Federally Mandated Car Safety Features Decrease the Rate and Severity of Pediatric Backover Trauma

Jeannette M. Joly, MD
Krysta M. Sutyak, DO
Neil G. Jayarajan, BS
Amber Rollins, BS
Janette Fennell, BBA
KuoJen Tsao, MD
Kevin P. Lally, MD, MS
Natalie A. Drucker, MD, MS

Pedestrian collision with a motorized vehicle-in-reverse is referred to as backover trauma. Resulting injuries carry significant morbidity and mortality, and they disproportionally occur in small children due to challenging visualization. For prevention, a federal mandate was passed on May 1, 2018 requiring all new vehicles to be equipped with a backup camera; however, older vehicles may still lack this safety feature. This study aims to characterize the impact of this mandate by evaluating the rate and severity of pediatric backover trauma before and after its enactment.

A retrospective pre-post observational study was conducted of patients less than 5 years of age with backover trauma between January 2011 and November 2024. Two sets of data were compared: electronic medical records of patients treated at a level one pediatric trauma center as identified by the institutional trauma registry, and data curated by Kids and Car Safety from publicly available injury records of the surrounding metropolitan counties to externally validate institutional trends. Trauma registry abstraction included demographics, injury severity score (ISS), hospital course, and disposition. Severe injury in pediatric trauma was defined as ISS >25. Backover trauma rates and severity were compared pre-mandate (01/2011-04/2018) versus post-mandate (05/2018-11/2024). Descriptive statistics, univariate analyses, and Poisson rate tests were utilized.

From trauma center data, 71 patients were identified: 53 (75%) pre-mandate, 18 (25%) post-mandate. Patients were a median age of 2 years (IQR: 1.6-2.8), 61% male, and 68% with governmental insurance. Overall median ISS was 10 (IQR: 5-19): no difference between groups (p=0.83). There were 10 cases of severe trauma pre-mandate (19%) versus 2 cases post-mandate (11%) (p=0.72), with one pre-mandate, in-hospital death. The trauma rate pre-mandate was significantly higher at approximately 7.2 backovers/year compared to 2.7 backovers/year post-mandate: a rate ratio of 0.38 (95% CI: 0.21-0.66; p<0.01). In public injury records, 23 victims were identified: 17 (74%) pre-mandate, 6 (26%) post-mandate. Injuries were reported fatal on scene or shortly after emergency medical service transport in 13 pre-mandate cases (76%) and 4 post-mandate cases (67%) (p=0.63). The trauma rate pre-mandate was higher at approximately 2.3 backovers/year compared to 0.9 backovers/year post-mandate: a rate ratio of 0.39 (95% CI: 0.13-1.05; p=0.06).

A decrease in the rate of backover trauma was observed following the 2018 federal mandate requiring backup cameras in all new vehicles. Severe injuries decreased by half, and the absolute number of publicly reported fatal cases decreased by 69%. Reduction in rate and severity of backover trauma justify public health-driven regulatory requirements. Post-manufacturing installation of backup cameras should be prioritized and subsidized for all vehicles manufactured prior to the 2018 federal mandate.

After listening to this presentation, the listener will be able to:
(1) Define backover trauma in pediatric patients
(2) Describe the impact of federally mandated backup cameras on pediatric backover injuries
(3) Summarize next steps for prevention, which include supporting a subsidized program to install backup cameras in cars without them