important? It has been well established that the child with primary tuberculosis who receives a one-year course of isoniazid prophylaxis wifi almost never develop tuberculous meningitis, miiary tu-berculosis, or the other serious forms of the disease.4

However, the child with primary tuberculosis can

be identified only by means of the tuberculin test. Children with uncomplicated primary tuberculosis rarely have symptoms.5 The failure of the physician to utilize the tuberculin test on a routine basis will preclude establishment of the diagnosis in the many

symptomless children whose contact with a

tuber-culous adult is not known.

REFERENCES

EDWIN L. KENDIG, JR, MD St Mary’s Hospital

Richmond, Virginia

1. Seventh report. WHO Tech Rep Ser 195:13, 1960 2. Steigman AJ, Kendig EL Jr: Frequency oftuberculin testing.

Pediatrics 56:160, 1975

3. AAP Section on Diseases of the Chest: The tuberculin test.

Pediatrics 54:628, 1974

4. Mount W, Ferebee SH: Preventive effects of isoniazid in the treatment of tuberculosis in children. N Engl JMed 265:713, 1961

5. Kendig EL Jr: Tuberculosis among children in the United

States. Pediatrics 62:269, 1978

The following two commentaries, triggered by

Baker’s epidemiologic study, present somewhat

different points of view. Widome urges

pediatri-cians to incorporate accident prevention in their

practice. Starfield points out the limited

informa-tion on its effectiveness. This may appear to be a

contradiction and represent confusion in the

Edi-tonal Office, but we believe both authors present

the state of affairs in accident prevention as it

exists today. Clinicians should do more but we

need data on effectiveness of such action.

Clini-cians can weigh the evidence and their own

inter-est, and make up their own minds as to how much

they will want to incorporate accident prevention

into their practice.

R.J.H.

Vehicle

Occupant

Safety:

The

Pediatrician’s

Responsibility

The preeminent position of the automobile as a childhood health hazard has been recently

empha-sized in both the medical and lay 2

Con-trary to the common impression, of the

approxi-mately 5,000 Americans below the age of 15 who die

in traffic accidents each year, a majority are vehicle

occupants.’ Baker, in this issue of Pediatrics (p

860) reemphasizes the magnitude of this public

health problem and provides us with important

additional information regarding the epidemiology

of this “disease.” Her vital statistics analysis

dem-onstrates that it is during the earliest months of

infancy, those months when, presumably, children

are most carefully supervised by their parents and most dependent on them for their survival, that

they are most likely to die in the automobile. As

Baker concludes, something about the quality of exposure rather than its quantity must be sought to explain the data.

A particularly risky and prevalent mode of auto-mobile travel for young infants is to be held on the lap of an unrestrained adult in the front seat.4 Recent crash tests conducted by the Insurance In-stitute for Highway Safety well demonstrate the mechanism of injury in this high risk travel arrange-ment.5 Upon frontal impact, adult and child con-tinue their forward motion unimpeded until

con-tacting the dashboard and windshield. The child is

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COMMENTARIES 967

crushed between the parent and the interior sur-faces of the car. Even when the adult is belted,

forces commonly encountered in even moderate

speed crashes are such that the average adult would

be unable to prevent the child from impacting the

dashboard or windshield.6 In a large observational survey, Williams7 found 145 of 344 or 42% of infants

less than 1 year of age to be traveling on a lap.

Reisinger and Williams8 observed that during the

infant’s first car ride, the ride home from the

hos-pital, nine out of ten times, parents choose the high

risk on-lap mode to transport their precious cargo. Proper use of approved, crash-tested, infant car

seats provides the best currently available

protec-tion for infants in automobiles.’ Such protection was provided to only 10% of infants observed by Williams.7

Over the past few years, Baker and others in the

field of injury research have provided an impressive

descriptive epidemiology of highway morbidity and

mortality. What, then is the appropriate role of the

pediatrician in society’s response to the problem?

Given a disease of such high incidence and a host

so susceptible so early in life, and given the

pedia-trician’s responsibility as continuing health

super-visor from birth onward, it is imperative that

pedia-tricians devote substantial energies toward

encour-aging all new parents to protect their infants in car

seats and thereby “immunize” them. This, however,

is clearly not being done. In a 1970 survey of

prac-ticing pediatricians in Monroe County, New York,

Pless9 found that 42% of respondents never dis-cussed automobile safety with their patients. A more recent 1977 parent survey in St Louis revealed that only a dismal 5% of parents of small infants recalled their physicians’ mentioning automobile

restraint

Multiple reasons exist for this discrepancy be-tween health need and service provided. I suspect that some believe that auto safety is more properly in the domain of the schools and the public service

advertising media. But, clearly the schools are quite

remote from parents of infants and pre-schoolers.

Media advertising as an isolated safety education strategy is also unlikely to have much impact. In a

controlled trial of TV commercials aimed at

en-couraging seat belt use, Robertson et al” found no

effect on observed usage.

There are others who do not counsel their

pa-tients’ parents for lack of information. A glance at the latest editions of the standard pediatric texts reminds one that this vital topic is quite removed from the mainstream of traditional pediatrics. The thorough discussion of vehicle occupant protection

in the new Hoekelman text3 is gratifying. My

over-stuffed reprint file on the subject, much of it from

recent pediatric journals also gives me reason for

optimism. However, it is imperative that we begin

to incorporate this information into pediatric and

general medical education. Likewise, strategies to prevent highway injuries must be stressed in post-graduate continuing education activities.

There are some who fail to counsel parents in

these matters in the belief that safety education

efforts are unlikely to have a sufficient impact to

justify the time investment. They find support for

this viewpoint in a recent study’2 in which there

was no difference in restraint use between a

physi-cian-counseled group of parents and a control group. However, studies do not provide a clear

consensus regarding physician effectiveness in changing health-related behavior. Bass and

Wil-son,’3 in a well-designed early study, demonstrated

favorable changes in behavior (installation of seat belts) with minimal investment of the pediatrician’s time.

Data regarding the precise factors associated with

the physician’s effectiveness as a health educator

are scarce.’4 Multiple variables interplay. We must

remember that the pediatrician does not approach

his responsibility as educator in a laboratory vac-uum. For example, other injury control strategies,

by themselves relatively ineffective, may act

syn-ergistically with personal physician counseling. We

need to examine physician impact in communities

that have car-seat loan programs or media

cam-paigns and in those states that adopt child restraint use legislation.’5

Furthermore, all studies are flawed to the extent that they cannot exactly duplicate the variables

within a pediatric practice. Others cannot

repro-duce your own style of practice, your own patient

population, and the quality of the relationship you

establish with your patients. Aware of this, we rightly set our priorities and decide how to spend our time based on our judgement as physicians, not statisticians. We have the ability to individualize

our approach from patient to patient in order to

maximize our effectiveness; this is the art of

medi-cine. There are some parents who will get our

message early and others who will never get it.

Improved passive restraint systems in the auto-mobile, such as air bags, are potentially the

pedia-trician’s greatest ally: protection is not dependent

on patient and parent compliance.’6 Meanwhile, the

highway epidemic continues unabated, threatening

most, our youngest patients. As pediatricians it is our mandate to respond aggressively with the tools

at hand.

MARK D. WIDOME, MD, MPH

The Milton S. Hershey Medical Center

Hershey, Pennsylvania

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968 PEDIATRICS Vol. 64 No. 6 December 1979 REFERENCES

1. Charles 5: Stepchild of American pediatrics: child transpor-tation safety. Pediatr Ann 6:726, 1977

2. Alter 5: Unsafe at any age, children and car safety: Parents

Magazine, February 1979

3. Mofenson HC, Greensher J: Childhood accidents, in

Hoe-kelman RA, Blatman 5, Brunell PA, et al(eds): Principals of Pediatrics, Health Care of the Young. New York, Mc-Graw-Hill, 1978, pp 1791-1823

4. Williams AF: Warning: In cars, parents may be hazardous to their children’s health, the hazards oflap travel. Washington, Insurance Institute for Highway Safety, 1978

5. The Highway Loss Reduction Status Report. Insurance Institute for Highway Safety. Vol 14, No 8, May 17, 1979, pp 2-7

6. Scherz RG: Restraint systems for the prevention of injury to

children in automobile accidents. Am J Public Health 66: 451, 1976

7. Williams AF: Observed child restraint use in automobiles.

Am JDis Child 130:1311, 1976

8. Reisinger KS, Williams AF: Evaluation ofprograms designed to increase the protection of infants in cars. Pediatrics 62: 280, 1978

9. Pless IB, Roughmann K, Algranati P: The prevention of

injuries to children in automobiles. Pediatrics 49:420, 1972

10. Simons PS: Failure of pediatricians to provide automobile

restraint information to parents. Pediatrics 60:646, 1977

11. Robertson LS, Kelly AB, O’Neill B, et al: A controlled study

of the effect of television messages on safety belt use. Am J Public Health 64:1071, 1974

12. Miller JR, Pless IB: Child automobile restraints: Evaluation of health education. Pediatrics 59:907, 1977

13. Bass LW, Wilson TR: The pediatricians’ influence in private

practice measured by a controlled seat belt study. Pediatrics

33:700, 1964

14. Casey P, Sharp M, Loda F: Child-health supervision for children under 2 years of age: A review of its content and effectiveness. J Pediatr 95:1, 1979

15. Tennessee Code Annotated Section 59-930 as amended by House Bill 300, The Tennessee Child Passenger Protection Act, 1977

16. Williams AF: Air bags and out-of-position children-a sur-vey. Accident Anal Prey 8:143, 1976

Love,

Logic,

and

Other

Approaches

to Prevention

Baker’s ‘data on accidents to passengers in motor vehicles inform us that infants, particularly young

infants, are at greatest risk of death. Most pediatri-cians would have guessed otherwise, knowing that

toddlers’ newly acquired locomotion skills,

indepen-dence, and inquisitiveness generally make them the most vulnerable target. Why, in this case, is the youngest most likely to suffer?

It is possible that young infants are at greatest

risk because they are passengers in cars more often

than older children, but Baker’ cites evidence that

they are actually less likely to travel in cars than older children. This means that the youngest, ex-posure for exposure, are even more at risk, probably because they are more vulnerable anatomically and

because they are held in arms rather than in proper

infant carriers.

Untoward events such as deaths, injuries, and illnesses occur because there is an external insult and a behavioral or biologic reaction to the insult. These behavioral or biologic reactions are, in turn,

conditioned by biosocial antecedents that

deter-mine how individuals under stress will react. Infant deaths from car accidents occur because of a com-bination of factors, including those which caused the accident and those due to a failure of the infant to be properly restrained. Failure to use adequate

restraints is, in turn, a result of many social,

envi-ronmental, and probably genetic factors.

Prevention can focus on any of these causes. Medical care itself often is aimed at inhibiting the

progress of ifiness or injury after both the insult and

the behavioral-biologic reaction have occurred.

However, some medical care interventions (ie,

im-munizations) actually alter the biologic response.

Recently, attention has shifted toward techniques that alter behavioral responses. Langlie2

demon-strated how difficult this process is likely to be. Her data show that the performance of certain health behaviors is not well correlated with the

perform-ance of others, and there are some notable inverse

correlations for some people, whom she calls

“in-consistents.” For these “inconsistents,” driving be-havior, pedestrian behavior, personal hygiene, smoking, and seat belt use are not related to their

seeking of medical checkups, dental care,

immuni-zation behavior, exercise patterns, or nutrition

habits. One good health practice does not beget

another, because each one is a product of many

influences, most of which are not evident to the

practitioner and may not even be conscious for the particular individual. This undoubtedly accounts for the disappointing results of physicians’ efforts to convince patients to wear seat belts.3

Noble attempts to mandate behavior by law run afoul of competing human instincts, as was evident when Tennessee legislators added an amendment

exempting children “held in the arms of an older person” from a 1968 law requiring children under

the age of 4 to ride restrained.4 As a result, use of

child restraints increased from 8% before the law to a maximum of only 15% after it. In a recent con-trolled trial parents were given, at no cost to them, infant carriers upon discharge from the nursery. All infants were strapped in by the nurse when the

family departed from the hospital, but many were

removed from the restraints once the car had left

the hospital grounds and was out of range of all but

the unobtrusive observer from the study staff. Why do mothers-or fathers-hold their infants in their laps even though the impact of an accident will tear an infant from the arms of eventhe

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1979;64;966

Pediatrics

Mark D. Widome