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Documentation:FIB book/Neck Injuries in Pediatric Vehicle Occupants During Frontal Collisions

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Importance of Topic

Motor vehicle collisions have emerged as an important concern in child safety research, as they pose a serious threat to children’s health. According to Transport Canada, approximately 4,500 children (aged 5 to 14) are injured in motor vehicle accidents each year, with over 200 suffering severe injuries[1]. The research conducted by S. Caskey et al. further identifies that motor vehicle collisions are “a significant source of pediatric mortality and morbidity”. In particular, frontal collisions account for 67.2% of all collisions[1][2]. Children have the fulcrum point of flexion in their cervical spine which increases tensile loads on the C2-C3 vertebrae during frontal impacts. Therefore, it is necessary to conduct in-depth studies on the mechanisms and distribution characteristics of child injuries in frontal collisions.

Among all types of injuries in motor vehicle crashes, neck injuries deserve particular attention due to their frequency and severity. A. Bener et al. reported that in most developed and developing countries, where cars are a common source of transportation, head and neck injuries in traffic crashes are among the most common causes of morbidity and mortality[3]. Given the critical role of the neck in the human body, such injuries are often more severe and accompanied by long-term consequences. In addition to whiplash injuries, neck trauma also includes neck fractures and cervical spinal cord injuries, which can be fatal or result in paralysis[4]. These severe outcomes not only negatively affect the well-being of victims and their families but also impose a large burden on healthcare and social resources.

As shown in Fig. 1, children have proportionally larger heads relative to their bodies[5]. This case is most obvious when comparing the left and rightmost image elements but can still be seen in the intermediary cases as the body segment lines are at no point linear. The approximate slope of the lines shows the comparatively greater growth designated by the top two lines compared to, most clearly, the bottom line which is nearly flat. These changes in growth proposition means that younger children also have  underdeveloped cervical structures, and are particularly prone to neck injuries during frontal impacts. With a relatively heavy head on a small body, a child’s neck experiences higher torques during a crash, making it more susceptible to flexion-extension injuries. Additionally, children’s lax ligaments allow a greater degree of spinal mobility, and their immature musculature makes it difficult to maintain neck stability during impact[5]. These anatomical and biomechanical differences are a key component in the  significantly different injury rates and patterns between children and adults in vehicle collisions. Mallory et al.’s research based on the National Trauma Data Bank (NTDB) found that a higher proportion of children aged 8 to 12 years sustain upper spinal injuries in car crashes than adults. In particular, catastrophic atlanto-occipital dislocations and vertebral body fractures are more common in this age group[6].

Therefore, it is necessary to conduct an epidemiological study on the incidence and patterns of cervical injuries in children during frontal crashes under different conditions. Some challenges present themselves, such as small sample sizes, older datasets and missing variables collected, such as posture or belt fit caused by limited ATD testing possibilities. The importance of the research work can be summarized as follows:

Fig. 1.  The proportional changes in body segments with age[7]

Academic significance: This literature review compares research on children’s neck injuries in vehicle collisions, focusing on injury causes and locations, collision testing and modeling, and pediatric neck biomechanics. This provides a more comprehensive and integrated perspective to support future research in this field.

Engineering significance: Also summarizing the working principles, practical effectiveness and limitations of booster seats and other restraint systems, providing valuable references for engineers to optimize restraint design.

Social significance: It exhibits the extent and severity of neck injuries sustained by children in vehicle collisions and analyzes the effects of how improper restraint use can exacerbate these injuries. It also contributes to raising public awareness of child passenger safety and offers significant guidance for policymakers to improve traffic safety regulations.  Policy makers can focus on targeting areas like improved belt fit guidelines, more enforcement of child restraint use, and standardized reporting of child postures in crash datasets.

Past Work

Pediatric Neck Injury

The research focuses on children's neck injuries, especially cervical spine injury, due to their high risk of fatality. Cervical spine injuries are more common in children, with a percentage making up between  60% to 80% of pediatric spinal injuries, while only 30% to 40% of adult spinal injuries are deemed cervical spine injuries. The difference stems from anatomical discrepancies, as child heads are relatively large compared to their bodies and their spines are highly flexible. As a result, the higher center of gravity and fulcrum of the neck lead to a higher risk of neck injuries[8][9].

Leonard et al. conducted a cohort study comparing hospitalized cases of cervical spine injury across 17 different hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) in children aged younger than 16 years old[9]. They concluded that the majority of children aged between 2 to 7 years old had suffered from axial injuries (C1-C2) while those aged 8 to 15 years old often had subaxial (C3-C7) vertebral body fractures. Additionally, motor vehicle collisions (MVCs) are the most common cause of cervical spine injury in children under 2 years of age, when unrestrained or improper use of the restraints is suspected[9].

To rule out previous pediatric cervical spine injury from child victims, imaging and information on trauma history, along with associated high-risk injuries in the head or neck region, should be considered. Gopinathan et al. suggested that all suspected injured children under 3 years old should undergo imaging, while post-injury symptoms should be taken into account in older children in addition to imaging[8]. This distinction is mainly due to how the cervical spine develops. Younger children have larger heads, more flexible ligaments, and incompletely ossified vertebrae, which makes serious upper-cervical injuries harder to detect clinically. Mallory et al. similarly reported higher rates of upper-cervical injuries in the 0 to 7 age group, including more C0–C1 dislocations. In older children, injury patterns shift toward lower cervical and thoracic levels and tend to present more clearly, so symptoms become more reliable as this recommendation applies specifically to cervical spine injuries.

Booster Seat and Restraint Effectiveness in Pediatric Occupants

In order to prevent the risk of injury and minimize injury severity, vehicle restraints such as seatbelts help transfer the force to the bony structure of the body, such as the pelvis and clavicle, which are in contact with the restraint. Belt positioning is crucial to safety, as forces acting on parts of the body other than the skeleton can result in injuries. Despite this, the use of a seatbelt alone might pose some danger to a child's growing body, as the force transmission sites are not aligned with the skeletal structure. To solve this issue, booster seats are designed to adjust the occupant's position so that the force of the seatbelt is directed onto the skeleton rather than soft tissues when used properly as shown in Fig. 2 and discussed below.

For one to assess the effectiveness of booster seats in reducing injuries in pediatric occupants from 0 to 10 years old, Ma et al. analyzed data reported to the NASS CDS (National Automotive Sampling System Crashworthiness Data System) from 1998 to 2009 for three restraint conditions: booster seats combined with seatbelts, only seatbelts, and no restraint[10]. The analysis resulted in children using seatbelts in combination with the booster seat being less likely to experience overall injury in most of the body regions except the neck, compared to the unrestrained group. Between seatbelt use with and without a booster seat, the risk of injury (Injury Severity Score: ISS > 0, Abbreviated Injury Scale: AIS > 2+) was equal; however, the risk of neck and thorax injury was higher in the booster seat group. Regarding the contradictory results, the researchers noted that the database did not capture child height/weight or whether restraints were used correctly. These factors can alter belt fit and crash biomechanics—for example, a misplaced shoulder belt can allow greater forward translation of the torso and increase neck loading (e.g., Nij). Ma et al. suggested that such restraint-fit issues may help explain the elevated neck and thorax injury risks and should be examined further[11].

Later, Anderson et al. conducted a study similar to that of Ma et al. to investigate the effectiveness of booster seat use among children in an older age group[11]. The data were acquired from the Washington State Department of Transportation (WSDOT) on MVCs involving pediatric occupants aged 8 to 12 years old from 2002 to 2015. The team compared children who were restrained in a booster seat with those who were restrained in the vehicle seatbelt. A key methodological difference is that Anderson et al. performed in-depth crash reconstructions using detailed police and crash reports, while Ma et al. relied on the national NASS database, which provides broader sampling but less detail on individual crash dynamics and restraint misuse. These methodological differences could influence their findings, as in-depth reconstruction may capture restraint fit, crash severity, and misuse more accurately, whereas NASS-based analyses may miss these nuances. They concluded that child occupants in this age range are less likely to be injured in MVCs when restrained in a booster seat than in a seatbelt alone[10].

Another research group compared booster seats and seatbelts, focusing on the reduction in injuries and mortality among pediatric occupants aged 4 to 8 years. Given the limited evidence on the association between booster seat and seatbelt use and reductions in injury and fatality, they highlighted the need for up-to-date observational studies on the topic[12].

Improper Restraint Use, Different Types of Restraints, and Neck Injury

In addition to comparing vehicle seatbelts and booster seats, the appropriate use of restraints for the child’s age and size should be considered, as improper use could lead to serious injury as illustrated in Fig.2 Brown et al. investigated data on serious injury associated with suboptimal restraint use in child passengers from 2 to 8 years of age. From the data between 2000 and 2005, 66 percent of subjects were restrained with an adult seatbelt, while only 25 percent were restrained with a forward-facing child seat or booster seat[13]. The retrospective case review showed that children who sustained serious injury were all inappropriately restrained, emphasizing the need to promote proper use of restraints.

Furthermore, it is important to note that restraint systems do not guarantee complete injury prevention. They are likely to reduce the overall severity of the injury, though some minor injuries can still occur.  Zonfrillo et al. focused on the MVC-related spinal injuries in restrained pediatric occupants. The data of passengers aged from 0 to 17 years old with at least one AIS 2+ from the Crash Injury Research and Engineering Network (CIREN) were used in the case series[14]. According to their report, spinal injuries, including cervical, thoracic, and lumbar, were frequently found in a high-speed frontal crash case and were generally from the flexion or lateral bending over the vehicle belt or child seat harness, especially in occupants less than 12 years old. Moreover, cervical spine injuries were mostly found in children aged below 7 who were restrained with a harness (aged 21 to 24 months), and a shoulder belt (ages 3 to 5 years), while lumbar spine injuries were found in occupants aged 7 years old restrained with a lap belt[14]. Another study by Ernat et al. was focused on the pattern of spine injuries associated with child restraint types. They found an association between seatbelt use and a lower risk of cervical spine injury compared with car seats or booster seats[15]. Nevertheless, it should be emphasized that the restraint used was not completely the cause of spine injury since the data were from high-speed crashes or cases lacking further information, such as speed and direction[14][15].

Pediatric Dummy Crash Test Associated with Neck Injury

Pediatric crash test dummies also play a significant role in evaluating different types of restraints and seating posture. Sherwood et al. conducted one of the most detailed evaluations of pediatric neck injury risk using the Hybrid III six-year-old dummy to simulate booster-seated children in frontal crashes[16]. The team performed sled tests at 49 km/h under three restraint setups—high-back booster with seatbelt, low-back booster with seatbelt, and a standard three-point belt—replicating FMVSS 213 conditions. An example of the collected neck load data from the upper and lower sensors were compared to cadaver experiments by Kallieris et al. to assess biofidelity of the ATD[17]. The results were determined from adults and had the dummy exhibit strong flexion and face-to-chest contact, producing tensile peaks above the Injury Assessment Reference Value: IARV = 1890 N. Although the overall motion resembled that of cadaver tests, the Hybrid III’s stiffer thoracic spine generated higher neck moments and flexion angles, revealing that current pediatric dummies overestimate true cervical loading in real children.

Building on that work, Zonfrillo et al. analyzed reconstructed crash cases and found that younger children were more likely to experience cervical flexion and upper-thoracic injuries, while older children tended to sustain lumbar compression injuries[14]. Kapoor et al. showed that when child restraints were used incorrectly—such as forgetting the top tether or not tightening the straps—neck loads rose by about 5%, highlighting how small mistakes in setup can noticeably increase stress on the cervical spine[18].These patterns highlight how restraint geometry and posture affect how crash forces travel through the spine. Kleinberger et al. and Eppinger et al. developed the Neck Injury Criterion (Nij) to help quantify when neck forces and bending moments become unsafe[19][20]. Since these criteria were based on adult crash data, Mertz et al. later proposed scaled versions for children, but their precision remains uncertain because of limited pediatric data and the simplified design of child crash dummies[21]. These age-dependent injury patterns also highlight a limitation of current pediatric ATDs, which tend to better represent older children; their stiffer spine design and reduced cervical flexibility make them less able to reproduce the upper-cervical motion and injury modes seen in younger children.

Collectively, these findings indicate that existing anthropomorphic test devices (ATDs) and scaling approaches fail to capture the complex biomechanical behaviour of the pediatric cervical spine. They also illustrate that neck injury prediction depends strongly on both dummy biofidelity and restraint geometry, pointing to the need for next-generation child-specific models and standards.

Fig. 2. Example of correct booster-seat belt fit.[22]

Biomechanics and Mechanisms of Neck Injury in Frontal Collisions

Biomechanical research helps explain how neck injuries occur in children during frontal vehicle collisions and why injury patterns differ from those of adults. As mentioned, children have proportionally larger heads, weaker neck muscles, and more flexible cervical ligaments, which make them more prone to flexion and tensile loading during a crash. While epidemiological studies can help identify which restraint systems correlate with lower injury rates, biomechanical work focuses on the physical mechanisms that generate these injuries and how restraint geometry or misuse contributes to them.

Simulation-based research has since refined these concepts. Kapoor et al. used finite element modelling to study how restraint misuse, such as loose belts, twisted harnesses, or reclined seats, affects cervical loading in frontal crashes[18]. At the same time, they found that improper restraint alignment can significantly amplify the neck tension and flexion forces, and these can be seen the most among smaller children, whose forward excursion increases before the belt engages. Some of these effects are shown in Fig. 2, created by the National Center for Injury Prevention and Control (NCIPC), where they demonstrate how booster seats can help with proper restraint alignment. In the “good fit” scenario, the booster raises the child so the shoulder belt sits across the mid-shoulder and chest, and the lap belt remains low on the upper thighs. This keeps forces travelling through stronger bony structures and maintains a low belt path, reducing the moment arm and the bending forces that reach the cervical spine.

In the “bad fit” scenario, the shoulder belt is positioned too high on the neck or face and the lap belt rides onto the abdomen. This elevated belt path increases the moment arm and amplifies forward-bending forces on the neck, while the poor lap-belt placement directs loads into the abdomen instead of the pelvis.

Overall, it shows that even slight errors in restraint fit can substantially increase cervical loading, underscoring the importance of proper installation and belt positioning.

Clinical and imaging-based studies complement these mechanical models. Ernat et al. reviewed 97 pediatric spine injury cases from vehicle crashes and classified outcomes by restraint type[15]. They found that children restrained by boosters or car seats tended to have more ligamentous cervical injuries.  Those using lap or shoulder belts sustained higher rates of thoracic and lumbar fractures. Unrestrained children suffered the most severe cervical trauma. Overall, these findings highlight that restraint type influences how crash forces are distributed through the spine. The results are consistent with simulation studies showing that restraint configuration strongly affects load transmission along the spinal column.

Fig. 3. A 10-year-old Hybrid III crash test dummy in a booster seat after a frontal collision.[23]

Through crash tests and computational modelling, Hauschild et al. examined how seating posture and recline angle affect booster-seated children, and found that small changes in recline position can alter head motion and neck extension forces during frontal impacts, indicating that posture can affect injury outcomes even with proper restraint use[24]. Fig. 3 shows a 10-year-old Hybrid III positioned in a booster seat, demonstrating the typical belt geometry and posture analyzed in restraint and seating research. These setups are used to evaluate shoulder and lap belt alignment before sled testing. Overall, it emphasizes how the seated posture of an individual can influence load transfer and potential neck flexion during impact. For example, when the torso pitches forward during a frontal crash, the head continues moving due to inertia, increasing the bending moment at the neck and amplifying the extension or flexion forces acting on the cervical spine. Their results underscore the importance of changing seating position and occupant kinematics in predicting realistic neck injury outcomes.

Together, these biomechanical studies show that restraint geometry, posture, and child anatomy all influence how loads are distributed through the cervical spine during frontal crashes. They also demonstrate that current pediatric ATDs and injury criteria may underestimate actual neck loading in children. The combined evidence supports the need for improved pediatric-specific models, more biofidelic dummies, and updated injury thresholds based on real biomechanical behaviour. These insights complement epidemiological findings by explaining the mechanics behind observed injury patterns and guiding the next generation of restraint designs and safety standards.

Limitations and Debates

Despite the extensive research on pediatric injury prevention, methodological and biomechanical limitations persist, as the challenges come with examining the mechanisms of neck injury in frontal motor-vehicle collisions involving children. These limitations include issues with dataset design, sample breadth, restraint classification, and the biofidelity of crash test surrogates. Understanding these weaknesses is essential to accurately evaluate how different restraints influence cervical loading during frontal crashes. Include a sentence explicitly labelling controversies.

Transition: Restraint vs. No Restraint — Setting the Context

Before examining specific limitations, it is important to note that the use of restraints, even when imperfect, reduces the overall severity of injury compared to no use of restraint at all. Studies such as Brown et al. and Ma et al. demonstrated that unrestrained children have a far higher likelihood of sustaining serious or fatal injuries, including cervical trauma, than those restrained by booster seats or seatbelts[13][11]. However, the nature of the restraint system—its type, fit, and usage quality—significantly affects the distribution of forces during impact. The effects from improper belt routing or restraint misuse can increase localized neck loads, sometimes producing whiplash or flexion-extension injuries even when the restraint mitigates overall fatality risk[14][18]. This paradox forms the foundation for ongoing debates in pediatric crash safety research.

Epidemiological and Methodological Limitations and Gaps

Epidemiological studies from early on provided valuable population-level information, but they lacked crash-type specificity and detailed biomechanical data. An example of this occurrence is when Agran et al. analyzed injury severity among occupants 4 to 14 years old and found that restrained children experienced significantly lower overall injury severity scores than unrestrained peers[25]. However, their dataset included mixed crash orientations—side, rear, and frontal impacts—making it difficult to isolate the mechanisms of cervical injury specific to frontal collisions.

Adult-oriented lap–shoulder belts used in those studies often crossed the neck and abdomen of smaller occupants, creating poor belt routing that can transfer crash forces into the cervical spine rather than the thorax[25]. Similarly, Johnston et al. compared the restraint use categories of seatbelt vs. car seat, but they failed to include booster seat users—a crucial omission given that children aged 4 to 12 are typically in transition between car seats and adult seatbelts and thereby limit data interpretability[26]. Without this middle category, the findings could not assess whether booster seats, which improve belt geometry, also reduce neck injury risk. These early studies thus provided broad associations between restraint use and injury reduction but did not explain why or how specific restraint geometries contribute to cervical injury mechanisms such as belt height relative to the shoulder changing the experienced bending load.

More recent epidemiological and crash reconstruction studies have improved data resolution yet continue to face sample-size and data-integration limitations. Caskey et al., for example, investigated booster seat use in pediatric frontal crashes using trauma registry data[2]. However, the number of booster-seat cases were small, and few moderate or severe cervical injuries were reported. The results of this show that hospital datasets underrepresent non-fatal or mild whiplash injuries, and injury-coding systems (e.g., AIS) may not capture ligamentous or soft-tissue neck trauma[6][14]. Consequently, while the study confirmed that booster seats improve lap-belt positioning, it could not determine their specific protective effect against neck flexion and axial compression.

While Brown et al. identified a link between suboptimal restraint use and higher injury risk, their research analysis relied on coded crash observations rather than experimental data, limiting the capacity to infer biomechanical causality[13]. One can address this knowledge gap by integrating epidemiological and biomechanical studies, enabling a more mechanistic understanding of injury patterns. Overall, this study points to the importance of combining epidemiological data with biomechanical modelling to turn observed injury trends into measurable load responses. Likewise, Durbin et al. relied on parental self-reports of restraint use, which may introduce bias and assume that restraint performance is unaffected by crash severity[27]. This means that the relationship between restraint type and neck injury risk may not have been accurately captured. Anderson et al. later studied children aged 8 to 12 years old and reported no significant difference in serious or fatal injuries between booster and seatbelt users, leaving questions about at what age booster use becomes unnecessary[10].

Biomechanical and Modelling Limitations

The use of biomechanical studies offers valuable insight into how cervical loads would develop during crashes, but comes with its own limitations. For instance, Zonfrillo et al. examined severe motor vehicle collisions in the CIREN database and found that 27 cervical spine injuries among 42 occupants, however, the lack of a control group of uninjured children made it impossible to assess injury risk by restraint type[14]. Moreover, the anthropomorphic test devices (ATDs) used—such as the Hybrid III child dummies—were originally adapted from adult models, meaning they do not fully replicate the flexibility, ligamentous laxity, or segmental motion of a real pediatric cervical spine[16][21].

Sherwood et al. and Mertz et al. showed that scaled injury criteria (e.g., IARVs, Nij) often over or underestimate neck tension because they are based on adult data rather than pediatric tolerance levels[16][21]. These incorrect estimations stem from synthesized combinations of empirical data interaction in unexpected ways when attempting to adapt adult critical values to children. This biofidelity limitation also leads to uncertainty when translating dummy measurements into actual child injury risk. Kapoor et al. and Hauschild et al. reported that even minor changes in posture or belt positioning can alter measured cervical forces by as much as 20%, showing how sensitive test outcomes are to initial setup and restraint geometry, as illustrated previously in Fig. 2[18][24]. These modelling uncertainties make it difficult to establish consistent, child-specific injury thresholds.

Data Standardization and Reporting Biases

Beyond modelling challenges, inconsistent data definitions and reporting gaps remain major issues. As Bener et al. reported, whiplash and “neck distortion” injuries are often overlooked or misclassified in national databases because of differences in diagnosis, insurance documentation, and police reporting procedures[3]. Mallory et al. and Ernat et al. pointed out that hospital registries often include only patients who are admitted, excluding children with mild neck injuries or those seen in outpatient clinics[6][15]. These missing cases distort overall injury statistics and reduce comparability between studies. A universal standard for transitioning children from a booster seat to an adult seatbelt would solve this problem but requires iterative development as the gaps from missing cases are slowly filled.

Lastly, the research studies by Ma et al. and Anderson et al. found that while booster seats help reduce injuries, there has not been a universal, precise age or standard for safely transitioning to seatbelt use[10][11]. This policy gap stems from limited empirical data linking restraint configuration, delta-V (crash severity), which is the change in velocity between one object and the other after collision, the greater the change, the more severe the collision, and cervical load response—key variables needed for defining evidence-based standards.

Future Research

Fig. 4. Interior of Google driverless car from 2016[28]

Pediatric neck injury is a field where research could be conducted to a significantly greater extent. Frontal crash injury epidemiology provides a look at how child-specific restraints specifically affect injury, as reviewed above. The variety of cases arising from vehicle or environmental conditions and from the size and relative positioning of the child versus their age makes crash tests become an exercise in data extrapolation. For instance the current lack of validated pediatric neck tolerance threshold data means that adult Nij values have to be scaled to be applied to pediatric cases. As highlighted in the above section, different sources converge, suggesting multiple beneficial directions for research such as improving belt fit for different child body sizes or positioning as pointed out in Fig. 2 Such data would aid in the development of booster transition standards. Progress can be made in the development and upkeep of child-specific restraints and standards, to account specifically for torso and neck protection[25].  

To improve predictive outcomes, data on delta v and posture angle from various epidemiological studies could be reevaluated to account for age-specific effects. Studied age windows overlap but are generally hampered by treating broad age ranges as if they have similar characteristics, even though children's actual body sizes within these ranges differ[26]. Computer simulations can help fill in these data gaps or account for overlaps. In addition to age and body size, relative vehicle positioning during testing is another area that could be studied to bridge different crash scenarios and paint a more complete picture of pediatric MVC modelling of the neck and head[18]. Furthermore, as car shapes and requirements change and are updated, such as with the advent of self-driving or electric vehicles, different approaches to safety will evolve and need to be incorporated into testing and standards. Fig. 4 shows a unique car interior from a 2016 driverless car, which represents an exceptional case where pediatric safety in the equivalent of a front "driver" seat would need to be considered. The lack of a front console and classic footwells means that different variables come into effect during collisions. Removing the requirement for an adult driver also allows children to sit in the front seat which does not generally occur in current data.

Struggles in injury reporting, outlined in the limitations section, create a gap that can be addressed through targeted research and improvements in education and enforcement. Biases in insurance and police reporting create the risk of misrepresenting critical data in a battle for case-specific success on all sides of an injury. This ethical issue is important to note, because comparing the current and future costs of inaccurate injury reporting is essential for improving database accuracy[13][14].  

References

  1. ↑ 1.0 1.1 Transport Canada, Canadian Motor Vehicle Traffic Collision Statistics: 2019–2023. Government of Canada, Ottawa, ON. [Online]. Available: https://tc.canada.ca/en/road-transportation/statistics-data
  2. ↑ 2.0 2.1 S. Caskey, J. Hammond, J. Peck, M. Sardelli, and T. Atkinson, “The effect of booster seat use on pediatric injuries in motor vehicle frontal crashes,” J. Pediatr. Orthop., vol. 38, no. 7, pp. e382–e386, Aug. 2018, doi: 10.1097/BPO.0000000000001189.
  3. ↑ 3.0 3.1 A. Bener, Y. S. A. Rahman, and B. Mitra, “Incidence and severity of head and neck injuries in victims of road traffic crashes: In an economically developed country,” International Emergency Nursing, vol. 17, no. 1, pp. 52–59, Jan. 2009, doi: 10.1016/j.ienj.2008.07.007.
  4. ↑ F. Li, N.-S. Liu, H.-G. Li, B. Zhang, S.-W. Tian, M.-G. Tan, and B. Sandoz, “A review of neck injury and protection in vehicle accidents,” Transp. Saf. Environ., vol. 1, no. 2, pp. 89–105, Nov. 2019, doi: 10.1093/tse/tdz012.
  5. ↑ 5.0 5.1 D. F. Huelke, “An overview of anatomical considerations of infants and children in the adult world of automobile safety design,” Annu. Proc. Assoc. Adv. Automot. Med., vol. 42, pp. 93–113, 1998, PMCID: PMC3400202.
  6. ↑ 6.0 6.1 6.2 A. Mallory, J. Stammen, and M. Zhu, “Cervical and thoracic spine injury in pediatric motor vehicle crash passengers,” Traffic Inj. Prev., vol. 20, no. 1, pp. 84–92, Feb. 2019, doi:10.1080/15389588.2018.1529412.
  7. ↑ “Babyhood (1885)” — Wikimedia Commons. [Online]. Available: https://commons.wikimedia.org/wiki/File:Babyhood_(1885)_(14783709405).jpg (Public Domain)
  8. ↑ 8.0 8.1 N. R. Gopinathan, V. K. Viswanathan, and A. H. Crawford, "Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts," (in eng), Indian J Orthop, vol. 52, no. 5, pp. 489-500, Sep-Oct 2018, doi: 10.4103/ortho.IJOrtho_607_17.
  9. ↑ 9.0 9.1 9.2 J. R. Leonard, D. M. Jaffe, N. Kuppermann, C. S. Olsen, and J. C. Leonard, "Cervical spine injury patterns in children," (in eng), Pediatrics, vol. 133, no. 5, pp. e1179-88, May 2014, doi: 10.1542/peds.2013-3505.
  10. ↑ 10.0 10.1 10.2 10.3 D. M. Anderson, L. L. Carlson, and D. I. Rees, “Booster seat effectiveness among older children: Evidence from Washington State,” American Journal of Preventive Medicine, vol. 53, no. 2, pp. 210–215, Aug. 2017, doi: 10.1016/j.amepre.2017.02.023.
  11. ↑ 11.0 11.1 11.2 11.3 X. Ma, R. Griffin, G. McGwin, D. B. Allison, S. B. Heymsfield, W. He, and S. Zhu, “Effectiveness of booster seats compared with no restraint or seat belt alone for crash injury prevention,” Academic Emergency Medicine, vol. 20, no. 9, pp. 880–887, Sep. 2013, doi: 10.1111/acem.12204.
  12. ↑ M. Asbridge, R. Ogilvie, M. Wilson, and J. Hayden, “The impact of booster seat use on child injury and mortality: Systematic review and meta-analysis of observational studies of booster seat effectiveness,” Accident Analysis & Prevention, vol. 119, pp. 50–57, Oct. 2018, doi: 10.1016/j.aap.2018.07.004.
  13. ↑ 13.0 13.1 13.2 13.3 J. Brown, M. E. McCaskill, M. Henderson, and L. E. Bilston, "Serious injury is associated with suboptimal restraint use in child motor vehicle occupants," *Journal of Paediatrics and Child Health*, vol. 42, no. 6, pp. 345–349, 2006, doi: 10.1111/j.1440-1754.2006.00870.x.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 M. R. Zonfrillo, C. M. Locey, S. R. Scarfone, and K. B. Arbogast, “Motor vehicle crash–related injury causation scenarios for spinal injuries in restrained children and adolescents,” Traffic Injury Prevention, vol. 15, suppl. 1, pp. S49–S55, 2014, doi: 10.1080/15389588.2014.934959.
  15. ↑ 15.0 15.1 15.2 15.3 J. J. Ernat, J. B. Knox, R. L. Wimberly, and A. I. Riccio, “The effects of restraint type on pattern of spine injury in children,” J. Pediatr. Orthop., vol. 36, no. 6, pp. 594–601, Sep. 2016, doi: 10.1097/BPO.0000000000000502.
  16. ↑ 16.0 16.1 16.2 C. P. Sherwood et al., "Prediction of cervical spine injury risk for the 6-year-old child in frontal crashes," (in eng), Traffic Inj Prev, vol. 4, no. 3, pp. 206-13, Sep 2003, doi: 10.1080/15389580309885.
  17. ↑ D. Kallieris, R. Mattern and J. S. H. M. Wismans, Comparison of human volunteer and cadaver head-neck response in frontal flexion, DOT HS 807-517, National Highway Traffic Safety Administration, U.S. Dept. of Transportation, Jan. 1988. [Online]. Available: https://rosap.ntl.bts.gov/view/dot/29928/dot_29928_DS1.pdf
  18. ↑ 18.0 18.1 18.2 18.3 18.4 T. Kapoor, W. Altenhof, A. Snowdon, A. Howard, J. Rasico, F. Zhu, and D. Baggio, “A numerical investigation into the effect of CRS misuse on the injury potential of children in frontal and side impact crashes,” Accident Analysis & Prevention, vol. 43, no. 4, pp. 1438–1450, Jul. 2011, doi: 10.1016/j.aap.2011.02.022.
  19. ↑ R. Eppinger, M. Kleinberger, S. Kuppa, R. Saul, and E. Sun, Development of improved injury criteria for the assessment of advanced automotive restraint systems, Conrad Technologies, Inc., for the National Highway Traffic Safety Administration, Washington, DC, USA, Jan. 1998. [Online]. Available: https://rosap.ntl.bts.gov/view/dot/14737
  20. ↑ F. Bandak et al., Development of improved injury criteria for the assessment of advanced automotive restraint systems: II, Conrad Technologies, Inc., for the National Highway Traffic Safety Administration, Washington, DC, USA, Nov. 1999. [Online]. Available: https://rosap.ntl.bts.gov/view/dot/14738
  21. ↑ 21.0 21.1 21.2 H. J. Mertz, P. Prasad, and A. L. Irwin, “Injury risk curves for children and adults in frontal and rear collisions,” in Proceedings of the 41st Stapp Car Crash Conference, SAE Paper No. 973318, Nov. 1997. [Online]. Available: https://smf.org/docs/articles/hic/Mertz_1997_Injury_Risk_Curves_for_Children_Adults_in_Front.pdf
  22. ↑ Centers for Disease Control and Prevention (CDC), “Resources – Child Passenger Safety,” [Online]. Available: https://www.cdc.gov/child-passenger-safety/resources/index.html (accessed Aug. 15, 2025). (Public Domain)
  23. ↑ Karco Engineering / NHTSA, “10-year old Hybrid III dummy in a booster seat after a frontal crash test,” Wikimedia Commons (Public Domain). [Online] Available: https://commons.wikimedia.org/wiki/File:V05265P096.jpg (accessed Nov. 4, 2025). (Public Domain)
  24. ↑ 24.0 24.1 H. Hauschild, J. Humm, J. Maheshwari, and V. Graci, “Characterizing neck and spinal response in booster-seated reclined children in frontal impacts,” Traffic Injury Prevention, vol. 24, suppl. 1, pp. S32–S40, 2023, doi: 10.1080/15389588.2023.2188985.
  25. ↑ 25.0 25.1 25.2 P. F. Agran, D. N. Castillo, and D. G. Winn, “Comparison of motor vehicle occupant injuries in restrained and unrestrained 4- to 14-year-olds,” Accident Analysis & Prevention, vol. 24, no. 4, pp. 349–355, Aug. 1992, doi: 10.1016/0001-4575(92)90047-M.
  26. ↑ 26.0 26.1 C. Johnston, F. P. Rivara, and R. Soderberg, “Children in car crashes: Analysis of data for injury and use of restraints,” Pediatrics, vol. 93, no. 6, pp. 960–965, 1994, doi: 10.1542/peds.93.6.960.
  27. ↑ D. R. Durbin, I. Chen, R. Smith, M. R. Elliott, and F. K. Winston, “Effects of seating position and appropriate restraint use on the risk of injury to children in motor vehicle crashes,” Pediatrics, vol. 115, no. 3, pp. e305–e309, Mar. 2005, doi: 10.1542/peds.2004-1522.
  28. ↑ David Castor, “Interior of Google driverless car,” Wikimedia Commons, CC0 1.0 Public Domain. Available: https://commons.wikimedia.org/wiki/File:Googlebil.jpg (accessed Nov. 4, 2025). (Public Domain)
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