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Safety in the car sri revista del hospital de niños de buenos aires junio 2013, vol.55 n° 249

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  • 1. SAFETY IN THE CAR CHILDREN AS PASSENGERS Jorge Fiorentino MD* and Graduate Axel Dell’ olio* * Chief of Urgency Department in Hospital de Niños R. Gutiérrez - **President of ADISIV (Asociación para la Disminución de Siniestros Viales). … The Transport Code, in the unremembered Act 24449, article 40, section “g” states that children under 10 years old must travel in the back seat. Its amendment in 2008 establishes that it is obligatory to “transport 4-year-old children in their corresponding child car seats.” INTRODUCTION: Being inspired by the seat belts used by aircraft pilots, Nils Bohlin registered and integrated the seatbelt with a diagonal sash in VOLVO automobiles, while working for that company in the 50s. A few years later, a series of accidents in the care of the Chevrolet Corvair triggered a public campaign in the United States in view of saving users’ lives. The lawyer who fostered this campaign was Ralph Nader, the author of “Unsafe at any speed.” His book brought about a true revolution in the automobile industry and made people aware of the situation. The industry had now realized that to protect and value human life, this passive safety device needed to be used. (1) Thereafter, the seat belt has saved many lives. However, what would have happened if nobody had thoroughly explained its importance and usage? Without awareness, fastening systems would have been excellent elements of passive safety, but they would have not been able to save the substantive number of drivers and passengers that participated in car accidents while using seatbelts. Child car seats started to be manufactured in the year 1980. They were thought to prevent injuries in the event of accidents or collisions. These safety and protection systems were designed by taking into account the children’s anatomy, their growth, and their typical behavior. Thus, in their standard we can recognize the result of a thorough investigation carried out by performing tests with “dummies.” Nowadays, these car seats are simple and are being used correctly. They are the equivalent of the seatbelts that adults use. If they are correctly secured in the car seats, they provide great immobilization and fastening, thus being a reliable method in terms of passive safety (2), as well as the best life insurance for young passengers. Seats belts are manufactured and installed according to ECE R16 regulations, which means that their manufacturing is supervised by trained and specialized professionals. On the other hand, child car seats are manufactured according to ECE R44/04 regulations, which means that parents and other users must somehow interpret the instructions manual. In this environment, the technical advice is not always professional, so parents have no choice but to place the child car seat in the car relying upon a simple
  • 2. instruction provided by a salesman (who may not always be an experienced one) or even other parents when their child is born. Pediatricians, teachers and road safety educators are in a privileged position when it comes to advising users. What we are trying to do is to encourage users to use these safety devices correctly, so they can prevent a great deal of foreseeable deaths. ISSUES RELATED TO EPIDEMIOLOGY: Unintentional traumatic injuries as a whole (formerly called accidents) are the third cause of death among all ages worldwide. It is also the first cause of death among people under 35 years old. Out of every deceased person, there are three patients with severe disabling injuries. (3-4) In addition to the social and emotional pain that may be caused by the death or disability of a child, we should take into account the high economic cost that society has to face as a whole. This means that this child would be missing school years, and as a consequence, there would be a lack of future work productivity. In Argentina, these costs amount to the equivalent of 1.5 to 2% of the annual Gross Domestic Product (GDP). (3) Morbidity and mortality rates on traffic related injuries are an important problem because of the differences in the coding of deaths and also because of deficiencies in notification and registration. As an example, traffic related injuries are one of the main three causes of deaths. The other two causes are heart diseases and cancer (1-2-3-4). People who die from the former diseases are mainly adults, while the people who die in traffic related injuries may also be – in a great extent- adolescents and youngsters (3). According to the WHO, traffic related injuries are the second cause of death among children between 5 and 14 years old in the world. The first cause is acute lower respiratory infections. (Report on the global situation of road safety: It is time to take some action. Magazine No. 6, page 3, year 2004.)
  • 3. TRAUMA IS A PREVENTABLE DISEASE! That is why we suggest that the term “incident” is used rather than “accident.” The connotations that the term “accident” carry, such as unpredictability and lack of control are counter-productive as regards prevention (4). It is extremely necessary to focus on the different private and public prevention campaigns. It is also crucial to endorse the role of pediatricians, technicians, parents and teachers in order to stand for policies that increase the available resources needed to prevent and reduce the frequency of this devastating disease. It is necessary to name some elements related to the physical environment of the City of Buenos Aires in order to understand the importance of the accidents (which are, as already said, mistakenly named.) According to the census of 2010, Buenos Aires has a permanent population of 3.000.000 inhabitants and an area of 202 km2. The Greater Buenos Aires conurbation has 9.500.000 inhabitants, and a total of nearly 12.500.000 inhabitants including the City of Buenos Aires, approximately 30% of the total population of Argentina (4- 5). 3,300,000 of them are children under the age of 15. (5) Traffic figures in the City of Buenos Aires: In addition to the 3,000,000 people who live in the City of Buenos Aires, there are 3,000,000 other people who enter the city from the conurbation during business hours and days. Half of them enter the city by car, especially because of the weak public transportation that Argentina has. Thus, approximately 1,500,000 vehicles circulate daily in the City of Buenos Aires. It is also estimated that in rush hours, there are 2 cars out of 3 inhabitants. This calculation does not include other means of transportation, such as over 9700 buses of diverse lines, 35,000 cabs, 3,500 remises, 3,500 “free offer” buses, and 50,000 trucks, motorcycles, bicycles, trains and subways that complete this reckless cocktail that takes place in this territory. Unfortunately, it is not rare to see children travelling with no protection in their car seats, or even sharing a seat with an adult. This is a clear demonstration of how ignorant adults are; as they ignore the risk they are taking. Injuries suffered by vehicle passengers are one of the most frequent causes of death and morbidity among children under 16 who are taken in the Hospital de Niños Ricardo Gutiérrez. Children who do not use seat belts or child car seats are more likely to suffer from serious injuries and to be expelled from the inside of the vehicle in the event of a collision, or simply hitting other passengers or internal parts of the vehicle.
  • 4. Traumatic brain injuries are the most frequent injuries among children who are not fastened. This can be explained if we take into account their anatomy. The correct use of child car seats reduces the risk of death in nursing babies to a 70%, while in children between 1 to 4 years the risk is reduced to a 54% (7). In contrast, injuries suffered by children who are correctly fastened in their seats are usually minor injuries, such as abrasions, lacerations and contusions, except when there is an intrusion of elements, impacts with objects that are inside the vehicle or injuries caused by airbags (6-7-8-9-10). CHILDREN AND CAR SEATS: During their growth stage, children change their weight, height, size and body proportions very fast. Babies and children have very different anthropometric sizes than those of an average adult, for whom safety measures are usually designed. The heads of nursing babies are disproportionately large, while their gravity center is too tall and is placed above their umbilicus. Their neck is short and their encephalic support is relatively poor. Their cervical structures are weak and their scapular waist is poorly developed (11-12). Intraabdominal organs (liver, spleen and kidneys) are poorly protected and are more exposed than those of adults. The bony pelvis does not provide a complete coverage of the bladder; hence the organs are highly vulnerable and may be seriously harmed in the event of a collision. As the iliac crests are not fully developed, the anchor points of seatbelts are unsatisfactory. That is why they may slide upwards, thus directly discharging the force on the abdomen. As a result, two things may occur: 1.the child may bend over the seatbelt in a collision (probably generating a spinal fracture caused by an hyper flexion of the spine over the seatbelt with a pressure injury of intraabdominal organs, or 2.- the pelvis may be immersed under the seatbelt (submarine effect.) As a result, the child falls on the floor and suffers unpredictable injuries. Children should use the diagonal band over the shoulder and clavicle. It should never be placed on the neck, simply because in the event of a collision, there may be serious injuries in the cervical spine. If the diagonal band is placed under the arm, it functions as another abdominal belt. In other words, it functions as a two-point seatbelt, which is basically a dangerous and unsatisfactory fastening (13). The trunk, pelvis and extremities have their own restrictions in movement. Given the important weight and volume of children’s heads, – the younger they are, the bigger their heads are – they should be facing rearwards when their weight is less than 10 kg. This should be done to avoid a cervical hyper flexion in the event of a head-on collision. Nowadays, a change in legislation to carry children who weight under 18 kg facing rearwards is being discussed in Europe, the United States and Canada. Children should never travel in the front seat, especially if the vehicle has airbags in the companion seat. The airbag is inflated with force (between 200 km/h and 300 km/h). This may cause serious burns and wounds, and even death in the event of an impact. However, if the child is facing rearwards, the situation does
  • 5. not improve, since the airbag may push the child to the back of the seat, thus causing an extremely violent impact. It is crucial to properly fasten the child car seat with the back seat seatbelt in three fixed points. BE CAREFUL In Argentina, some vehicles only have a two-point seatbelt in their central back seat. This would cause the child car seat to flip over without any resistance, since it does not have an upper anchor. Latest news: There is a safer anchor. ISOFIX (ISO 13216 regulation) is a system that has been used by the European Community as of February, 2011. This system has 3 anchor points. Two of them fasten the lower part of the child car seat to the vehicle (picture No. 1). The third point – named TOP TETHER – secures the upper part of the child car seat, avoiding a forward ejection in the event of a head-on collision (picture No. 2). It is also useful to enhance the stability of the seat in the event of lateral impacts. To be on the same page, the name it received in Canada is UAS (Universal Anchorage System) and in the United States LATCH (Lower Anchors and Tethers for Children.) Both countries established that as of September, 2002, their vehicles (national or imported) shall incorporate these necessary modifications. The Ministry of Internal Affairs, the Ministry of Industry and the National Road Safety Agency (ANSV) signed an agreement with the manufacturers and importers of cars. This agreement stated that as of the year 2016, every vehicle shall have an ISOFIX system or the like. In the meantime, vehicles that do not have this system must have a child car seat that should be fastened with the car’s seatbelts so that the seat is correctly fastened and stabilized. (11-12) Picture No. 1 Picture No. 2 Child car seats also have strict regulations as regards production. In Europe, the current legislation is the ECE R44/04, while in North America is the FMVSS 213 (Federal Motor Vehicle Safety Standard.) These regulations establish the manufacturing materials of the seats, the type of labeling they should have, and the tests that they have been subject to. That is why it is always better to buy approved child car seats. Unlike national seats, those that are approved have undergone strict quality tests. The way to identify these products is by reading the following label, which should be different if applicable to Europe (Figure No. 1) or to the United States (Figure No. 2.) In Argentina, approval standards for child car seats will enter into force in 2013 under the TIAM 3680.1 and 3680.2 regulations, in which work is currently being done. (11-12-13)
  • 6. Figure No. 1 Figure No. 2 TYPES OF CHILD CAR SEATS: (7-9-10) “Children first, but correctly placed in their car seats, always in the back seat, and with the car seat properly installed.” There are 5 groups with different characteristics (12-13): (Please see Figure No. 3)  Group “0”: For children who weigh less than 10 kg.  Group “0+”: For children who weigh less than 13 kg.  Group “I”: For children who weigh between 9 and 18 kg.  Group “II”: For children who weigh between 15 and 25 kg.  Group “III”: For children who weigh between 22 and 36 kg.
  • 7. Figure No. 3. Current types of child car seats - GROUPS 0 AND 0+ In Spanish, they are usually called “huevito” [little egg] or “capazo” [large basket]. It is a child car seat that should be used until the child is one year of age or weighs more than 13 kg. This is recommended mainly to protect the backbone in the event of a head-on collision. When facing an abrupt horizontal deceleration, the child’s body will be completely leaning on a large flat base, constituted by the same back of the seat. It is also advisable that the child’s head be fastened. The head needs to be facing rearwards to avoid a forced flexion or extension. It is also recommended to use a lateral padding in children. Child car seats that are being sold nowadays are prepared with these characteristics. - GROUP I These seats are prepared for children who weigh between 9 and 18 kg (approximately between 1 and 4 years old.) The seat is attached to the vehicle with the seatbelt or other systems such as ISOFIX (please see section ISOFIX). In Europe, some regulations have started to be developed so that Group I seats may be manufactured as rearward-facing seats. Many specialists believe that the use of rearward-facing seats should not only be limited to babies. This is because the bone formation process does not end until the child is 6 or 7 years old. Until then, the child’s skull is still weaker than an adult’s. It is also crucial to have an appropriate lateral protection in case there is an intrusion of blunt objects or collisions. In view of these details, manufacturers take into consideration factors such as rigidity and resistance of the materials used when manufacturing these seats. - GROUP II These seats are designed for children who weigh between 15 and 25 kg (approximately between 4 and 6 years old). These seats have backrests and help the child’s anatomy to commensurate with the three-point seatbelt. Thus, the diagonal sash is crossed over the clavicle, sternum, ribs and iliac crest. - GROUP III These seats are designed for children who weigh between 22 and 36 kg (between 6 and 12 years old). They are also called “booster seats”. The main difference between these seats and the former ones is that booster
  • 8. seats do not have backrests. Being designed for older children, they do not provide lateral protection like Group II seats. Nowadays, there are many companies that manufacture seats belonging to groups I, II and III. The protection they offer is guaranteed since the child is one year old until he/she can use the car seatbelt. This is achieved when the child is 1.5 meters high. - SEATBELT: Once the child’s height is over 150 cm, he or she is ready to use adults’ seatbelts (usually between 10 and 12 years old). The seatbelt should be correctly used, i.e. it should be placed over the clavicle, sternum, rib cage and iliac crest. Its correct collocation will prevent neck or abdominal injuries. It will also avoid the “submarine effect”, which is very common when the diagonal sash is loosely or incorrectly arranged. SPECIAL SITUATIONS: - A) Pregnant women: The best way to protect the fetus is by protecting its future mother. The most efficient way to do it is by using the three-point seatbelt. The sash should be placed over the shoulder and clavicle, descending into the breasts. The lower sash should be placed below the pregnant belly. It should always be placed over the hip, NEVER OVER THE BELLY (please see Figure No. 4). Industrialized countries have seatbelts especially designed for pregnant women that meet the requirements of the European regulation R16. These seatbelts safely hold the seatbelt under the pregnant belly, making it impossible to lift. Unfortunately, these seatbelts are not available in Argentina. Figure No. 4: Seatbelts and their correct use during pregnancy - B) Newborns and premature babies Just like nursing babies, newborns and premature babies need to be correctly fastened in their seats to travel safely. These babies are characterized by having a particularly fragile neck. This determines that the fastening of their heads must be extremely thorough. Their heads should be fastened not only in an anteroposterior
  • 9. direction (to prevent anteroposterior flexion or extension), but they also need a lateral padding with a support (to prevent lateroflexion movements, which are as harmful as the previous ones.) For this matter, the seat reducer is used to adjust the seat to the small size of newborns or premature babies. Those children who suffer from oxygen desaturation, bradycardia, or documented apnea in a half-sitting position should be examined by a neonatologist before they are discharged from the hospital so that an adequate child car seat is recommended. In addition, the neonatologist will recommend a position in which the children should travel. The seat should be facing in the same direction as those seats designed for children who weigh less than 10 kg. However, the seat should be placed horizontally in 45° to provide an adequate support of the head and back. It will also help to prevent a potential obstruction of the airway in the event of a collision (Picture No. 3 and Figure No. 5). Picture No. 3: Seat reducer - Figure No. 5: Traveling position C) Children with different needs: Children who suffer from static encephalopathy, neuromuscular or breathing alterations, or any other disorder that generates a temporary or permanent bad postural habit cannot adapt their bodies to the regular seats, nor travel erect. In these particular cases, these children should travel in special seats, which are specifically designed to help their back be evenly supported by the back of the seat. The fastening sashes are adapted to every particular case by keeping in mind the same precautions that for other children. Nowadays, companies such as Brtiax Romer manufacture child car seats for children with spina bifida. - D) Ambulances Even though it is not illegal, carrying a child in their mother’s arms when they need to be transported in an ambulance is not the safest option. That is why strongly advise against it. That is why there is a company in Europe named Kidy Safe that designed a tested and validated product that respects the regulations stipulated by law. This product was created to transport patients who travel in ambulances and/or patient transportation (11) in stretchers. This fastening system has a five-point fastener, a
  • 10. chest protector with a harness, and a simple mechanism that attaches the body to the stretcher by using anchorage straps. (Please see Figure No. 6 and Picture No. 4) Picture No. 6 - Photo No. 4 E) Bicycles Britax developed the Britax Jockey Comfort system (12) for bicycles. It is designed for children under 7 years old. It can be installed in 26” y 28” bicycles. By using this system, the ride becomes a safe activity in terms of accidents. Those who developed this system recommend that those who ride this bicycle are over 16 years old. It is also recommended that children passengers use a helmet, as well as the rider. (Please see Pictures No. 5 and 6) Preventive measures should aim at enhancing cyclists’ safety by enforcing the use of a helmet and the padding of handlebars. The former should be protected in their free end points, as well as in the rim breaks. Picture No. 5 - Picture No. 6 F) School transport A great deal of children travel daily in school vehicles through our city streets in rush hours.
  • 11. School buses are certainly the safest vehicles. Given their large size and structural strength, injuries are less common among their small passengers in the event of a collision. It is legally stipulated that every child shall travel sitting in their seats with the windows closed. They shall be accompanied by an adult (besides the driver). The number of adult companions varies according to the number of children who travel. This is made to control and supervise their behavior during the trip. According to legislation (National Act No. 24449 and its amendment Act No. 25857, article 55), it is stated that: “… These vehicles shall have – in the conditions that the law sets – attached seats, necessary structural and distinctive safety elements and adequate sanitation and hygiene. They shall come with inertial and combined seatbelts, which shall be compulsorily used in every seat of the vehicle…” The current legislation in the City of Buenos Aires (Acts No. 1665 as amended by Act No. 1919 and 2148) determines that: 1. No child under the age of twelve (12) years old shall travel in the front seat. 2. The use of seatbelts is mandatory for every person traveling in the vehicle. Those who travel in the front seats shall use the three-point seatbelts, whilst those traveling in the back seats shall use waist seatbelts. 3. In the case of three-point seatbelts, when the size of the person does not make the resting of the sash over their shoulder possible, “… the seat shall be adapted to attain a proper rest by using a child car seat with a height that matches the person’s physique…” REMEMBER: Having addressed these regulations, it is also very important to ask for references and to know those people who are in charge of transporting our children and keeping them safe. One should be very well-behaved when transporting children LATEST NEWS: Taking into consideration the anatomic vulnerability of children, Stephen Rouhana, Senior Technical Leader for Safety, Research and Advanced Engineering in Ford Motor Company, has designed a seatbelt with some particular characteristics. This new seatbelt combines the qualities of the ordinary seatbelt with those of an airbag. It increases the level of protection, since the range of protection in the chest in the event of head-on collisions is increased. It is estimated that when the seatbelt is inflated, the pressure generated by the collision is buffered up to 5 times more. (Please see picture No. 7)
  • 12. Picture No. 7: Seatbelt with airbags incorporated to the diagonal sash MOST FREQUENT MISTAKES WHEN USING CHILD CAR SEATS (15)         Not using or incorrectly using the seatbelt buckle. Not using or incorrectly using the retaining harness belt or buckle. Incorrect orientation of the fastening system. The use of the seatbelt in children who weigh less than 18 kg, or who are less than 1 meter high creates conflicts regarding the adaptation of the child to the seatbelt. The adult shares both the seat and seatbelt with the child (the child seats in the adult’s lap). Children traveling in the front seat. Carrying the child in arms. Incorrectly fastening the child car seat to the vehicle. COMMENTS: It is well-known that the risk of getting a disease or even dying varies throughout the biographic history of each individual. We all know that there are several differences between adults – men and women – and children regarding the susceptibility of each age group. Ever since they are born, children are being shaped with the influence of their families (membership group). Then, they are influenced by their environment (with a special emphasis on environments such as: school, club, friendships, etc.) This makes humans absorb transmitted beliefs, thus accepting cultural and family traditions that will strongly influence them. (13) “… Children will use seatbelts if they see their parents using them and if they learn it at school…”
  • 13. While in Argentina the number of incorrectly named “accidents” that kill hundreds of children continues to increase, safety measures to prevent these accidents seem inexistent or are always poor. The ignorance of adults is here an ally of death, as our children face these dangers unarmed. The most appropriate and inexpensive treatment to reduce the “accident disease” is PREVENTION. In this way, the protection of children as passengers should begin with a set of efficient rules and laws that raise awareness among those who are responsible for their safety. When children travel in cars, fastening systems that are suitable for their age should be used. Not using them exposes children to injuries and avoidable deaths (2-4-9-10). Safety has become a priority among European and North American car manufacturers. In Argentina, there seems to be a similar intention, which has started just now. The sales of child car seats and special cushions are growing. It is also expected to be a growth in the protective conscience of parents. We, as educators and health care workers are in a privileged position when it comes to advising people, in the pursuit of promoting the use of these safety systems, which prevent the deaths of those who cannot and do not know how to defend themselves. Trauma is a foreseeable disease. Children are everyone’s responsibility. During the years 2011 and 2012, the Hospital de Niños Ricardo Gutiérrez, the National Road Safety Agency (ANSV) and the Association for the Reduction of Road Incidents (Asociación para la Disminución de Siniestros Viales ADISIV) held the first conferences on road prevention and safety for children. During these conferences, the issues presented were: injuries in children as a result of traffic incidents, and the importance of having an official approval criterion for child car seats, as it happens in Europe. Recently, an agreement has been signed among these three organisms to work collectively with the objective of providing a better guidance as regards road safety in children. FINAL RECOMMENDATIONS: 1. Children first, but correctly placed in their car seats and always in the back seat. Keep in mind that vehicles have airbags that are designed to protect an average adult who uses a seatbelt with a diagonal sash. 2. Never travel with a child on your lap. It is even more important not to share a seatbelt with a child, even when distances are short. 3. Newborns should be transported in their corresponding child car seat since the moment they leave the hospital. They should be slightly leaning backwards and there should always be a person
  • 14. 4. 5. 6. 7. 8. 9. 10. 11. 12. watching them. If you return from the hospital in a cab, the child car seat should be prepared along with the bag you prepare for the birth day. Buy approved products in stores that employ people who are specialists in the area. Do not buy “second-hand” products. In case of having had an impact, replace the system. This is because the materials have been altered as a result of the impact. Use the child car seat in accordance with the child’s body mass and remember to install it correctly. Never let children travel in the rear window or in the loading area of a pickup truck. These areas are prepared to be deformed and to absorb more energy than the rest of the vehicle in the event of back impacts (14-15). Always respect the installation instructions that come with the child car seat you bought. Do not make your own innovations! Remember that an incorrectly installed seat can cause injuries not only in the child, but also in the rest of the passengers. Do not travel with loose objects in the vehicle. In the event of a hard brake or a collision, these objects will become real “missiles.” Encourage every passenger to fasten their seatbelts. Make sure to correctly fasten the safety sashes to your body, as well as the sashes in the child car seat. Check that they are not loose or that they pass above the throat. You may avoid a ticket, but you will not avoid the consequences of a traffic incident. (15-16) Get your seatbelts checked by a professional if they have been used during a collision. If they need to be changed, demand that they comply with every current technical regulation (IRAM – IATA 1- K14). (15) 13. If at this point you were not convinced, remember what the great master Juan Manuel Fangio once said: “…always use your seatbelt, because your life may depend on it…”
  • 15. A SEAT FOR EVERY AGE 0Kg 5Kg 10Kg * 9 – 12 m 15Kg 20Kg 25Kg 30Kg 35Kg * 8 years old Groups 0 and 0+ Nursing babies facing rearwards Groups 0 and 0+, child facing rearwards until he weighs 10 kg (1 year old) Group I, child facing forward (until 4 years old) Group I Facing forward. Between 9 and 18kg (1 to 4 years old) Groups II and III, children who weight between 15 and 36 kg. It is advisable that their height is 150 cm, so that the seat belt is placed in the lap and shoulder. For their correct installation, follow the instructions provided by the manufacturers of the child car seat and the car manual. There are variations in the use of seatbelts according to the car brand or model, the child car seat or the child’s height. * Average age for that height. It may vary in every particular case. Since the child is 150 cm high (approximately between 10 and 12 years old). Three-point seatbelt (clavicle, sternum and iliac crest)
  • 16. BIBLIOGRAPHY: 1. Kirbus FB.: Seguridad de la prevención a la protección total. AP Americana de Publicaciones S.A, 1998. 2. American Academy of Pediatrics Policy Statement. Committee on injury and poison prevention. Selecting and using the most appropriate car safety seats for growing children: Guidelines for counseling parents. Pediatrics. 97:761-762,1996. 3. Neira JA; Muro MR; Outes A.: Organización de la Atención del Traumatizado en la Argentina. SAME 7(1): 7-32,1999. 4. Tapia Granados J: La reducción del tráfico de automóviles: una política urgente de promoción de la salud. Rev Panam. Salud Pública / Pan Am J Public Health 3 (3), 1998. 5. Indicadores Básicos. Argentina 1999. Programa Especial de Análisis de Salud. Ministerio de Salud, OPS, OMS. INDEC 1999. 6. Agran, P; Winn RN; Anderson; C: Protección de niños pasajeros de automotores. Pediatrics in Reviw.18(12):4-12, 1997. 7. NHTSA Auto Safety Hotline: Transportation safety tips. For information on recalls and issues related to CRSs: www.http://www.ntsa.dot.gov 8. Huaier FD, Fiorentino JA, Gómez Traverso RE: Uso incorrecto del cinturón de seguridad. Revista del Hospital de Niños. Vol 42,n°187,34-38, 2000 9. American Academy of Pediatrics Policy Statement. Safe transportation of premature and low birth weight infants. Pediatrics;97:758-760, 1996. 10. American Academy of Pediatrics Policy Statement.: Transporting child with special needs. Pediatrics AAP Safe Ride News Winter, 1993. 11. http://euraslog.com/archivos/Kidysafe_resumproduct.pdf 12. http://www.britax.co.uk/bike-seats/overview-bike-seats/britax-jockey-comfort 13. Fiorentino JA, Blidner l: Los niños y el Tránsito. Revista del S.A.M.E; Vol 6, n°1:36-40,1998. 14. Paladín E: Temas sobre seguridad. Revista Parabrisas. Abril 1995. 15. Bovio J: El cinturón de seguridad. El A.C.A y la Seguridad. Rev. Autoclub. Pag 6-7, 1997. 16. ¿Los niños son pasajeros seguros? (Temas de Pediatría Ambulatoria) Revista del Hospital de Niños. Vol. 43, n° 192, junio de 2001. SUGGESTED READING  Norma ECE R44/04.  Norma ECE R16.
  • 17.  Monclús J. (2010). Panorama de la SEGURIDAD INFANTIL EN EL AUTOMÓVIL (1990-2009) Veinte años: Mucho recorrido, mucho por recorrer. España: Fundación MAPFRE.  Dell’ olio A. (2011). Proteger a nuestros hijos bien o… Argentinamente. Argentina.  DIRECTIVA 2003/20/CE del parlamento Europeo y del consejo. Diario oficial de la Unión Europea de 8 de abril de 2003.  Norma FMVSS 213, Child restraint systems. Code of Federal Regulations, Title 49, Part 571.213. Estados Unidos.  Ley de Tránsito y Transporte N° 2.148. Ciudad Autónoma de Buenos Aires. Argentina.  Ley Nacional N° 24.449, Dto. Reglamentario 779/95. Argentina.  Ley Nacional N° 26.363, Dto. Reglamentario 1716/08. Argentina.  Fundación MAPFRE. (2012). Asientos de seguridad para niños Situación en Iberoamérica y el Caribe. España. Fundación MAPFRE  Plan Mundial para el Decenio de Acción para la Seguridad Vial 2011-2010 Jorge Arturo Fiorentino MD (CCPM) Pediatrician, coroner and child surgeon. Chief of Urgency Department in the Hospital de Niños Ricardo Gutiérrez. Chief of the workgroup Surgery of Trauma in the Hospital de Niños Ricardo Gutiérrez. Teacher in courses of Emergency Medicine at SAME. Teacher in courses of pediatric ITLS. Former Chief of internships in Surgery of Pediatric Trauma (GCBA). Former Chief of the Pediatric Trauma of the Argentine Medicine Society and Surgery of Trauma. General Coordinator in Pediatric Surgery Internships (Training and Teaching, City of Buenos Aires Government). Graduate Axel Dell’ olio Graduate in Transport and Road Prevention. Chief of ADISIV (Association for the Reduction of Road Incidents.) Teacher on theoretical concepts for professional drivers. Member of the Regulation Commission IRAM 3680.1 and IRAM 3680.2 on child car seats. Department of Road Safety of the Association of Transport and Traffic Journalists in Argentina (APTTA, Asociación de Periodistas de Tránsito y Transporte en Argentina.) Translated by Florencia Ambos Certified EN-SP Translator - florenciaambos@hotmail.com

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