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Children Plus All Nonautomobile Motorized Vehicles (Not Just All-Terrain Vehicles) Equals Injuries

^a Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, Columbus, Ohio
^b Department of Pediatrics, Colleges of Medicine and Public Health, Ohio State University, Columbus, Ohio

	ABSTRACT

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OBJECTIVES. The goals were to describe the epidemiological features of pediatric nonautomobile motorized vehicle–related injuries sustained between 1990 and 2003 and to compare all-terrain vehicle–related injuries with other types of nonautomobile motorized vehicle–related injuries.

METHODS. An analysis of nationally representative pediatric nonautomobile motorized vehicle–related injury data from the US Consumer Product Safety Commission National Electronic Injury Surveillance System was performed.

RESULTS. Nationally, an estimated 1203800 children were treated in hospital emergency departments for nonautomobile motorized vehicle–related injuries between 1990 and 2003. These children had a mean age of 12.7 years (range: 1 month to 19 years), and 77.0% were male. The majority of injuries were associated with all-terrain vehicles (44.8%), 2-wheeled off-road vehicles (21.1%), and go-carts/buggies (13.7%). The most common diagnoses were contusions/abrasions (28.3%), fractures (24.2%), and lacerations (20.0%). Overall, the number of injuries increased 86% from 70500 injuries in 1990 to 130900 injuries in 2003. The numbers of all-terrain vehicle–related, 2-wheeled off-road vehicle–related, 2-wheeled on-road vehicle–related, and go-cart/buggy-related injuries all increased significantly from 1990 to 2003. There were greater proportions of all-terrain vehicle-associated injuries among children 16 years of age (48.0%) and children 12 to 15 years of age (46.6%) than among children <12 years of age (40.3%). Conversely, the proportion of other nonautomobile motorized vehicle–related injuries among children <12 years of age (47.2%) was greater than that among children 12 to 15 years of age (30.3%) and children 16 years of age (23.0%).

CONCLUSIONS. Although most public health and legislative attention to date has been focused on all-terrain vehicles, parents, children, and public officials should be educated about the injury risk that all types of nonautomobile motorized vehicles pose to children.

Key Words: nonautomobile motorized vehicle • all-terrain vehicle • injury • pediatric

Abbreviations: ED—emergency department • NEISS—National Electronic Injury Surveillance System • CPSC—Consumer Product Safety Commission • IPR—injury proportion ratio • CI—confidence interval • ATV—all-terrain vehicle

In 2005 alone, there were an estimated 40400 all-terrain vehicle (ATV)-related injuries sustained by children <16 years of age who were treated in US emergency departments (EDs).¹ In addition, between January 1982 and December 2005, there were 7188 ATV-related deaths, with 30% of those fatalities occurring among children <16 years of age.¹ More than 6.5 billion dollars are spent each year for the treatment of ATV-related injuries.² Despite the startling number of ATV-related injuries and deaths and the high health care costs, there are an estimated 7 million ATVs in use in the United States.^1,2 This dichotomy has led some advocates and lawmakers to call for ATV legislation, including stricter ATV use guidelines and bans on the use of ATVs by adolescents.^3,4

Multiple studies have examined pediatric ATV-related injuries.^1–3,5–10 Additional studies have examined other types of nonautomobile motorized vehicle–related injuries, such as those associated with motorbikes, motorcycles, and snowmobiles.^11–15 A few previous studies compared ATV-related injuries with other nonautomobile motorized vehicle–related injuries; however, those studies were limited to the patient population of one trauma center.^16–19 The focus of most legislative efforts has been on ATVs, despite the fact that other nonautomobile motorized vehicles also present the risk of injury or death to children.²⁰ For example, between 2001 and 2004, 23800 pediatric off-road motorcycle-related injuries were treated in US EDs.¹² A greater understanding of the pediatric injury risk associated with different types of nonautomobile motorized vehicles is needed to drive effective recommendations, guidelines, and legislation.

This study is the first to use a nationally representative sample to describe the epidemiological features of all pediatric nonautomobile motorized vehicle–related injuries and to compare ATV-related injuries with injuries associated with other types of nonautomobile motorized vehicles.

	METHODS

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Data were obtained from the US Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS), which collects information on individuals treated for injuries in a nationally representative stratified probability sample of 98 US hospital EDs, including 8 children's hospitals.²¹ The NEISS data set, which is updated daily, provides patient demographic information and specific information about the injury and injury event for each patient presenting for treatment. Statistical weights provided by the CPSC are applied to the NEISS sample data for calculation of national estimates of the number of injuries.²¹

All injuries among children 19 years of age that were presented to NEISS EDs between 1990 and 2003 and were identified as nonautomobile motorized vehicle–related injuries on the basis of NEISS consumer product codes were included in the analysis. The types of nonautomobile motorized vehicles included ATVs (product codes 3285, 3286, 3287, and 3296), 2-wheeled off-road vehicles (including trail bikes and dirt bikes; product codes 3258 and 5036), 2-wheeled on-road vehicles (including licensed 2-wheeled vehicles, mopeds, minibikes, and scooters/skateboards; product codes 1910, 3215, 5035, and 5042), go-carts/buggies (including go-carts and beach and dune buggies; product codes 3259 and 3288), grass/farm-related vehicles (including tractors, golf carts, and powered riding lawnmowers; product codes 1062, 1213, 1405, and 1422), water-related vehicles (including powered personal watercraft and boats; product codes 3292 and 3298), snow-related vehicles (including snowmobiles and ice/snow boating vehicles; product codes 1290 and 3247), and unspecified vehicles (including powered riding toys and motorized vehicles not otherwise classified; product codes 1330 and 1744) (NEISS does not collect data on automobile-related injuries).²² Injuries not associated directly with the operation of a nonautomobile motorized vehicle (such as a child injured when tripping in the garage and falling against a parked ATV or a child injured while loading a snowmobile onto a trailer) were excluded from the analyses.

Other NEISS variables of interest were the child's age and gender, injury diagnosis, body part injured, and injury disposition. Age was divided into 3 groups on the basis of child development milestones and current ATV regulations, that is, <12 years of age, 12 to 15 years of age, and 16 years of age. The 26 sites of injury (ie, body part injured) were categorized into 6 body regions, including head, face, upper extremity (including shoulder, upper arm, elbow, lower arm, wrist, hand, and finger), lower extremity (including upper leg, knee, lower leg, ankle, foot, and toe), and other (including neck, trunk, and pubic region, 25%–50% of the body, as coded in the NEISS data, and >50% of the body, also as coded in the NEISS data). Injury narratives for all cases were read to categorize 2 additional variables, namely, involvement and protective equipment. Involvement was categorized as driver, passenger, on vehicle but unspecified status, or bystander. Use of protective equipment was categorized as worn, not worn, or unspecified. This study was approved by the institutional review board of the Columbus Children's Research Institute.

Data were analyzed by using SPSS 14.0 (SPSS, Chicago, IL) with the complex samples module, with adjustment for sample weights and the stratified survey design, as recommended by the CPSC, to produce national injury estimates.²¹ Injury estimates are rounded to the nearest 100 in the text of this article. Injury rates were calculated by using annual population estimates from the US Census Bureau.²³ Statistical analyses included the ² test with Yates’ correction and linear regression. Injury proportion ratios (IPRs) were calculated by using 95% confidence intervals (CIs) and P values to assess statistical significance (P values of <.05 were considered significant). For example, the calculation comparing the proportions of head injuries among ATVs and 2-wheeled off-road vehicles is as follows: IPR = (national estimated no. of ATV-related head injuries/national estimated total no. of ATV-related injuries)/(national estimated no. of 2-wheeled off-road vehicle–related head injures/national estimated total no. of 2-wheeled off-road vehicle–related injuries).

	RESULTS

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Overall Injury Epidemiological Features
Nationally, an estimated 1203800 children 19 years of age were treated in US EDs for nonautomobile motorized vehicle–related injuries between 1990 and 2003. These children had a mean age of 12.7 years (SD: 4.3 years; range: 1 month to 19 years), and 77.0% were male (Table 1). Of all nonautomobile motorized vehicle–related injuries, the majority were associated with ATVs (44.8%), 2-wheeled off-road vehicles (21.1%), and go-carts/buggies (13.7%) (Table 1). Other types of nonautomobile motorized vehicles associated with injury were 2-wheeled on-road vehicles (8.6%), grass/farm-related vehicles (7.6%), snow-related vehicles (3.2%), water-related vehicles (0.2%), and unspecified vehicles (0.8%). Regarding involvement status, the child's involvement as a driver, passenger, or bystander was unspecified for 81.8% of injuries. However, 3.4% of injured children were bystanders who were injured when they were struck by, run over by, or burned by a nonautomobile motorized vehicle. Only 7.9% of the injury narratives in the NEISS data set mentioned the absence or presence of protective gear.

Although the majority (90.8%) of children were treated and released from the ED (Table 1), an estimated 69900 children were admitted to the hospital for treatment of their injuries, and an estimated 1900 children died. The most common body regions injured among children who were admitted were the lower extremities (31.8%), head (24.1%), and upper extremities (16.9%), and the most common diagnoses were fractures (51.3%) and internal injuries (14.5%). The most common body regions injured among children who died were the head (55.1%) and trunk (13.5%). One fifth (20.5%) of injuries that resulted in death were to >50% of the body, as coded in the NEISS data for body part injured. The most common diagnoses among children who died were internal injuries (46.8%) and not stated (29.3%). Other diagnoses among these children were submersion (10.1%), fractures (9.1%), and crushing (4.7%), also as coded in the NEISS data.

Trends Over Time According to Type of Nonautomobile Motorized Vehicle
Overall, the number of nonautomobile motorized vehicle–related injuries increased significantly from 70500 injuries in 1990 to 130900 injuries in 2003 (P < .01). The overall pediatric nonautomobile motorized vehicle–related injury rate increased significantly from 1.0 injuries per 1000 pediatric US population in 1990 to 1.6 injuries per 1000 pediatric US population in 2003 (P < .01). Figure 1 shows the trends over time in the numbers of injuries according to type of nonautomobile motorized vehicle. In each year from 1990 through 2003, ATVs accounted for the greatest proportion of all motor vehicle–related injuries (40.0%–49.0% of total injuries in each year). The number of ATV-related injuries increased significantly from 33500 injuries in 1990 to 59300 injuries in 2003 (P < .01). Although fewer injuries were related to 2-wheeled off-road vehicles, the trends over time for these nonautomobile motorized vehicles were very similar to the trends for ATVs. The number of 2-wheeled off-road vehicle–related injuries increased significantly from 14000 injuries in 1990 to 31700 injuries in 2003 (P < .01). In addition, from 1990 through 2003, the numbers of 2-wheeled on-road vehicle–related injuries (P = .05) and go-cart/buggy-related injuries (P < .01) increased significantly.

View larger version (18K): [in this window] [in a new window]   FIGURE 1 Trends over time in estimated numbers of nonautomobile motorized vehicle–related injuries treated in EDs in the United States from 1990 to 2003, according to type of nonautomobile motorized vehicle.

Comparison of Age Groups
In general, between 1990 and 2003, the number of nonautomobile motorized vehicle–related injuries treated in US EDs increased in all 3 age categories (<12 years, 12–15 years, and 16 years) (Fig 2). In each year except 1997, children 12 to 15 years of age accounted for the greatest proportion of all motor vehicle–related injuries (35.0%–41.7% of injuries in each year). The number of nonautomobile motorized vehicle–related injuries sustained by children <12 years of age increased significantly from 23000 injuries in 1990 to 44400 injuries in 2003 (P < .01). The numbers of nonautomobile motorized vehicle–related injuries sustained by children 12 to 15 years of age and children 16 years of age also increased significantly between 1990 and 2003 (P < .01 for both age groups).

View larger version (14K): [in this window] [in a new window]   FIGURE 2 Trends over time in estimated numbers of nonautomobile motorized vehicle–related injuries treated in EDs in the United States from 1990 to 2003, according to age.

	DISCUSSION

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This study is the first to use a nationally representative sample to describe the epidemiological features of all pediatric nonautomobile motorized vehicle–related injuries and to compare ATV-related injuries with all other types of nonautomobile motorized vehicle–related injuries to children. A great deal of attention has been given to the prevention of pediatric ATV-related injuries.^1,3–5,9,23 Although ATV-related injuries are a serious concern, so are pediatric injuries related to other types of nonautomobile motorized vehicles. There has been a relative lack of attention toward these other nonautomobile motorized vehicle–related injuries, which collectively made up more than one half of the 1.2 million pediatric nonautomobile motorized vehicle–related injuries sustained nationally from 1990 through 2003.

Consistent with previous studies,^1–10 we found that the number of pediatric ATV-related injuries treated in US EDs increased significantly from 1990 through 2003. During the same time period, the number of injuries related to other types of nonautomobile motorized vehicles also increased. In particular, although substantially fewer injuries were associated with 2-wheeled off-road vehicles, compared with ATVs, the trends over time for 2-wheeled off-road vehicle–related injuries and ATV-related injuries were very similar. In 2000, the American Academy of Pediatrics recommended that children <16 years of age should be prohibited from using 2-wheeled off-road vehicles and ATVs.²⁴ With the popularity of 2-wheeled off-road vehicles continuing to increase,¹² additional focus should be placed on the prevention of 2-wheeled off-road vehicle–related injuries as well as ATV-related injuries.

Pediatric injuries associated with other nonautomobile motorized vehicles, including 2-wheeled on-road vehicles, go-carts, buggies, grass/farm-related vehicles, snow-related vehicles, and water-related vehicles, are also of concern.^11,13–15 Because the proportions of head and facial injuries associated with ATVs and other nonautomobile motorized vehicles were very similar, children operating or riding on any type of nonautomobile motorized vehicle should wear a helmet with facial protection. Other nonautomobile motorized vehicle–related injuries are of particular concern among children <12 years of age, because nearly one half (47.2%) of all injuries sustained by this age group were associated with nonautomobile motorized vehicles other than ATVs and 2-wheeled off-road vehicles. More specifically, 1 of 5 injuries sustained by children <12 years of age were go-cart/buggy-related and another 12.5% of injuries were grass/farm vehicle–related. Formal guidelines and recommendations should be developed for the use of all types of nonautomobile motorized vehicles, especially with respect to younger children.

Although many states have some age regulations regarding the use of ATVs, requirements vary by state, with minimal operating ages ranging from 10 years to 18 years.^2,6 In this study, we found that, in almost every year from 1990 to 2003, children 12 to 15 years of age sustained the greatest proportion of nonautomobile motorized vehicle–related injuries. More than two thirds of injuries sustained by these children were ATV or 2-wheeled off-road vehicle related. Children 12 to 15 years of age also sustained a significantly greater proportion of concussions than did children <12 years and 16 years of age. On the basis of these findings, we recommend that specific nonautomobile motorized vehicle–related injury prevention efforts should be targeted at this age group and that regulations to limit the use of nonautomobile motorized vehicles should include all children <16 years of age.

The main limitations of this study were associated with the data set. The NEISS data provide only limited additional information, of inconsistent quality and breadth, about injury events in the narratives. For example, for 81.8% of nonautomobile motorized vehicle–related injuries, the child was reported in the narrative to have been on the vehicle; however, it was not specified whether the child was a driver or a passenger, which is important for the development of targeted injury prevention programs and policies. Furthermore, only 7.9% of the injury narratives in the NEISS data set mentioned the absence or presence of protective equipment. Adding a protective equipment variable to NEISS, even just a yes/no/not applicable categorization of protective equipment use, would provide researchers with valuable data for the development of injury prevention programs and polices. Information about other factors that might influence the risk of injury, such as parental supervision or nonautomobile motorized vehicle size, was also unavailable. Because such data were not available in the NEISS data set, future studies are needed to examine the impact of these factors on all types of pediatric nonautomobile motorized vehicle–related injuries. Another limitation is that children treated in EDs may not be representative of all children who are injured during nonautomobile motorized vehicle–related activities, because less severely injured children may seek other or no medical attention. Despite these limitations, the NEISS data set provides the only nationally representative sample of nonautomobile motorized vehicle–related injuries in the United States. Although exposure-based injury risk rates could not be calculated because of a lack of denominator data, such as the number of children who actually ride nonautomobile motorized vehicles and the frequency of rides or the amount of time spent on the vehicle, comparisons of estimated numbers of injuries, analyses of trends over time, and descriptions of patterns of injuries based on this stable long-term database yielded important information.

All types of nonautomobile motorized vehicles pose a risk of injury to children. As shown by the number of injuries found in this study and in similar studies, children, especially those <16 years of age, do not have the judgment and motor skills needed to operate any type of nonautomobile motorized vehicle safely.²⁴ On the basis of our findings, we support several safety recommendations. As recommended by the American Academy of Pediatrics, children <16 years of age should be restricted from riding 2-wheeled, 3-wheeled, and 4-wheeled off-road vehicles.²⁴ Although this study was limited by the amount of available data on protective gear, our findings regarding injuries to the head and face support the recommendation that appropriate protective equipment, including helmets and eye protection, should always be worn when nonautomobile motorized vehicles are ridden. Because one fifth of injuries that resulted in death were to >50% of the body, future research is needed to examine the risk of fatal injury resulting from the heavy weight of the vehicle and potential for high impact.

Parents, children, and public officials should be educated about the injury risk all types of nonautomobile motorized vehicles pose to children. In addition, parents should be aware of the risk of injury that nonautomobile motorized vehicles pose to all children, including passengers and bystanders as well as drivers. Future research is needed to evaluate existing legislation for ATV and 2-wheeled vehicle use (ie, minimal requirements for operations and helmet requirements), to determine effectiveness. All states in the United States should be encouraged to adopt the most effective policies, and these polices should be expanded to include all types of nonautomobile motorized vehicles.

	ACKNOWLEDGMENTS

 
This study was not supported by any funding agency.

We thank the US CPSC and the NEISS for providing the data.

	FOOTNOTES

 
Accepted Feb 16, 2007.

Address correspondence to Christy Collins, MA, Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: collinsc{at}ccri.net

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

	REFERENCES

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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Collins, C. L. Articles by Comstock, R. D. Search for Related Content PubMed Articles by Collins, C. L. Articles by Comstock, R. D. Related Collections Office Practice

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