ABSTRACT
BACKGROUND:
Motor vehicle crashes (MVCs) are the leading cause of death among children in Saudi Arabia. Childhood injuries can be prevented or minimized if safety measures, such as car seats, are implemented. The literature on the epidemiology of head and facial injury among children is limited, which affects the ability to understand the extent of the burden and hinders investment in public health prevention.
OBJECTIVE:
Describe the epidemiology of head and facial injuries among children admitted to the hospital following MVCs.
DESIGN:
Retrospective chart review.
SETTING:
Five hospitals in several regions.
PATIENTS AND METHODS:
We collected data on all patients ≤16 years old, who were admitted to the hospital following MVCs between 2016-2019. Differences in various characteristics like head injury status and age groups were compared.
MAIN OUTCOME MEASURES:
Head and facial injuries.
SAMPLE SIZE:
253 patients.
RESULTS:
Of the injured population, 97 (38.3%) sustained a head injury, and 88 (34.8%) had a facial injury. Thirteen (9.1%) children were driving the car at the time of the crash. About half of the children were seated in the back (53.8%) without a seatbelt or safety seat.
CONCLUSION:
The prevalence of head and facial injuries is striking. In addition, the study revealed that driving among children is not uncommon, which warrants monitoring and implementing interventions. Improved documentation of restraint use and police enforcement of safety laws can play a significant role in reducing associated injuries. The study findings highlight the importance of combination or rear seating as well as age-appropriate restraint in order to reduce the likelihood of head or facial injuries among children.
LIMITATIONS:
Retrospective study using the electronic search system to identify patients, but may have missed cases that were not coded correctly. Large amount of missing data for some variables. Additionally, the analysis was limited to those admitted to the hospital.
CONFLICT OF INTEREST:
None.
INTRODUCTION
Worldwide, more than 1.3 million victims die every year due to motor vehicle crashes (MVCs).1 In the United States, MVCs are the leading cause of death among children younger than one year of age and account for about 3% of emergency department visits.2 MVCs are also the leading cause of death among children and young adults aged 5-29 years, and this will likely remain the case in the future.3 Although there is a decline in the burden in developed countries, MVC deaths have increased in developing countries.4 Saudi Arabia is among countries with a high burden of traffic injuries despite being a developed high-income country.5 It is widely recognized that MVC injuries are preventable. Despite that, the country still lags behind when it comes to investment in primary prevention aimed to reduce the burden of MVCs.6 This could be due, in part, to the poor understanding of the epidemiologic burden, as is the case in many developing countries.7,8
When compared to other body parts, head injuries pose a higher risk for morbidity and mortality in adults.9,10 This can be pronounced even further in children due to the immaturity of their skeletal system and the larger head-to-body ratio.11 In addition, head injuries pose a significant burden on healthcare facilities. In the United States, approximately half a million children experience a traumatic brain injury each year.12 MVCs are a leading cause of head injuries among children. Some studies have found up to 70% of those injured in an MVC sustained head injuries.13 The use of child restraints, such as car seats, seat boosters, and seat-belts provide good protection from bodily injuries, and decrease the risk of death among infants and young children by 71% and 54%, respectively.14
Developed countries have long recognized the value of safety measures to reduce injuries following MVC. In Australia and the United States, both seatbelt and child car seat compliance rates are very high (86-97%).1 On the other hand, the rate of child restraint use varies from developed to developing countries.15,16 Despite the fact that using safety measures such as seatbelts and car seats are mandated for children by Saudi law, consistent seatbelt use remains as low as 15.3%.17 Other self-reported surveys stated that only 43.3% of parents reported using a car seat for their children.18 Currently, the frequency of use and the consequences of misuse of child restraints are still unknown in the country. More importantly, data published on the epidemiology of MVC injuries among children and their association with restraint use is limited.
Several local studies examined the burden of MVC, but none focused on car seat compliance and their consequences, such as head injuries.19-21 Moreover, most of the work that was done previously emphasized adult facial injuries due to MVC without a focus on children.22 Aside from the risk of mortality, nonfatal injuries among children may lead to permanent disabilities that impact the population health and healthcare utilization for extended periods. In this study, we aimed to describe the prevalence of head and facial injuries among pediatric patients following MVC injuries. In addition, we aimed to examine the association between various variables and head or facial injuries among children seeking medical care after traffic crashes.
METHODS
This was a retrospective study that used the electronic medical record (EMR) system at five hospitals of the National Guard Health Affairs (NGHA) in Saudi Arabia. This network is responsible for providing healthcare services to all National Guard personnel and their families and serves a population of over one million beneficiaries. Care is coordinated via a single EMR system known as BESTCARE. This system was implemented in January of 2016.
For the purpose of this study, we searched the system for all traffic crash-related admissions, and all patients meeting the inclusion criteria were identified. Data captured included five locations: King Abdulaziz Medical City in Riyadh, King Abdulaziz Medical City in Jeddah, King Abdulaziz Hospital in Al Ahsa, Al-Imam Abdulrahman bin Faisal Hospital in Dammam and Prince Mohammad Bin Abdulaziz Hospital in Al-Madinah. Cases from King Abdulaziz Medical City in Jeddah and Prince Mohammad Bin Abdulaziz Hospital in Al Madinah were combined to represent the western region while cases from King Abdulaziz Hospital in Al Ahsa and from Al-Imam Abdulrahman bin Faisal Hospital in Dammam were combined to represent the eastern region.
All patients 16 years of age or younger involved in MVCs as vehicle passengers between 2016-2019 were included in this study. Children who were involved as pedestrians or as motorcycle riders were excluded. In addition, patients who were transferred to another hospital due to ineligibility were excluded from the study due to limited information about whether they were passengers and their health outcomes. Initially, the system identified 1236 patients as children admitted due to any injury. Next, two trained research registrars reviewed all the medical records and identified 253 children who met the inclusion criteria. Excluded patients sustained other mechanisms of injuries such as falls or pedestrian injuries.
A predesigned data collection sheet was used to collect data from the EMR. The data collection sheet included demographics, anatomic, physiologic, and outcome information. In addition, the data included information about the child position, safety measures (car seat or seatbelt), and the description of sustained injuries. This included fractures, contusion, abrasion, and site on the body. This study was reviewed and approved by the King Abdullah International Medical Research Center Institutional Review Board.
All statistical analyses were conducted using STATA 15 for Microsoft. Descriptive statistics were summarized in the form of frequencies or mean (standard deviation). To examine differences across groups, chi-square tests were used. For cell counts of less than five observations we used Fisher's exact test. Statistical significance was set at 5% (P<.05). The outcome was the prevalence of facial or head injuries, defined as the proportion of children with such injuries as part of the overall injured population. The prevalence of non-compliance to safety measures was in accordance with the American Academy of Pediatrics (AAP) Recommendations on motor vehicle safety for children.23 The AAP recommends that all children younger than 13 years of age must be fastened in the back seat of the vehicle.
RESULTS
We identified 253 patients who met the inclusion criteria and were included in all analyses (Table 1). Most children (43.0%) were between the ages of 6-12, and age ranged from the newly born to 16 years. The mean (SD) was 8.1 (4.6). Over two-thirds of children were males (68.7%). Of the injured children, 190 (75.1%) were from Riyadh, and the remaining were from the other regions. Only four children (1.5%) used safety measures (car seat in one case and seatbelt in three cases), 125 (49.4%) were not restrained, and the remaining 124 (49.0%) did not have documented safety measures. Among those without missing seating information, 41.7% were seated in incorrect positions. Injured children stayed a mean (SD) of 3.7 (8.4) days in the hospital.
Table 1.
Baseline characteristics of the pediatric population admitted to National Guard facilities following motor vehicle crashes (n=253).
| Age (years) | 8.2 (4.6)/8.0 (7) |
| Age group (years) | |
| 0-5 82 | (32.4) |
| 6-12 | 109 (43.1) |
| 13-16 | 62 (24.5) |
| Gender | |
| Female | 79 (31.2) |
| Male | 174 (68.8) |
| Safetya | |
| No | 125 (49.4) |
| Yes | 4 (1.6) |
| Missing | 124 (49.0) |
| Child position | |
| Correct | 85 (33.6) |
| Incorrect | 61 (24.1) |
| Missing data | 107 (42.3) |
| Head injury | |
| Yes | 97 (38.3) |
| No | 156 (61.7) |
| Facial injury | |
| Yes | 88 (34.8) |
| No | 165 (65.2) |
| Head and facial injury | |
| Yes | 87 (34.4) |
| No | 166 (65.6) |
| Length of stay hospital (days) | 3.7 (8.4) |
Data are number (%) or mean (standard deviation)/median (interquartile range).
Car seat or seatbelt.
Overall, 97 (38.8%) of children sustained head injuries, and 88 (34.7%) sustained facial injuries (Table 1). Among children ages: 0-5, 6-12, and 13-16, the documented prevalence of non-use of a car seat or seatbelt was 56.1%, 44.0%, and 50.0%, respectively (Table 2). Children younger than six years of age were more likely than other age groups to be seated incorrectly (P<.01). In addition, they were more likely to be seated in the front seat (24.4%, P<.01). Twenty percent of children ages 14 to 16 were drivers, and 21.7% of children aged 0-4 were sitting on the passengers’ lap (Table 2).
Table 2.
Association between age groups and safety patterns among the study population.
| Age | Total | P value | |||
|---|---|---|---|---|---|
| 0-5 | 6-12 | 13-16 | |||
| Car seat or seatbelt | .60 | ||||
| No | 46 (56.1) | 48 (44.0) | 31 (50.0) | 125 (49.4) | |
| Yes | 1 (1.2) | 2 (1.8) | 1 (1.6) | 4 (1.6) | |
| Missing | 35 (42.7) | 59 (54.1) | 30 (48.4) | 124 (49.0) | |
| Child position | <.01 | ||||
| Correct | 19 (23.2) | 34 (31.2) | 32 (51.6) | 85 (33.6) | |
| Incorrect | 29 (35.4) | 20 (18.4) | 12 (19.4) | 61 (24.1) | |
| Missing | 34 (41.5) | 55 (50.5) | 18 (29.0) | 107 (42.3) | |
| Child location | <.01 | ||||
| Back | 25 (30.5) | 34 (31.2) | 18 (29.0) | 77 (30.4) | |
| Front | 20 (24.4) | 19 (17.4) | 14 (22.6) | 53 (21.0) | |
| Driver | 0 (0.0) | 1 (0.9) | 12 (19.4) | 13 (5.1) | |
| Missing | 37 (45.1) | 55 (50.5) | 18 (29.0) | 110 (43.5) | |
| Seating status | <.01 | ||||
| On the seat | 29 (35.4) | 58 (53.2) | 44 (71.0) | 131 (51.8) | |
| On lap | 21 (25.6) | 2 (1.8) | 0 (0.0) | 23 (9.1) | |
| Car seat | 1 (1.2) | 0 (0.0) | 0 (0.0) | 1 (0.4) | |
| Missing | 31 (37.8) | 49 (45.0) | 18 (29.0) | 98 (38.7) | |
Data are number (%).
Of those who sustained head and facial injuries, children aged 6- to 12-years old were the largest group (49.4%). The same was true for patients who sustained facial injuries (Table 3). Males represented the majority of those who sustained head and facial injuries (74.2%, 73.8%, respectively). Six (2.3%) children died due to the injuries. We did not find a statistically significant association between incorrect child seating and head or facial injuries (Table 3).
Table 3.
Characteristics of the head and facial injuries in the study population.
| Total | Head Injuries | P value | Facial Injuries | P value | |||
|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | ||||
| Age group | .25 | .21 | |||||
| 0-5 | 82 (32.4) | 27 (27.8) | 55 (35.3) | 27 (30.7) | 55 (33.3) | ||
| 6-12 | 109 (43.0) | 48 (49.5) | 61 (39.1) | 44 (50.0) | 65 (39.4) | ||
| 13-16 | 62 (24.5) | 22 (22.7) | 40 (25.6) | 17 (19.3) | 45 (27.3) | ||
| Gender | .14 | .20 | |||||
| Female | 79 (31.2) | 25 (25.8) | 54 (34.6) | 23 (26.1) | 56 (33.9) | ||
| Male | 174 (68.8) | 72 (74.2) | 102 (65.4) | 65 (73.9) | 109 (66.1) | ||
| Region | .86 | .83 | |||||
| Riyadh | 190 (75.1) | 72 (74.2) | 118 (75.6) | 68 (77.2) | 122 (73.9) | ||
| Western | 23 (9.1) | 10 (10.3) | 13 (8.3) | 7 (8.0) | 16 (9.7) | ||
| Eastern | 40 (15.8) | 15 (15.5) | 25 (16.0) | 13 (14.8) | 27 (16.4) | ||
| Car seat / seatbelt | .138 | .237 | |||||
| Yes (%) | 4 (100.0) | 0 (0.0) | 4 (100.0) | 0 (0.0) | 4 (100.0) | ||
| No (%) | 123 (100.0) | 44 (35.8) | 79 (64.2) | 41 (32.8) | 84 (67.2) | ||
| Missing | 123 (100.0) | 53 (43.1) | 70 (57.0) | 47 (37.9) | 77 (62.1) | ||
| Child position | .31 | .58 | |||||
| Correct | 85 (33.6) | 32 (33.0) | 53 (34.0) | 30 (34.1) | 55 (33.3) | ||
| Incorrect | 61 (24.1) | 19 (19.6) | 42 (27.0) | 18 (20.5) | 43 (26.1) | ||
| Missing | 107 (42.3) | 46 (47.4) | 61 (39.1) | 40 (45.5) | 67 (40.6) | ||
| Outcome | .55 | .07 | |||||
| Alive | 247 (97.6) | 94 (97.0) | 153 (98.0) | 88 (100.0) | 159 (96.3) | ||
| Death | 6 (2.4) | 3 (3.1) | 3 (1.9) | 0 (0) | 6 (3.6) | ||
Data are number (%).
Of all head injuries, facial trauma accounted for the highest proportions (n=88, 34.8%), followed by brain injury (n=19, 7.5%). Skull fracture, facial fracture, and dental trauma were 3.6%, 2.1%, and 1.6%, respectively. The most common type of facial injury was abrasions, which were sustained in 52/93 (55.9%) of children. The second most common injury was a facial contusion, accounting for 34/59 (57.6%) of facial injuries, followed by laceration among 19/74 (25.6%) of the patients. Equally, 39.2% of children suffered from upper and lower extremities fractures while 17.8% and 10.7% of children sustained rib and spinal fractures, respectively (data not shown).
DISCUSSION
The study found that over a third of children injured in MVCs sustained head or facial injuries. This prevalence is striking and has major implications on population health. Head injuries are a leading cause of death and disability among children.24,25 Hence, further investment in traffic safety is warranted to facilitate primary prevention and to reduce preventable injuries. Despite existing laws that limit driving to those 18 years or above and mandate the use of child safety measures, the high prevalence of these violations may be due to the absence of effective enforcement systems.26 Saudi Arabia has made traffic safety a high priority by including it in the Vision 2030 initiative aimed to improve individual health and prosperity.27 Therefore, the study findings may support these efforts by engaging the public, clinicians, and policymakers in the implementation of public health interventions. Our findings can serve as a baseline assessment to guide future initiatives to improve the safety and wellbeing of children in the country.
Our findings lend credence to previous literature documenting the burden of injuries following MVCs on children's health.22,28-30 However, none of the pre vious national studies have evaluated the prevalence of head or facial injuries among occupants of motor vehicles.
The prevalence of head or facial injuries in the current study was substantially higher than that of other countries such as the United States and Australia.31 Among MVC patients, one study found that only 0.07% of children's injuries included facial fractures.32 Another population-based study of US children between the ages of 0-14 years found the prevalence of head injuries to be around 3%.33
Strikingly, only one child (0.4%) was restrained in a car seat. This is negligible compared to previous literature (n=123; 31.9%).17 A study in the United Arab Emirates found that none of injured children in MVC used car seats.34 Similar findings were observed in the US by Quiñones-Hinojosa et al stated that only six children (2.3%) were properly restrained.35 It is essential to recognize that wearing seatbelts among children who are supposed to be in a car seat can still pose a risk for injuries in case of crashes. One study found that children who were restrained in seatbelts were over four times more likely to sustain a significant head injury than children in a car seat or booster seats.36 Proper child restraint and seating position could have prevented most injuries, particularly those to the head.
Because as many as 51% of facial injuries among children lead to nose injuries, such injuries can lead to facial disfiguration.32,37 Consequently, if a disfiguration occurs, this may lead to a negative impact on children's mental health as well as their family.38 Further research is warranted to estimate the prevalence of permanent disabilities and disfiguration following MVCs in Saudi Arabia.
Our study did not find a significant association between safety measures and head or facial injuries. This does not represent evidence of their lack of benefit. This could be due to the small sample size of the study or missing observations, which leads to a lowering of the statistical power. Previous studies among children and adults have provided evidence of the value of complying with seatbelt or car seat laws.39 Arbogast et al found that unrestrained children had a 60% greater risk for facial injuries compared to appropriately restrained children.32
In our study, 53 children (20%) were sitting in the front seat. Previous studies suggest that children seated in the front were more likely to sustain more severe injuries.40 Similarly, another study found that children were at greater risk of serious injury when seated in front.41 Traffic police ought to investigate the prevalence of front seat violations further and plan for enforcement with public strategies to reduce safety measure violations and, ultimately, childhood injuries.
The prevalence of children in incorrect positions in this study may underestimate the true magnitude of the problem. Even among children seated in the back, they may have been sitting without correct age-appropriate safety measures. This is not in accordance with the AAP recommendations and does pose a risk for injuries and death.23 Proper car seats are available and affordable on the market, so the continued low compliance rate is unfortunate and poses a major risk to population health.42 Therefore, much work needs to be done to increase the awareness of parents of the risks associated with placing children in incorrect positions while vehicles are in motion. Moreover, awareness campaigns should be integrated into the school curriculums, and monitoring systems should be modified to ensure proper enforcement.
Public health professionals and clinicians can use the findings presented in this study to educate parents about the significance of proper seating position and age-appropriate restraints. Moreover, policymakers can use the study to facilitate the implementation of traffic safety rules and law enforcement measures that will preserve many lives and hundreds of millions of riyals. The country can also build on experience from neighboring countries, with similar characteristics, that implemented prevention programs to facilitate traffic safety.43
The Committee on Injury and Poison Prevention of the AAP states that all hospitals should set policies requiring newborns to be discharged in a car safety seat.44 This is the current practice in most hospitals in countries like the United States and Canada. However, this is not the case in Saudi Arabia. Such implementation will likely reduce traffic-related injuries among infants. Like other child protection initiatives, healthcare facilities in the country should push for legislation that ensures that all institutions comply with these guidelines in order to facilitate children's safety.
To our knowledge, this is the first multi-centered study to document the prevalence of facial and head injuries in children in Saudi Arabia. However, the study is not without limitations. One limitation is that it was a retrospective study, and we used the electronic search system to identify patients, so may have missed cases if clinicians had not specified that admissions were crash related. In addition, we limited our population to those admitted to the hospital. Specifically, if a child was injured in an MVC and then treated in the emergency department without inpatient admission, he or she was not captured in our dataset. This, in turn, may underestimate the burden of head or facial injuries. Another limitation was the large amount of missing values for variables such as safety measure use. Missing values remain a major challenge for empirical research on injuries in Saudi Arabia.45 In order to generate evidence and evaluate risk factors, there needs to be a major investment in comprehensive, high-quality data sources. Many successful examples of registries aimed to improve traffic safety exist in developed countries and can be adapted to support local efforts. Unlike various developed countries, there is yet to exist a national trauma registry in the country.
In conclusion, over a third of children injured following an MVC sustained head or facial injuries. This prevalence reflects the burden and cost of injuries due to MVCs. The study findings highlight the importance of combination or rear seating as well as age-appropriate restraint to reduce the likelihood of head or facial injuries and improve population health. Finally, investment in national registries of traffic injuries can facilitate data-driven decision making to improve traffic safety in Saudi Arabia. We recommended strategies to increase car seat use such as car restraint laws appropriate for age, height and weight, an enhanced enforcement program, wide advertisement in the media and prevention education program for parents and caregivers.
Funding Statement
None.
REFERENCES
- 1.Global Status Report on Road Safety. Geneva, Switzerland: 2018. [Google Scholar]
- 2.Ramdzan SN, Liew SM, Khoo EM. Unintentional injury and its prevention in infant: Knowledge and self-reported practices of main caregivers. BMC Pediatr 2014;14(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Foreman KJ, Marquez N, Dolgert A, Fukutaki K, Fullman N, McGaughey M, et al. Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016–40 for 195 countries and territories. Lancet 2018;392(10159):2052–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Global Status Report on Road Safety 2018. [DOI] [PubMed]
- 5.Mansuri FA, Al-Zalabani AH, Zalat MM, Qabshawi RI. Road safety and road traffic accidents in Saudi Arabia: A systematic review of existing evidence. Saudi Med J [Internet] 2015;36(4):418–24. Available from: http://www.smj.org.sa/index.php/smj/article/view/smj.2015.4.10003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Al-Naami MY, Arafah MA, Al-Ibrahim FS. Trauma care systems in Saudi Arabia: an agenda for action. Ann Saudi Med [Internet] 30(1):50–8. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2850182%7B&%7Dtool=pmcentrez%7B&%7Drendertype=abstract [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Brown JK, Jing Y, Wang S, Ehrlich PF. Patterns of severe injury in pediatric car crash victims: Crash Injury Research Engineering Network database. In: Journal of Pediatric Surgery. 2006;362–7. [DOI] [PubMed]
- 8.Consunji R, Malik S, El-Menyar A, Mollazehi M, Al-Thani H, Peralta R. Pediatric road traffic injuries in Qatar: Evidence for a developmental stage approach to road safety. Qatar Med J. 2020;2020(1):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers Dis Control Prev Natl Cent Inj Prev Control [Internet] 2010;891–904. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23630120 [Google Scholar]
- 10.McCarthy ML, MacKenzie EJ, Durbin DR, Aitken ME, Jaffe KM, Paidas CN, et al. Health-related quality of life during the first year after traumatic brain injury. Arch Pediatr Adolesc Med 2006;160(3):252–60. [DOI] [PubMed] [Google Scholar]
- 11.Tingvall C. Some aspects of the safety of children as car passengers in road traffic accidents. acta Paediatr. 1987;76(339):1–35. [DOI] [PubMed] [Google Scholar]
- 12.Peterson A. Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths-United States, 2014. Centers Dis Control Prev US Dep Heal Hum Serv 2019;
- 13.Hanna R. Children Injured in Motor Vehicle Traffic Crashes (DOT HS 811 325 Tec). Natl Highw Traffic Saf Adm 2010;(May):27.
- 14.Facts T. National Highway Traffic Safety Administration. US Dep Transp 2002;809(616). [Google Scholar]
- 15.Chan M. The Global status report on road safety 2013 [Internet]. Geneva: 2013. Available from: http://www.who.int/violence%7B_%7Dinjury%7B_%7Dprevention/road%7B_%7Dsafety%7B_%7Dstatus/2013/report/en/index.html [Google Scholar]
- 16.El-Menyar A, Consunji R, Asim M, Abdelrahman H, Zarour A, Parchani A, et al. Underutilization of occupant restraint systems in motor vehicle injury crashes: A quantitative analysis from Qatar. Traffic Inj Prev 2016;17(3):284–91. [DOI] [PubMed] [Google Scholar]
- 17.Alsanea M, Masuadi E, Hazwani T. Use of child restraint system and patterns of child transportation in Riyadh, Saudi Arabia. PLoS One 2018;13(1):e0190471. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Alowirdi FS, Al-harbi SA, Abid O, Aldibasi OS, Jamil SF. Assessing parental awareness and attitudes toward leaving children unattended inside locked cars and the risk of vehicular heat strokes. Int J Pediatr Adolesc Med [Internet] 2019;(xxxx):0–4. Available from: 10.1016/j.ijpam.2019.11.004 [DOI] [PMC free article] [PubMed]
- 19.Ageli MM, Zaidan AM. Road Traffic Accidents in Saudi Arabia: An ARDL Approach and Multivariate Granger Causality. Int J Econ Financ 2013;5(7):26–31. [Google Scholar]
- 20.Alghnam S, Palta M, Hamedani A, Alkelya M, Remington PL, Durkin MS. Predicting in-hospital death among patients injured in traffic crashes in Saudi Arabia. Injury [Internet] 2014;45(11):1693–9. Available from: 10.1016/j.injury.2014.05.029 [DOI] [PubMed] [Google Scholar]
- 21.Alghnam S, Towhari J, Alkelya M, Binahmad A, Bell TM. The effectiveness of introducing detection cameras on compliance with mobile phone and seatbelt laws: a before-after study among drivers in Riyadh, Saudi Arabia. Inj Epidemiol [Internet] 2018. [cited 2019 Feb 16];5(1):31 Available from: http://www.ncbi.nlm.nih.gov/pubmed/30079438 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Abdullah WA, Al-Mutairi K, Al-Ali Y, Al-Soghier A, Al-Shnwani A. Patterns and etiology of maxillofacial fractures in Riyadh City, Saudi Arabia. Saudi Dent J 2013;25(1):33–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Durbin DR, Gardner HG, Baum CR, et al. Policy statement - Child passenger safety. Pediatrics. 2011;127(4):788–93. [DOI] [PubMed] [Google Scholar]
- 24.Ichikawa R, Maeda Y, Shibuya A, Umesato Y, Kondo Y, Maeda T, et al. Prediction of Poor Prognosis After Severe Head Injury in Children Using Logistic Regression. Pediatr Emerg Care [Internet] 2018. [cited 2020 Apr 20];34(12):825–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29095390 [DOI] [PubMed] [Google Scholar]
- 25.Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg [Internet] 2019. [cited 2020 Apr 20];130(4):1080–97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29701556 [DOI] [PubMed] [Google Scholar]
- 26.DeNicola E, Aburizaize OS, Siddique A, Khwaja H, Carpenter DO. Road Traffic Injury as a Major Public Health Issue in the Kingdom of Saudi Arabia: A Review. Front Public Heal [Internet] 2016;4:215 Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5044776/ [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Dahim MAH. Impact of vision 2030 on traffic safety in Saudi Arabia. Int J Pediatr Adolesc Med [Internet] 2018;5(3):103–9. Available from: 10.1016/j.ijpam.2018.08.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Alghnam S, Towhari JA, Al Babtain I, Al Nahdi M, Aldebasi MH, Alyami M, et al. The associations between injury mechanism and extended hospital stay among pediatric patients: Findings from a trauma Center in Saudi Arabia. BMC Pediatr 2019;19(1):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Alhabdan S, Zamakhshary M, Alnaimi M, Mandora H, Alhamdan M, Al-Bedah K, et al. Epidemiology of traumatic head injury in children and adolescents in a major trauma center in Saudi Arabia: Implications for injury prevention. Ann Saudi Med 2013;33(1):52–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Lawoyin TO, Lawoyin DO, Lawoyin JO. Factors associated with oro-facial injuries among children in Al-Baha, Saudi Arabia. Afr J Med Med Sci [Internet] 2002. [cited 2020 Apr 21];31(1):37–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12518927 [PubMed] [Google Scholar]
- 31.El-Matbouly M, El-Menyar A, Al-Thani H, Tuma M, El-Hennawy H, AbdulRahman H, et al. Traumatic brain injury in Qatar: Age matters - Insights from a 4-year observational study. Sci World J 2013;2013. [DOI] [PMC free article] [PubMed]
- 32.Arbogast KB, Durbin DR, Kallan MJ, Menon RA, Lincoln AE, Winston FK. The role of restraint and seat position in pediatric facial fractures. J Trauma 2002;52(4):693–8. [DOI] [PubMed] [Google Scholar]
- 33.Viano DC, Parenteau CS, Xu L, Faul M. Head injuries (TBI) to adults and children in motor vehicle crashes. Traffic Inj Prev 2017;18(6):616–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Grivna M, Eid HO, Abu-Zidan FM. Pediatric and Youth Traffic-Collision Injuries in Al Ain, United Arab Emirates: A Prospective Study. PLoS One 2013;8(7):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Quiñones-Hinojosa A, Jun P, Manley GT, Knudson MM, Gupta N. Airbag deployment and improperly restrained children: A lethal combination. J Trauma - Inj Infect Crit Care 2005; [PubMed]
- 36.Winston FK, Durbin DR, Kallan MJ, Moll EK. The Danger of Premature Graduation to Seat Belts for Young Children. Pediatrics [Internet] 2000. [cited 2020 Apr 20];105(6):1179–83. Available from: http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.105.6.1179 [DOI] [PubMed] [Google Scholar]
- 37.Converse JM. Facial Disfigurement in Automobile Accidents. JAMA [Internet] 1963. [cited 2020 Apr 20];185(5):354 Available from: http://jama.jamanet-work.com/article.aspx?doi=10.1001/jama.1963.03060050032016 [DOI] [PubMed] [Google Scholar]
- 38.Rusch MD, Grunert BK, Sanger JR, Dzwierzynski WW, Matloub HS. Psychological Adjustment in Children after Traumatic Disfiguring Injuries: A 12-Month Follow-Up. Plast Reconstr Surg [Internet] 2000. [cited 2020 Apr 20];106(7):1451–8. Available from: http://insights.ovid.com/crossref?an=00006534-200012000-00001 [DOI] [PubMed] [Google Scholar]
- 39.Park GJ, Ro YS, Shin S Do, Song KJ, Hong KJ, Jeong J. Preventive effects of car safety seat use on clinical outcomes in infants and young children with road traffic injuries: A 7-year observational study. Injury [Internet] 2018;49(6):1097–103. Available from: 10.1016/j.injury.2018.04.001 [DOI] [PubMed] [Google Scholar]
- 40.Ehrlich PF, Brown JK, Sochor MR, Wang SC, Eichelberger ME. Factors influencing pediatric Injury Severity Score and Glasgow Coma Scale in pediatric automobile crashes: results from the Crash Injury Research Engineering Network. J Pediatr Surg 2006;41(11):1854–8. [DOI] [PubMed] [Google Scholar]
- 41.Newgard CD, Lewis RJ. Effects of child age and body size on serious injury from passenger air-bag presence in motor vehicle crashes. Pediatrics [Internet] 2005. [cited 2020 Apr 20];115(6):1579–85. Available from: http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2004-0555 [DOI] [PubMed] [Google Scholar]
- 42.Consunji R, Malik S, Allen KA, Mehmood A, Tariq T, Hyder AA, et al. A rapid market survey on the availability of car seats in Qatar: Implications for child passenger safety. Qatar Med J 2019;2019(1):1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Consunji R, Mekkodathil A, Abeid A, El-Menyar A, Al-Thani H, Sekayan T, et al. Applying the five-pillar matrix to the decade of action for road safety in Qatar: Identifying gaps and priorities. Trauma Surg Acute Care Open 2018;3(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Keller K. Safe Transportation of Newborns at Hospital Discharge. Pediatrics [Internet] 1999;104(4):986–7. Available from: http://sk.sagepub.com/reference/obesity/n14.xml [PubMed] [Google Scholar]
- 45.Alghnam S, Alkelya M, Al-Bedah K, Al-Enazi S. Burden of traumatic injuries in Saudi Arabia: lessons from a major trauma registry in Riyadh, Saudi Arabia. Ann Saudi Med 2014;34(4):291–6. [DOI] [PMC free article] [PubMed] [Google Scholar]