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Maneesha Agarwal, MD
Elena Petkovska, MD
Dylan P. Hurley, MPH, MAB, HEC-C
Yin Zhang, MS
Wendy J. Pomerantz, MD, MS

Injuries are the leading cause of morbidity and mortality in children. A child presents to a U.S. emergency department for a consumer product–related injury (PRI) approximately every six seconds. Evidence shows that children with autism spectrum disorder (ASD) experience higher rates of injury-related healthcare visits compared to neurotypical peers. Despite this increased risk, differences in PRIs between children with ASD and those without documented ASD remain poorly understood. The primary objective of this study was to compare PRIs in children with ASD to peers without documented ASD.

This retrospective cohort study used data from the US Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS). Data were extracted for patients aged 0–21 years from 2005-2024. Variables included demographics, injured body part, diagnosis, disposition, product involved, and narrative text. Cases were classified as ASD if the narrative included terms such as autism, autistic, autism spectrum disorder, ASD, Asperger, pervasive developmental disorder, or PDD. Weighted injury rates per 100,000 children were calculated using ASD prevalence estimates from the CDC and national pediatric population data. Descriptive statistics characterized the populations. Using NEISS, total PRIs with 95% confidence intervals and injury rates were estimated for children with and without documented ASD, including product-specific differences. Comparative analyses were performed.

Over the 20-year study period, 2,174 PRIs were identified in children with ASD, corresponding to an estimated 60, 260 injuries (95% CI 42,908-77,613), compared to 3,597,027 cases in children without documented ASD, representing an estimated 109,850,428 injuries (95% CI 87,019,914-132,680,941) (Table 1). Children with ASD were more likely to be male and injured at home. Children without documented ASD were more likely to be treated and released and injured at a place of recreation or sports. Injury mechanisms differed, with more foreign body related injuries and poisonings in children with ASD. During the study period, PRI rates increased in children with ASD from 23 to 246 cases per 100,000 children with ASD (slope = 7.4, 95% CI 5.7-9.1) while decreasing in children without documented ASD from 192,303 to 165,606 cases per 100,000 children (slope = -2844.4, 95% CI -3777.6 - -1911.1). The most commonly implicated products also differed (Table 2). Elements of the built environment were more frequently associated with injuries in children with ASD whereas sports activities were more common among children without documented ASD.

Children with ASD experience distinct patterns of consumer product-related injuries compared to peers without documented ASD. These findings highlight the need for targeted injury prevention strategies and messaging for children with ASD and their caregivers.

1. Describe differences in the epidemiology of consumer product–related injuries between children with ASD and children without documented ASD.
2. Identify differences in injury mechanisms, injury locations, and consumer products associated with injuries among children with ASD compared with their peers.
3. Consider implications of these differences for developing targeted injury prevention strategies for children with ASD and their caregivers.

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Maneesha Agarwal, MD
Elena Petkovska, MD
Dylan P. Hurley, MPH, MAB, HEC-C
Yin Zhang, MS
Wendy J. Pomerantz, MD, MS

Children with autism spectrum disorder (ASD) experience higher rates of injury-related healthcare encounters than their neurotypical peers. Self-injurious behavior (SIB), defined as behaviors directed toward oneself that may result in tissue damage, is common among children with ASD and may contribute to distinct injury patterns. However, little is known about how product-related injuries (PRIs) resulting from SIB differs from other PRIs among children with ASD. This study aimed to characterize SIB–related PRIs among children with ASD and compare them with non–self-injury PRIs.

This retrospective cohort study utilized data from the U.S. Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS) from 2005–2024. Children aged 0–21 years with documented ASD were identified through narrative review. Cases were categorized as self-injury or non–self-injury based on injury narratives and coding. Demographic characteristics, injury location, diagnosis, body part injured, and disposition were analyzed. National estimates and weighted rates per 100,000 children with ASD were calculated.

Among 2,174 PRIs identified in children with ASD, 513 cases (23.6%) were related to SIB, corresponding to an estimated 14,731 injuries (95% CI: 10,582–18,880), while 1,661 represented an estimated 45,529 non–self-injury injuries (95% CI: 32,400–58,659). Children with SIB–related injuries were older than those with non–self-injury PRIs (mean age 12.7 vs 9.0 years), with nearly half occurring in adolescents aged 15–21 years (49.0% vs 19.0%). Males accounted for the majority of injuries in both groups. Compared with non–self-injury cases, injuries from SIB occurred more frequently at school (19.6% vs 12.6%) and less frequently at home (42.4% vs 54.7%). Injury characteristics also differed. SIB-related cases were more commonly associated with internal organ injuries (34.4% vs 11.6%), contusions or hematomas (25.9% vs 10.8%), and lacerations or punctures (28.3% vs 19.2%). Head and face injuries predominated among SIB-related PRIs (65.2% vs 38.0%); these cases also demonstrated slightly higher rates of hospitalization (6.2% vs 4.7%) or transfer (5.9% vs 2.8%).

SIB–related PRIs among children with ASD demonstrate distinct demographic and injury patterns compared with non–self-injury PRIs. These injuries were more common among older children and adolescents and more frequently involved head and face injuries and potentially more severe injury types. These findings may help inform targeted injury prevention strategies and environmental modifications for children with ASD who engage in SIB.

1. Characterize self-injury–related product injury patterns among children and adolescents with ASD.
2. Compare demographic and clinical injury features between self-injury–related and non–self-injury product-related injuries in children with ASD.
3. Consider how patterns of self-injury–related product injuries can inform targeted prevention strategies and environmental modifications for children with ASD.

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Patricia Bonatakis PT, DPT
Christine Frugard, MSN, RN, PNP-AC

A spica cast is a type of orthopedic cast used to immobilize the hip, pelvis, and one or both legs, which is essential for proper healing following pediatric hip surgery. This procedure is most often required for children with developmental hip dysplasia or those who have sustained traumatic femur fractures. A significant challenge arises during patient discharge: the fixed, wide-angle position of the spica cast makes it incompatible with standard car seats. The variability in cast angles, dependent on the child's specific needs, further complicates safe transportation. Historically, our hospital has relied on ambulance services for these discharges. However, this solution is neither practical nor cost-effective, as the high costs are often not covered by insurance, placing a substantial financial burden on families. More importantly, this approach fails to address the family's long-term need for safe transportation to crucial follow-up appointments and any subsequent emergency visits, leaving them without a viable or sustainable solution.

To establish a safe and approved transportation protocol for pediatric patients in spica casts, a multi-step approach was implemented.

1. Manufacturer Consultation and Equipment Selection: All major U.S. car seat manufacturers were contacted to determine their policies regarding the use of their products for children in spica casts. Of those contacted, only Evenflo provided a solution. Evenflo issued a formal medical letter to our institution, authorizing the use of their car seats on the condition that the child fits correctly and securely while in the cast.

To accommodate children who cannot fit into a conventional car seat due to cast width or because they exceed the seat's height and weight limits, the hospital also procured EZ-ON 503 lay-down vests as an alternative restraint system.

2. Addressing Liability and Procurement: The hospital's Risk Management department initially advised against the direct purchase of car seats due to liability concerns. To overcome this barrier, a partnership was established with the New Jersey State Police, who agreed to provide Evenflo car seats through an in-kind donation.

In collaboration with Risk Management, a network-wide liability waiver was developed. This form must be signed by the parent or caregiver before receiving a car seat. The waiver explicitly transfers the responsibility for the proper installation and use of the car seat to the family, thereby mitigating hospital liability. Upon discharge, the family retains ownership of the car seat, ensuring they have a consistent and safe transportation solution for follow-up appointments and other travel needs.

3. Evaluation of Alternatives: Specialized car seats designed for spica casts, such as the Merritt Wallenberg seat, were evaluated but deemed unfeasible for our operational model. The significant financial cost, the logistical complexities of implementing a loaner program (including tracking, cleaning, and maintenance across multiple orthopedic groups), and challenges related to ownership made this option impractical for widespread implementation.

Since the program's inception in 2025, five pediatric patients in spica casts have been successfully discharged using the new protocol. In all five cases, the children were properly fitted into a donated Evenflo car seat. Key outcomes include: Patient Impact: All five families were provided with a permanent, safe transportation solution at no cost, eliminating their need for ambulance services. Compliance: 100% of parents/caregivers successfully executed the liability waiver prior to receiving the car seat. Financial: The program operated at zero cost to both the families and the hospital, as all car seats were secured through an in-kind donation. The non-return policy provides a sustainable long-term solution for families.

The safe and cost-effective transportation of pediatric patients in spica casts presents a significant logistical and financial challenge for both healthcare institutions and families. This initiative successfully addressed this critical gap in care by developing a multi-faceted program built on manufacturer collaboration, strategic partnerships, and proactive risk mitigation.

The initial implementation has demonstrated unqualified success, providing a safe, no-cost transportation solution for all participating families while simultaneously eliminating hospital liability and procurement costs. By creating a standardized protocol that is both sustainable and replicable, we have established a new standard of care for this patient population. This program serves as a model for how innovative, inter-departmental problem-solving can enhance patient safety, improve family satisfaction, and optimize resource management.

Identify the transportation safety challenges for pediatric patients in spica casts and recognize the approved car seat and alternative restraint solutions implemented to address this gap.

Describe the process for overcoming institutional barriers, such as liability concerns and procurement costs, through the implementation of a liability waiver and a strategic community partnership.

Explain the benefits of a standardized spica cast car seat program, including enhanced patient safety, reduced financial burden on families, and mitigated liability for the hospital

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Melissa Smith, LCSW, CPST

Motor vehicle crashes (MVCs) are one of the leading causes of pediatric injury and death in the United States. While it’s known proper restraint use reduces the risk of injury after a MVC, usage continues to remain a challenge for some families. Hospital-based Injury and Violence Prevention (IVP) programs can play a key role in identifying needs and providing appropriate restraints for children. We wanted to re-design our program to improve pediatric occupant protection outcomes by implementing universal occupant protection screening, creating more opportunities for intervention, and increasing staff knowledge on occupant protection hospital wide.

This program was developed at a tertiary care children’s hospital and includes both inpatient and outpatient pediatric populations.

In 2024, our injury prevention team began by mapping existing occupant protection workflows to better understand how inpatient and outpatient families were being screened and how car seats were distributed. This process involved close collaboration with nursing, supply chain, and philanthropy stakeholders. Gaps identified included inconsistent screening practices and variation in how restraints were distributed, as well as limited programming for older children and children with special healthcare needs (CSHCN).

As a result, inpatient and outpatient screening tools were developed for children 0-18 and paired with need-based intervention pathways. Because our trauma data shows the region’s highest fatalities are from unrestrained 13–19-year-olds, we wanted to ensure we were adequately screening longer than typically deemed necessary. Additional work focused on streamlining the ordering and distribution processes for restraints, as well as providing education to non-injury prevention staff to support screening and intervention.

Due to a concurrent electronic medical record (EMR) transition, data collection and analysis for some measures have been delayed. Ongoing evaluation will include development of key performance indicators (KPIs) and tracking process and outcome measures.

Following implementation, our hospital established a more consistent approach to screening and intervention across various care settings. In the first year, collaboration with supply chain and standardizing our ordering and distribution processes resulted in an estimated cost savings of $60,000.

Clearer workflows also reduced variation in practice and decreased the need for injury prevention staff involvement in many cases, allowing the program to serve additional children without needing to dedicate additional FTE.

Limited data are currently available due to the EMR transition; however, KPI development is expected by June 2026, with reporting beginning in summer 2026. Baseline data will be used to inform future quality improvement efforts.

A more consistent, systemwide approach to pediatric occupant protection improved efficiency, reduced costs, and strengthened program capacity. Hospital-based injury prevention programs are well positioned to identify gaps, support staff, and improve access to car seats and education for families. Continued evaluation will help guide future improvements and expand the impact of this work on preventing pediatric injury.

1. Talk through common gaps in pediatric occupant protection that can show up in hospital settings.
2. Use a simple, consistent approach to screen for adequate restraints and respond with appropriate interventions.
3. Take away practical ideas for improving workflows and expanding access to car seats and seat belt education through collaboration across teams.

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Ashley N. Downs, MPH
Rachel K. Myers, PhD, MS
Christina Labows, MPH
Isabella Tullio, MPH
Jennifer McCain, MD
Emma Sartin, PhD, MPH

Despite advances in child passenger safety interventions and restraint recommendations, motor vehicle accidents remain a major cause of injury and death for children in the United States. Further, gaps in restraint use and access to injury prevention resources persist. Understanding patterns of restraint status and referral to child passenger safety resources documented during medical evaluations following motor vehicle crashes present natural opportunities for improving education and intervention. The purpose of this study was to characterize documentation of restraint status and dissemination of child passenger safety resources among crash-involved child passengers using electronic health record (EHR) data.

Data on child passengers (0-18 years old) who sought medical evaluation following a motor vehicle crash from 1/1/2018-5/23/2025 were retrospectively extracted from two tertiary, level 1 pediatric hospitals’ EHR. We used International Classification of Diseases, 10th Revision, (ICD-10-CM) codes from Emergency Department (ED) visits to identify eligible patients. Data regarding the crash, injuries, and medical care were abstracted and descriptively analyzed. We summarized restraint status (restrained, unrestrained, unknown/other) and provision of child passenger safety resources during the ED encounter (e.g., referral to web-based education, provision of a new car seat).

As of May 2026, 482 crash-related visits from 2018-2025 were abstracted. While most patients were noted to be restrained (75.9%), 14.9% were unrestrained, and 9.1% had an unknown or other restraint status documented. Overall, 28.6% of patients had information regarding provision of child passenger safety resources noted in the EHR. These included: provision of informational diagrams or video links, referral to a community-based car seat check, or distribution of a hospital-provided new car seat. Approximately 1 in 5 patients, regardless of restraint status, received any child passenger safety resources. Rates of receiving information differed by restraint status, with restrained patients more likely to receive resources or new car seats compared with unrestrained patients (29.5% vs. 22.2%, respectively).

We observed that only a small proportion of patients received child passenger safety resources, including unrestrained patients, who may represent a higher-risk population. Findings highlight an opportunity to strengthen hospital-based injury prevention education and interventions to continue efforts to improve child passenger safety. Ongoing evaluation of child passenger safety education and resource dissemination efforts may help to identify barriers in accessing child passenger safety resources and inform strategies to improve hospital-based injury prevention efforts for children involved in motor vehicle crashes.

1. Describe patterns of child restraint use among pediatric patients involved in motor vehicle crashes using electronic health record data.
2. Evaluate differences in rates of sharing child passenger safety resources based on restraint status.
3. Identify potential gaps for child passenger safety counseling in pediatric emergency care settings.