Published online August 1, 2006
PEDIATRICS Vol. 118 No. 2 August 2006, pp. 739-745 (doi:10.1542/peds.2006-0711)
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ARTICLE

Improving Safety-Restraint Use by Children in Shopping Carts: Evaluation of a Store-Based Safety Intervention

Gary A. Smith, MD, DrPH

Department of Pediatrics, The Ohio State University College of Medicine and Public Health, and Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, Columbus, Ohio


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: OBSERVATION DATA FORM
 REFERENCES
 
OBJECTIVE. Approximately 20700 children who are <5 years old are treated in US hospital emergency departments annually for shopping cart–related injuries. The objective of this study was to evaluate the effectiveness of an in-store intervention to increase the use of restraints in shopping carts by children who are <5 years old.

METHODS. The study intervention consisted of greeters at the store entrance who encouraged the use of appropriate shopping cart restraints plus the use of a small cash coupon incentive. The study used a preintervention and postintervention design with an untreated "control" group. Three stores served as intervention stores, and 4 stores served as nonintervention stores. Trained study personnel conducted the observations unobtrusively in all 7 stores simultaneously, recording the status of children's restraint use in the shopping cart as caregivers approached store checkout areas. The main outcome measure of the study was the change in the proportion of children who were <5 years old, riding in a shopping cart, and restrained correctly.

RESULTS. There were a total of 967 observations, 57% of which were in the 4 nonintervention stores and 43% of which were in the 3 intervention stores. There were 442 observations on the baseline day and 525 on the follow-up day. Interrater reliability was good. Overall, among the 761 cases in which a shopping cart was used, 38% of children were transported in the shopping cart seat with the restraint off or used improperly, and 24% were seated with the restraint used correctly. In the 4 nonintervention stores, the percentage of children who were in shopping carts and restrained correctly increased from 19% at baseline to 31% during the follow-up observation period 1 week later. In the 3 intervention stores, the percentage of correct restraint use among children in shopping carts went from 15% at baseline to 49% after the intervention during the second observation period. The change in correct restraint use among children in shopping carts in intervention stores was significantly greater than that in nonintervention stores.

CONCLUSIONS. A safety intervention, consisting of a $2 incentive coupon plus greeters at the store entrance who encouraged the use of appropriate shopping cart restraints, significantly increased the correct use of restraints among young children who rode in shopping carts. The correct use rate increased to 49% in stores with this modest intervention. However, half of the young children in shopping carts remained unrestrained or restrained incorrectly. Higher rates of correct restraint use may occur with a more comprehensive and sustained shopping cart safety intervention. Shopping cart designs that seat children close to the floor and that do not rely on caregiver behavior change and vigilance for injury protection also should be implemented and evaluated as a passive strategy to prevent shopping cart–related injuries to young children.

Key Words: pediatric • children • injury • trauma • falls • shopping cart • restraint • seat belt • prevention

Abbreviations: ASTM—American Society for Testing and Materials

Shopping carts are an important source of injury among children who are younger than 5 years.1–9 An estimated 20700 children who were younger than 5 years were treated in US hospital emergency departments for shopping cart–related injuries in 2005.10 Approximately 4% of these children required hospital admission.10 A fracture is the most common (45%) diagnosis that results in hospitalization.1 Head and neck injuries account for 79% of shopping cart–related injuries that require emergency treatment.1 Deaths have been reported from falls from shopping carts and cart tipovers.11,12

Interventions to prevent shopping cart–related injuries are based on the mechanisms of injury. The most frequent mechanism is a fall from the cart, followed by cart tipover. Data from 1 study demonstrated that falls and cart tipovers accounted for 58% and 26% of shopping cart–related injuries, respectively, with injuries caused by a tipover occurring primarily among children who were younger than 2 years.2 The current study focused on prevention of the main mechanism of injury (falls) by conducting an in-store intervention that promoted the use of restraints for children while riding in shopping carts. Ferrari and Baldwin13,14 are the only other investigators, to our knowledge, to evaluate in-store interventions to increase shopping cart safety behaviors to protect young children from injury. In contrast to these previous investigators, we used a different intervention in this study that included greeters at the entrance of stores and "cash off at the register" incentive coupons. To our knowledge, our study is the first to report the use of an incentive to promote in-store shopping cart safety behaviors.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: OBSERVATION DATA FORM
 REFERENCES
 
An evaluation of a shopping cart safety intervention was conducted in the Columbus, Ohio, area at stores of a large national supermarket chain. The study used a preintervention and postintervention design with an untreated "control" group. Three stores served as intervention stores, and 4 stores served as nonintervention stores. Nonintervention stores were chosen to be similar to intervention stores with respect to store size, shopper volume, and community demographics (Table 1). Baseline observations were conducted simultaneously in all 7 stores by trained observers from Children's Hospital regarding the correct use of child restraints for children who were younger than 5 years and riding in shopping carts. The baseline observation period was on a Saturday from 11:00 AM to 3:00 PM, and there were 2 or 3 observers in each store. A field supervisor visited each store during the observation period to be sure that the study was proceeding without difficulty. Supervisors also participated in the evaluation of interrater reliability of study observations. One week later on the next Saturday, observations were repeated during an identical 4-hour period by the same observers in the same 7 stores. The shopping cart safety intervention was conducted in the intervention stores during the second observation period.


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  		TABLE 1. Demographic Information Regarding the Populations Living in Each Store's Zip Code Area

 
The intervention consisted of stationing at the entrance of each intervention store on the second observation day 2 adult greeters who were study personnel and were instructed to approach adults who entered the store with young children and ask whether their child was going to ride in a shopping cart. When a shopper answered affirmatively, the greeter politely encouraged the caregiver to secure the child using a safety restraint provided with the cart. Caregivers were given a coupon for $2 off at the cash register as an incentive to use a child restraint as they entered the store. All eligible caregivers were approached by the greeters, and all caregivers received the incentive coupon regardless of their compliance with the request to use a shopping cart safety restraint.

Four types of shopping cart restraint systems were available for use at stores in this study. A 2-point lap belt was available in almost all shopping carts. Shop-A-Long attachments were installed on 1 or 2 carts at each store. These devices provide a seating area with restraints for 2 children outside the cart at the rear, between the basket and the caregiver who is pushing the shopping cart. In addition, an infant carrier was bolted across the top of the cart basket of 1 or 2 carts at each store. The fourth type of shopping cart restraint used in this study was the Petey Harness, which is a 5-point harness that attached to a rigid seat back, which was installed in the seating area of 15 to 25 shopping carts at each store. Before this study, Petey Harnesses were not found in these stores; they were installed in carts as part of the study.

The main outcome measure of the study was the change in the proportion of children who were younger than 5 years and riding in a shopping cart and were restrained correctly. This was calculated by dividing the number of observations for item 8f by the sum of the observations for items 8b, 8c, 8d, 8e, and 8f on the Observation Data Form (see Appendix). A child was considered to be restrained correctly when he or she was positioned correctly in an age/size-appropriate restraint with the straps crossing the body at the appropriate location(s) and buckled. Examples of incorrect use of a restraint include the straps' crossing the wrong part of the body; the straps' being tied together rather than buckled; or the child's being out of position, such as facing the wrong way in a seat. The snugness of the restraint was not assessed, because of the difficulty in determining this by observation. The chosen outcome measure is the best evaluation of the intervention, because greeters instructed caregivers to use a restraint for children who were riding in a cart. They were not educating caregivers about other possible safe shopping behaviors, such as having the child walk along while the caregiver used a shopping cart or not using a cart at all. This outcome measure excludes children who were not in the cart, even though the adult caregiver was using a cart. It also excludes children who were with an adult caregiver who was shopping without a cart. This study tested the hypothesis that the safety intervention led to a greater increase in the proportion of children who were in shopping carts and were restrained correctly in intervention stores compared with the change in the proportion in nonintervention stores.

The age and the gender of children were estimated by observers, on the basis of visual cues, such as size and height (age) and style of dress, facial features, and length and style of hair (gender). Child's age was recorded by observers in 1-year age groups; however, age was aggregated as younger than 5 years for statistical analyses because of the inherent difficulty in determining age by 1-year age groups among young children. Observers conducted the observations unobtrusively, while standing near the checkout area of the store. The status of children's restraint use was observed and recorded once as the caregiver approached the store checkout area with the shopping cart. An observation data form was used by observers in this study (see Appendix). Observers were given a 1-hour training session before beginning the study to discuss the importance of shopping cart safety and to familiarize them with the study observation data instrument, shopping cart features, and types of safety restraints. A total of 19 observers and 6 field supervisors participated during the 2 study observation periods.

Data were analyzed using EpiInfo software.15 Statistical analysis was performed using the 1-tailed 2-sample test for binomial proportions. A difference between groups was considered to be statistically significant at P < .05. Interrater reliability was calculated using the {kappa} statistic and was considered to be good for values >0.7. This study was approved by the Human Subjects Research Committee of Children's Hospital with a waiver of written informed consent from individuals who were observed during this study.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 APPENDIX: OBSERVATION DATA FORM
 REFERENCES
 
There were 442 (46%) observations on the baseline day and 525 (54%) observations on the follow-up day, yielding a total of 967 observations. Forty-three percent (417) of observations were in the 3 intervention stores, and the remaining 57% (550) were in the 4 control stores. The child was a male in 49% of cases. The distribution of estimated age of observed children was as follows: younger than 1 year, 108 (11.2%); 1 year, 96 (9.9%); 2 years, 183 (18.9%); 3 years, 256 (26.5%); and 4 years, 324 (33.5%). However, age was aggregated as younger than 5 years for all statistical analyses. The gender of the adult caregiver was female in 71% (683) of cases and male in 21% (200), and there was both a male and a female caregiver in 8% (84) of cases. There was at least 1 other child accompanying the adult caregiver in addition to the child being observed in 46% (445) of cases. The range in the number of other children was 1 to 5 children, with 1 additional child in 69% (306 of 445) of multichild cases, 2 children in 23% (101 of 445) of these cases, and 3 or more children in 8% (38 of 445) of these cases.

A shopping cart was used by 79% (761) of adult caregivers, whereas 21% (206) of adults with a young child chose to shop without using a cart. Among cases in which a cart was not used, 80% (164 of 206) of children walked, 16% (34 of 206) were carried, and 4% (8 of 206) were in a stroller. Among the 761 cases in which a shopping cart was used, 38% (288 of 761) of children were transported in the shopping cart seat with the restraint off or used incorrectly, and 24% (181 of 761) were seated with the restraint used correctly (Table 2).


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  		TABLE 2. Location of Child When Caregivers Used a Shopping Cart

 
In the 4 nonintervention stores, 19% (33 of 174) of children who were younger than 5 years and were riding in a shopping cart were restrained correctly during the baseline observation period. This increased to 31% (63 of 204) during the follow-up observation period 1 week later. In the 3 intervention stores, 15% (19 of 124) of children who were younger than 5 years and riding in a shopping cart were restrained correctly during the baseline observation period. After the intervention, during the second observation day, the proportion of children who were restrained correctly in carts increased to 49% (66 of 134). In other words, the proportion of young children who were restrained correctly in shopping carts increased by 12 percentage points in nonintervention stores compared with an increase of 34 percentage points in intervention stores, when baseline observations were compared with follow-up observations 1 week later. The change in correct restraint use among children in shopping carts in intervention stores was significantly greater than that in nonintervention stores (P = .002).

Interrater reliability was calculated for 146 cases in which an observer and a supervisor recorded observational data on the same child. Only cases in which a cart was used were included in this calculation, and observations were dichotomized into children who were restrained correctly in the cart seat and those who were not. Of the 146 cases, the observer and the supervisor agreed in 128 (87.7%) and disagreed in 18 (12.3%). Because observers and supervisors might agree by chance alone, a {kappa} statistic was calculated to adjust for chance agreement. The value of the {kappa} statistic in this study was 0.71, which indicates good interrater reliability.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 APPENDIX: OBSERVATION DATA FORM
 REFERENCES
 
Strategies to prevent injuries that are associated with shopping carts include shopping cart redesign, use of restraints for child passengers in shopping carts, adult supervision, and providing alternatives to placing children in carts while caregivers shop. Shopping cart redesign to prevent falls and tipovers passively, or automatically, offers the best protection against shopping cart–related injuries because it obviates the need for frequent human action and vigilance.16 Adequate safety design must provide for effective child restraint and cart stability to prevent falls from the cart and cart tipovers, respectively. The most commonly used restraint is a lap belt. However, 3-point or 5-point harnesses are used in some shopping carts in the cart seat area, in infant carriers that are bolted across the top of the cart basket, or in combination with an attachment to shopping carts (Shop-A-Long attachment) that places toddler-aged children on plastic seats between the shopper and the rear of the cart. All of these restraint options were available to shoppers for use in the current study.

Child restraint systems in shopping carts have limitations. All currently available systems are active rather than passive and therefore require the shopper initially to secure the child correctly in the restraint and to remain vigilant to ensure that the child stays in the restraint. The effectiveness of shopping cart restraints in preventing falls is unknown, and they do not protect adequately against injuries when a shopping cart tips over. Harrell and Reid17 demonstrated that children who were restrained in the seat of a shopping cart were less likely to handle potentially dangerous household products, but they did not address the influence of restraint use on falls from shopping carts.

Because the severity of a fall is related directly to the height of the fall, locating the seating position for a child closer to the ground is a desirable modification of cart design. Some cart designs have incorporated this solution by locating the child in a stroller-like seat or a miniature model of a motor vehicle in front of the shopping cart basket.18,19 Placing the child in a lower seat position in the cart also lowers the center of gravity and, thereby, decreases cart tipover potential. These modifications also accommodate toddlers and preschool children, who are too big to fit in the typical seating position in a cart and who, therefore, often are placed unrestrained in the cart basket. Because shopping cart–related injuries to toddlers and preschool children commonly result from a fall from the cart basket, these cart modifications offer an important alternative location for these children to ride more safely.

Parents and other child caregivers cannot be expected to ascertain the effectiveness of a shopping cart restraint system or the relative stability of a shopping cart by visual inspection. For this reason, an effective US performance standard for shopping carts is needed. Shopping cart standards exist in 19 European countries (European Standard EN 1929-1:199820) and Australia and New Zealand (AS/NZS 3847.1:199921). European Standard EN 1929-1:1998 includes a cart stability test but does not contain specifications for shopping cart child safety restraints.20 The joint Australian/New Zealand Standard AS/NZS 3847.1:1999 includes a cart stability test and a child restraint requirement. However, there is no performance standard for the restraint system. The standard states that the child restraint "may take any form, examples being a strap or straps or a tray table. If straps are provided, the minimum shall be a waist strap or straps."21 A shopping cart safety performance standard for the United States should include a clear and comprehensive performance requirement for the child safety-restraint system in the cart.

Attempts to establish a safety standard for shopping carts in the United States date back to at least 1975. The Consumer Product Safety Commission denied petitions to promulgate mandatory standards for shopping carts in 1975,22 automatic child restraints in carts in 1994,23 and shopping cart stability in 1998.24 At the time the petition was denied in 1975, the industry indicated that it would pursue development of a voluntary standard for shopping carts. Twenty-seven years later, in September 2002, American Society for Testing and Materials (ASTM) International formed Subcommittee F15.56 on Shopping Carts to develop a voluntary standard for shopping carts. The Standard Consumer Safety Performance Specification for Shopping Carts F2372-04 was published in July 2004.25 However, unlike the existing standards in 21 other countries, the US standard does not address shopping cart stability. In addition, ASTM F2372-04 does not specify an adequate performance standard for shopping cart restraint systems. Therefore, the ASTM F2372-04 standard does not address adequately the leading mechanisms of shopping cart–related injury to children: falls and cart tipovers.8

Although poor adult supervision has been cited as a risk factor for shopping cart–related near-injuries to children in grocery stores,26 supervision by an adult caregiver, when used as the sole prevention strategy, is insufficient to prevent these injuries. Parents are present at the time of injury in >90% of shopping cart–related injury episodes.2 Because it is difficult to browse store shelves and supervise closely a child in a shopping cart at the same time, it is not surprising that >80% of adults leave their children unattended at least once during a shopping trip.17 Shopping cart–related injuries occur quickly and unexpectedly, often in the time it takes to reach for something on a shelf.

Holden27 studied parental supervision in grocery stores and found that parents frequently practice measures to keep their children safe and away from displayed products. Parents often push the cart down the center of the aisle away from shelves; skip the aisles with attractive nuisances; and distract children with conversation, toys, and food. In addition, attempts have been made to teach children appropriate shopping behavior through parent training in the supermarket setting using traditional behavior management techniques.28 However, the effectiveness of these measures to prevent child injury is unproved.

Several additional strategies sometimes are available to parents. Some stores provide a supervised play area for children as an alternative to placing them in a cart while caregivers shop. Use of a stroller, front pack, or backpack is an option for some caregivers instead of transporting a child in a shopping cart. In addition, an older child can be asked to walk.

Four criteria have been identified for an effective prompting intervention. To increase the frequency of a desired behavior, a prompt or message should be (1) stated politely, (2) stated clearly, (3) specific to the desired response behavior, and (4) presented in immediate proximity to the behavior.29 The intervention used in our study met these criteria.

Ferrari and Baldwin13,14 are the only other investigators, to our knowledge, who have evaluated in-store interventions to increase shopping cart safety behaviors to protect young children from injury. They demonstrated in a short-term study that an intensive educational effort (prompt-only group) with fliers, signs, and taped messages over the public address system in stores resulted in a change in shopping cart seatbelt usage from 1% to 14%. During another study intervention condition, in addition to these prompts, a male experimenter approached shoppers with young children to encourage use of seatbelts (prompt plus personal contact group). Belt usage increased to 51% in this group. The authors concluded that prompts with personal contact were more effective than prompts alone in increasing shopping cart seatbelt usage.13 However, their study did not evaluate the effects of the personal contact approach alone, an incentive intervention, or the combination of personal contact and use of incentives, such as was done in our investigation. In another short-term study, Ferrari and Baldwin14 showed that use of prompts alone (fliers, posters, buttons, and a taped message) without personal face-to-face contact raised belt usage from 15% to 32% in 1 store and from 10% to 27% in a second store. In addition, different gender combinations of the child and adult caregiver did not significantly influence safety belt use outcome.

In our study, the 49% correct restraint use rate among children in shopping carts in intervention stores after the intervention is a substantial increase, given that the correct use rate started at 15% and given the limited scope of the intervention. This observed increase is similar to that reported by Ferrari and Baldwin13 among the group of subjects in their study, who received face-to-face personal contact with a study team member. However, their study used intensive educational messages with fliers, signs, and taped messages, whereas we provided a small incentive without additional storewide prompts. To our knowledge, our study is the first to report the use of an incentive to promote shopping cart safety behaviors. Although one half of young children remained unrestrained or restrained incorrectly in our study, the increase in correct use of restraints may be even higher if a more comprehensive and sustained shopping cart safety intervention were implemented. In addition to using greeters to encourage shopping cart restraint use, a more comprehensive intervention might include having greeters encourage children to walk rather than ride in a cart or to use an in-store supervised child care area. Informational signs, fliers, and public address system announcements within stores to remind shoppers about safe shopping cart use also could reinforce appropriate safety behaviors, as demonstrated by Ferrari and Baldwin.13,14 Incentives for shoppers that are contingent on adoption of the desired safety behavior may result in higher rates of behavior change. In the current study, shoppers received the $2 coupon as they entered the store, regardless of their subsequent decision about restraining their child correctly in a shopping cart. Training of store personnel regarding the importance of shopping cart safety and how to reinforce appropriate safety behaviors by shoppers will be vital to a comprehensive and sustained intervention. During the current study, store personnel received no training and therefore were not able to reinforce a consistent safety message to shoppers. Although greeters routinely are employed at some stores, possible alternative strategies include a taped message that is triggered when a shopper enters a store or periodic announcements in the store entrance area where shopping carts are parked. These prompts might help to sustain restraint use by repeat shoppers, once that behavior is established by the use of greeters and other measures.

This study had some limitations. First, the intervention was short-term. It is uncertain whether the effectiveness of the study intervention would be sustained over time. Perhaps repeat shoppers would become accustomed to the messages from greeters and the incentives, and, therefore, the frequency of the desired behavior possibly could decrease over time. Alternatively, the reinforced desired behaviors may become routine over time with repeat shoppers. In addition, restraint nonusers might choose to use a restraint once most of the shoppers around them are using them. This would represent a shift in the "social norm" among shoppers. A second possible study limitation was that the status of children's restraint use was recorded once as the caregiver approached the store checkout area with the shopping cart, and restraint use elsewhere in the store was not observed. However, shoppers rarely switch between nonuse and use of shopping cart restraints once they are in a store. In 1 study, shoppers were observed to switch <0.2% of the time.14 Another limitation of the study included that the snugness of the restraint could not be assessed, because of the difficulty in determining this by observation. Snugness of fit would be important for adequate restraint and protection from a fall. Finally, the generalizability of our findings is a possible limitation of our relatively small study in 1 group of stores in 1 city. However, the findings of our study are similar to those of other authors,13 which supports their external validity.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
APPENDIX: OBSERVATION DATA FORM
 REFERENCES
 
A safety intervention that consisted of a $2 incentive coupon plus greeters at the store entrance who encouraged the use of appropriate shopping cart restraints significantly increased the correct use of restraints among young children who were riding in shopping carts. The correct use rate increased to 49% in stores with this modest intervention. However, one half of young children in shopping carts remained unrestrained or restrained incorrectly. Higher rates of correct restraint use may occur with a more comprehensive and sustained shopping cart safety intervention. Shopping cart designs that seat children close to the floor and that do not rely on caregiver behavior change and vigilance for injury protection also should be implemented and evaluated as a passive strategy to prevent shopping cart–related injuries to young children.


   APPENDIX: OBSERVATION DATA FORM
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: OBSERVATION DATA FORM
REFERENCES
 

  1. Observer's initials: ___
  2. Store no. (circle one): 1; 2; 3; 4; 5; 6; 7
  3. Estimated child's age (years): <1; 1; 2; 3; 4; Other: ___
  4. Child's gender: Male; Female; Uncertain
  5. Primary adult caregiver's gender: Male; Female; Uncertain
  6. Accompanied by other child(ren): No; Uncertain; Yes, give number: ___
    Observed Behavior
  7. No cart used: child is (circle one): Walking; Carried; In stroller; In-store child care; Other: ___
  8. Cart used
    1. Child not in cart: child is (circle one): Walking; Carried; In stroller; In-store child care; Other: ___
    2. Child riding in cart: child is (circle one): Hanging on outside; In basket; Other: ___
    3. Child seated/no restraint on cart
    4. Child seated/restraint off (circle one): Seatbelt; Harness; Shop-A-Long; Infant carrier; Other: ___
    5. Child seated/restraint used incorrectly (circle one): Seatbelt; Harness; Shop-A-Long; Infant carrier; Other: ___
    6. Child seated/restraint used correctly (circle one): Seatbelt; Harness; Shop-A-Long; Infant carrier; Other: ___

  9. Comments: ___


   ACKNOWLEDGMENTS
 
Brenda J. Shields, MS, is gratefully acknowledged for assistance with data analysis. Jean Powers, PhD, also is acknowledged for statistical advice and support. In addition, the secretarial assistance of Lisa Erb is recognized with sincere thanks.


   FOOTNOTES
 
Accepted May 15, 2006.

Address correspondence to Gary A. Smith, MD, DrPH, Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: gsmith{at}chi.osu.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX: OBSERVATION DATA FORM
 REFERENCES
 

  1. Smith GA, Dietrich AM, Garcia CT, Shields BJ. Epidemiology of shopping cart–related injuries to children: an analysis of national data for 1990 to 1992. Arch Pediatr Adolesc Med. 1995;149 :1207 –1210[Abstract/Free Full Text]
  2. Smith GA, Dietrich AM, Garcia CT, Shields BJ. Injuries to children related to shopping carts. Pediatrics. 1996;97 :161 –165[Abstract/Free Full Text]
  3. Parry ML, Morrison LG, Chalmers DJ, Wright CS. Shopping trolley-related injuries to children in New Zealand, 1988–97. J Paediatr Child Health. 2002;38 :51 –54[CrossRef][Web of Science][Medline]
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  8. Smith GA; American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. Technical report: shopping cart–related injuries to children. Pediatrics. 2006;118(2) . Available at: www.pediatrics.org/cgi/content/full/118/2/e540
  9. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. Policy statement: shopping cart–related injuries to children. Pediatrics. 2006;118 :825 –827[Abstract/Free Full Text]
  10. US Consumer Product Safety Commission. National Electronic Injury Surveillance System Data for 2005 [from database]. Washington, DC: US Consumer Product Safety Commission; 2006
  11. US Consumer Product Safety Commission. National Injury Information Clearing House Reported Incident File for Grocery/Shopping Carts (Code 1679) January 1991–June 1993. Washington, DC: US Consumer Product Safety Commission; 1993
  12. Centers for Disease Control and Prevention. Deaths associated with infant carriers—United States, 1986–1991. MMWR Morb Mortal Wkly Rep. 1992;41 :271 –272[Medline]
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  18. Showalter K. Rolling to Sears' aid. Columbus Business First. November 24, 2000;17 :A1
  19. Lee E. Go, cart, go: parents and children alike scramble for new grocery carts that keep youngsters happy and let mothers shop in peace. Atlanta Journal-Constitution. June 10, 2002;1E
  20. European Committee for Standardization. European Standard EN 1929-1: 1998. Basket Trolleys: Part 1—Requirements and Tests for Basket Trolleys With or Without a Child Carrying Facility. Brussels, Belgium: European Committee for Standardization (CEN); 1998
  21. Council of Standards Australia and Council of Standards New Zealand. Joint Australian/New Zealand Standard AS/NZS 3847.1:1999. Shopping Trolleys: Part 1— For General Use. Homebush, Australia: Standards Australia; 1999
  22. US Consumer Product Safety Commission. Briefing Package CP 75-23: Petition Concerning Grocery Carts. Washington, DC: Consumer Product Safety Commission; 1977
  23. US Consumer Product Safety Commission. Shopping Cart Petition Briefing Package. Washington, DC: Consumer Product Safety Commission; 1994
  24. US Consumer Product Safety Commission. Shopping Cart Petition Briefing Package CP 97-2. Washington, DC: Consumer Product Safety Commission; 1998
  25. ASTM International. Standard Consumer Safety Performance Specification for Shopping Carts F2372-04. West Conshohocken, PA: ASTM International; 2004
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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Making Shopping Carts Safer for Young Children
Journal Watch (General), September 12, 2006; 2006(912): 7 - 7.
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G. A. Smith and for the Committee on Injury, Violence, and Poison
Shopping Cart-Related Injuries to Children
Pediatrics, August 1, 2006; 118(2): e540 - e544.
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