Car Safety

Nichole L. Hodges and Gary A. Smith

Pediatrics in Review 2014;35;155
DOI: 10.1542/pir.35-4-155

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Article

injury prevention

Car Safety
Nichole L. Hodges, MPH,*
Gary A. Smith, MD, DrPH*

Educational Gap
The American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention released a revised Policy Statement and Technical Report on child passenger safety in
2011; (1)(2) however, confusion and lack of knowledge about the recommendations persist among some clinicians and parents.

Author Disclosure
Ms Hodges and
Dr Smith have
disclosed no financial
relationships relevant
to this article. This
commentary does not
contain a discussion of
an unapproved/
investigative use of
a commercial product/

Objectives

After reading this article, readers should be able to:

1. Identify the appropriate child restraint system based on the age and weight of an
infant or child.
2. Discuss the special considerations for preterm and low-birth-weight infants in child
safety seats.
3. Identify noncrash vehicle-related hazards for young children.
4. Describe recommended graduated driver licensing restrictions for teen drivers.

device.

Introduction

Abbreviations
AAP:
BPB:
CPS:
CPST:
CSS:
GDL:
LATCH:

In the United States, motor vehiclerelated crashes are the leading cause of death for children and teens, starting at 3 years and older. (3) Despite signicant reductions in crash rates
since the mid-1970s, motor vehicle crashes continue to take a substantial toll on society in
terms of crash-related mortality and morbidity, as well as associated medical and indirect
costs. (4) Properly used child safety seats (CSSs) have been reported to be highly efcacious
in the reduction of motor vehicle crashrelated injuries among children. It is estimated that
using a forward-facing CSS can reduce the risk of serious injury to 1- to 4-year-olds in
a crash by up to 78% compared with using a seat belt alone. (5) Unfortunately, not all children are currently being protected by CSSs when they ride in a vehicle. Only 65% of US
children 4 to 7 years of age are properly restrained in a CSS or belt-positioning booster
(BPB) seat when they ride, and of the remaining children in this age group, 10% ride completely unrestrained in the vehicle. (6) Although older children and teens may have outgrown their CSSs and BPBs, they are not immune to the dangers of motor vehicle
related crashes. In 2010 alone, 2406 teens 13 to 18 years of age died in motor vehicle
crashes in the United States. (3)
The purpose of this review is to provide an overview of child passenger safety (CPS) and
teen driving best practice recommendations, with a focus on the appropriate stages of
CSS use. For more detailed information, readers are encouraged to refer to the American Academy of Pediatrics (AAP)
Policy Statement and Technical Report on this topic. (1)(2)

American Academy of Pediatrics

belt-positioning booster
child passenger safety
child passenger safety technician
child safety seat
graduated driver licensing
lower anchors and tethers for children

Epidemiology
In 2011, an estimated 387,678 children in the United States
younger than 19 years were treated in hospital emergency
departments for injuries resulting from motor vehicle
crashes. (3) Among children, the head is the most frequently
injured region of the body during motor vehicle crashes.
This is important given the potential that head injuries have

*Center for Injury Research and Policy, The Research Institute at Nationwide Childrens Hospital, Columbus, OH.

Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.

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injury prevention

car safety

to cause long-term complications. In addition to injuries

to the head, injuries to the thorax, abdomen, and extremities are also common. Injury severity, type, and location
vary based on the age, restraint type, crash characteristics
and seating location of the child.
As with many topics in public health, motor vehicle
crashes do not affect all populations equally. Motor vehicle
related mortality rates are higher among black and
American Indian/Alaskan Native children than among
white, Hispanic, or Asian/Pacic Islander children. Studies of child restraint use have found that non-Hispanic
white and Asian children are more likely to be restrained
while riding in a motor vehicle than non-Hispanic black
and Hispanic children. (6) Among teens, seat belt use is
signicantly lower for non-Hispanic black drivers and
passengers than for whites or Hispanics. The reasons
for these disparities are unclear.

2.

3.

4.

5.

Risk Reduction
Despite the high incidence of motor vehicle crash injuries
in the United States, there are effective known countermeasures available to help families protect children in
a crash. CSSs are readily available throughout the country
and are offered at a variety of price points to accommodate a multitude of budgets. CSSs are highly effective
when used correctly. Children 2 to 6 years of age are
28% less likely to be killed in a motor vehicle crash if they
are restrained in a CSS rather than a seat belt. (7) Likewise, the use of BPBs rather than a seat belt alone lowers
the risk of injury among children 4 to 7 years of age by
59% in a crash. (8)
Each state in the United States has CPS laws; however,
these laws vary signicantly from state to state, and in
many states the laws fall short of best practice recommendations. Currently, only 2 states, Florida and South
Dakota, do not have booster seat laws in place to promote motor vehicle protection for older children who
have outgrown their CSSs. It is important for clinicians
to be familiar with the CPS laws in their state.

Best Practice RecommendationsOverview

There are 4 stages of CPS protection for children, each
with its own guidelines and parameters. As a result, understanding the recommendations and maintaining a safe
motor vehicle environment during every ride is an ongoing challenge for many parents. On the basis of current
research in the eld, the AAP supports the following
evidence-based best practice recommendations:
1. Infants and toddlers should ride rear-facing in an appropriate CSS until they are at least 2 years of age or

until they outgrow their convertible CSS by weight or

height.
Children 2 years or older and those who have outgrown
their convertible CSS by weight or height should ride
forward-facing in a CSS with a harness. Children should
continue to use a forward-facing CSS with a harness until they outgrow the seat by weight or height.
Children who have outgrown their forward-facing
CSS with a harness by weight or height should use
a BPB seat. Children should continue to use a BPB
until they are able to t the vehicles lap and shoulder
seat belt properly. Most children are not physically developed enough to transition out of a BPB until they
are 4 ft 9 in tall and 8 to 12 years of age.
Children who are ready to use the seat belt alone
should use a seat belt with both lap and shoulder restraints for best protection. Parents should ensure that
children and teens are wearing their seat belt properly.
The AAP also recommends that all children younger
than 13 years ride in a back seat of the vehicle for maximum protection in a crash.

Each transition a child makes in the CPS progression,

from rear-facing to forward-facing, from forward-facing
with a harness to a BPB, and so on, is associated with a decrease in safety. Although many parents view these transitions as a rite of passage, it is important to emphasize
that such transitions should not be made prematurely
and that children should remain in their current stage
as long possible.

Rear-Facing Infants and Toddlers

It is important for infants and toddlers to ride in a rearfacing CSS from birth until they reach at least 2 years of
age or until they outgrow their CSS by height or weight.
The rear-facing seating position signicantly reduces
a childs risk of serious injury in a frontal crash and provides greater protection, particularly for the head, neck,
and spine. (2) For infants, many parents prefer the convenience of a rear-facing infant-only CSS with a carrying
handle that allows the seat to be removed from the vehicle easily while leaving the base in the car for simple reinstallation. The weight limits of rear-facing infant-only
CSSs vary by manufacturer, but most can be used until
the child is 22 to 35 lb or more. When the top of the
childs head is within 1 in of the top of the CSS, the child
is too tall for the seat and should be transitioned to a rearfacing convertible seat.
Convertible seats are another rear-facing CSS option,
and although they are less convenient than infant-only
seats because the entire CSS stays secured in the vehicle,

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injury prevention

they are ideal for toddlers and families that may not be
able to afford the added expense of the infant-only seats.
As long as a newborn is not below the minimum weight
requirement of the convertible seat and the parent is able
to get a snug t with the harness, a convertible seat can be
used right from birth. Convertible seats get their name
from the fact that they can be used rear-facing initially
and then installed forward-facing as the child grows.
Most convertible CSSs now have rear-facing weight limits
of at least 40 lb, allowing parents to keep children rearfacing longer.
Given the current emphasis on keeping children rearfacing longer, many parents worry about the safety and
comfort of their toddlers. Parents may be concerned that
their child will be more likely to incur injuries to the legs
and feet in a crash or that their child will be uncomfortable. Fortunately, there is no evidence of increased risk of
lower-extremity injuries among children who are in
a crash while riding rear-facing in a CSS. Further, the
rear-facing position does not seem to be problematic
for young children, and this concern about discomfort
seems to manifest primarily from the parents rather than
the children.
Like all children younger than 13 years, rear-facing infants and toddlers should be placed in a rear seat of the
vehicle.
One additional note about infants and CSSs: parents
may be tempted to use rear-facing infant-only CSSs as
seats or sleeping devices outside the vehicle; however,
CSSs are designed to be used only for travel. Thousands
of infants have been injured as a result of falls from elevated surfaces while sitting in their CSSs. (2) Also, given
that infants often fall asleep in their CSSs, on arriving at
their destination some parents will place the sleeping infant directly in a crib or on another soft surface, CSS and
all. This is a dangerous situation because the CSS could
easily tip over, putting the child at risk of suffocation, or
the infant could slide into a slouched position in the CSS,
potentially compromising the childs airway.

Forward-Facing CSSs for Young Children

Children who are at least 2 years of age or those who have
outgrown their rear-facing convertible CSS by height or
weight are ready to move to a forward-facing car seat with
a harness. This seat can either be a convertible CSS used
in the forward-facing position or a forward-facing-only
CSS, such as a combination CSS that can later be used
as a BPB.
Although many parents may be eager to transition their
children to a BPB, it is important to remind caregivers of

car safety

the added protection of a CSS with a harness vs a BPB.

The harness system of the child restraint reduces injuries
by spreading crash forces over a wider area and more effectively limiting head excursion.

BPB Seats for School-age Children

BPB seats are recommended for children who have outgrown their forward-facing CSS by weight or height.
BPB seats reduce injuries by positioning the child so that
the motor vehicles seat belt, which is designed for adults,
ts the child correctly, low over the hips and thighs and
across the middle of the chest and shoulder, not over the
face or neck. The use of BPB seats can reduce the risk of
seat belt syndrome, which is the combination of cervical
and lumbar spine and abdominal injuries that can occur as
a result of restraining a child in an ill-tting seat belt.
BPB seats come in 2 varieties, high-back and lowback, and should only be used in seating positions with
both a lap and shoulder seat belt. In general, low-back
BPB seats are appropriate for use in vehicle seating positions in which there is a head rest or vehicle seat back that
extends above the childs ears. High-back BPB seats are
important for seating positions that have low seat backs
or lack head rests to protect the child from whiplash injuries to the neck.

Lap and Shoulder Seat Belts for Older Children

and Teens
Children should use BPB seats until they are able to t
correctly in the motor vehicle seat belt. Most children
are not ready to move out of a BPB until they meet
the following criteria: (1) the child can sit with their back
against the vehicle seat with their legs bending naturally
at the seat edge; (2) the seat belt ts low and snug over
the hips and thighs; (3) the shoulder portion of the seat
belt crosses the middle of the chest and shoulder and does
not ride up over the neck or face; and (4) the child can
remain in this proper seating position for the duration of
the ride.
Although 48 states in the United States (Florida and
South Dakota not included) currently have booster seat
laws in place for older children, the laws vary substantially
in their requirements for BPB seat use. It is important to
remind parents that the law in your state may not be in
alignment with best practice recommendations and that
most children are not able to t properly in a motor vehicle seat belt without a booster seat until they are at least
4 ft 9in tall and 8 to 12 years of age.
Children who are ready to transition to using a seat
belt should always be restrained in a lap and shoulder
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belt, rather than a lap belt alone. The combined lap and
shoulder belt provides better protection in a crash and reduces the risk of abdominal injuries. Again, the lap portion of the seat belt should be worn low over the hips and
thighs, and the shoulder belt should cross the middle of
the chest and shoulder and never be worn under the arm
or behind the back.

Riding in a Back Seat

Riding in a back seat of the vehicle provides the best protection for children. It is estimated that children riding in
the front seat are at up to 70% greater risk of injury than
those in rear seating positions. (2) The AAP recommends
that all children ride in rear vehicle seating positions until
they are at least 13 years of age.

Recommending a CSS
Aside from suggesting the appropriate type of CSS to parents (rear-facing, forward-facing with a harness, or
BPB), clinicians can also promote best practice recommendations by offering the following advice to parents
about choosing a CSS:
It is important to recognize that all CSSs sold in
the United States are required to meet the same
federal safety standards. Parents should not think
that their child will be unprotected if they cannot
afford one of the most expensive CSSs on the
market.
Used CSSs with an unknown history are not recommended. Second-hand CSSs may be recalled, expired,
or missing instructions or parts that may be difcult to
determine just by looking. More importantly, the CSS
may have been in a crash and therefore could be unsafe
for future use.
There are a wide variety of CSSs on the market. Parents should be encouraged to choose the CSS that ts
their child, ts their vehicle, and is one that they feel
condent that they can use correctly each and every
time.
Parents in cold climates should be advised that bulky
coats and snowsuits are not recommended for use with
CSSs because the extra material can make it difcult to
tighten the harness properly, which will decrease the
effectiveness of the CSS in the event of a crash and
can increase the likelihood of injury.

CSS Installation
Installing a CSS is no easy task, as evidenced by the fact
that most CSSs that are examined at car seat check events

across the country are found to have at least one misuse

error. One of the keys to maximum protection in a crash
is that the CSS must be installed tightly. It is recommended that CSSs be installed with less than 1 in of movement from side to side or toward the front of the
vehicle when tested at the belt path. The CSS may be installed using the vehicles seat belt or lower anchors and
tethers for children (LATCH) if the vehicle is equipped
with the LATCH system. Parents are often concerned
about the safety of using the seat belt vs the LATCH system, but they should be reassured that both systems are
equally safe. It is just a matter of choosing what works
best for their CSS and vehicle and which system allows
for a better installation.
Another important issue regarding the installation of
rear-facing CSSs only is ensuring that the seat is installed
at the proper recline angle. The proper angle provides
maximum protection for the infant without compromising the childs airway by positioning the child too upright. The proper recline angle for CSS installation is
approximately 45 but may vary slightly, depending on
the seat. Parents should refer to their CSS instruction
manual to learn about the angle indicator and recommendations for their particular CSS.
Given that the precise details of CSS installation are
beyond the scope of this review, it is important to know
whom to refer parents to if they need help. Individuals
installing a CSS should always refer to both the instruction manual that was provided with the CSS and the
vehicle owners manual for important information regarding the proper way to install the CSS. In addition,
child passenger safety technicians (CPSTs) are trained
professionals in the eld of CPS and CSS education
and offer their expertise to families at a variety of venues
throughout the nation. To nd a CPST in your area, refer to information on the websites of the National Child
Passenger Safety Training Program (http://cert.safekids.org/) or the National Highway Trafc Safety Administration (http://www.nhtsa.gov/apps/cps/index.
htm).

Special Circumstances
Preterm and low-birth-weight infants are a population of
particular concern within the eld of CPS. Given that infants are being sent home from the hospital after birth
much sooner and at much lower weights than in the past,
it is important that parents pay extra attention to the selection and installation of the CSS if their infant falls into
these special populations. Not all CSSs are appropriate for
low-birth-weight infants. Often CSS manufacturers

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designate a minimum weight for use of their seats, frequently 4 or 5 lb. Parents with infants weighing less than
4 lb at discharge will need a CSS recommended for lower
weights or from birth.
Because preterm infants are at increased risk of oxygen desaturation, apnea, and bradycardia, particularly
when in semireclined positions, the AAP recommends
that preterm infants successfully complete a car seat test
or challenge before being released from the hospital.
During the car seat test, the infant is secured in his/her
own CSS for a designated period, typically at least 90
minutes, during which time the infant is monitored to
determine if he/she has stable cardiorespiratory function. If an infant fails to pass the car seat test, a car
bed may be recommended for transportation. For preterm and low-birth-weight infants who will be going
home in a rear-facing CSS, particular attention must
be paid to the recline angle during installation because
an overly upright position may result in neck exion
with respiratory distress. (9)
Children with special short-term or long-term health
care needs are another important population to consider
when discussing CPS recommendations. Given the wide
variety of physical, developmental, and behavioral health
care needs that may be relevant to choosing and installing
an appropriate CSS, an extensive discussion of this topic is
beyond the scope of this review. However, there are 2 key
items that all clinicians should be aware of: (1) a child
with special health care needs may not need a special
CSS; many parents are able to meet their childs needs
with an off-the-shelf CSS, often at a savings of hundreds
of dollars; and (2) resources are available for individuals
seeking more information on this topic. The AAP has
a separate policy statement specic to the topic of transporting children with special health care needs. In addition, CPSTs and childrens hospitals can typically provide
additional assistance specic to children with special
health care needs.

Noncrash Vehicle Hazards for Young Children

Motor vehicles can be dangerous places for young children, even if they are not involved in a crash. Parents
may overlook the following hazards. (10)
Tragically, each year in the United States dozens of
young children die of hyperthermia after being left
alone in parked cars. Parents and caregivers should
be reminded to always check the back seat for children
before walking away from the vehicle. Placing something the parent typically carries, such as a purse, telephone, or briefcase, in the back seat of the vehicle can

car safety

help to serve as a reminder to look in the back before

locking up.
More than 100 children die each year in the United
States and thousands more are injured when they
are run over by slow-moving vehicles when the driver
does not see them, usually while in a driveway or parking lot. Drivers should take care to walk around all
sides of the vehicle before putting it in motion, and
parents should ensure they know where their children
are before starting to drive. Features in newer model
motor vehicles that allow the driver to see behind the
vehicle, provide a proximity alarm, or automatically
stop the vehicle when an object is behind it provide
additional protection against back-over injuries to
children.
Children should never be left alone in or around cars.
Children have been injured or killed as a result of being
strangled by power windows, becoming trapped in vehicle trunks, or unintentionally shifting a vehicle into
gear.

Supporting Teen Drivers

Motor vehiclerelated crash fatalities account for onethird of all deaths among US teens. In 2010, this totaled
more than 3000 adolescents 15 to 19 years of age. (3)
The fatal crash rate per mile driven for 16- to 19-yearolds is 3 times the rate for drivers 20 years and older.
(4) In 2011, 26% of drivers 15 to 20 years who were
killed in motor vehicle crashes had a blood alcohol concentration of 0.08 g/dL or greater. Male teenagers are
nearly twice as likely to drive after drinking alcohol as
females.
Clinicians can support the development of safe teen
drivers by empowering parents to talk to their teens
about safe driving responsibilities and expectations and
encouraging them to set limits for novice drivers. Driving
agreements between parents and teens may inuence
teen driving behavior; however, additional research is
needed on this topic.
Clinicians can also promote safe driving among teens
by supporting the enactment and enforcement of strong
graduated driver licensing (GDL) laws. GDL laws are an
evidence-based policy strategy for reducing motor vehiclerelated crashes among teen drivers. By setting limits
on new teen drivers, they are able to develop driving skills
in a more controlled environment. Effective components
of GDL laws include nighttime driving restrictions, extended learner periods that delay licensure for new drivers, passenger restrictions, and primary seat belt laws for
teen drivers.
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2. Durbin DR; Committee on Injury, Violence, and Poison Pre-

Summary
On the basis of strong research evidence, motor
vehiclerelated crashes are a significant cause of
morbidity and mortality among children and teens in
the United States. (1)(2)(3)(4)
On the basis of strong research evidence, child
passenger safety can be viewed as consisting of 4
steps, with each transition resulting in a reduction in
protection for the occupant. (1)(2)
On the basis of strong research evidence, some
populations, including preterm and low-birth-weight
infants and children with special health care needs,
may require extra assistance to provide for their child
passenger safety needs. (9)
On the basis of strong research evidence, parents
should be alerted to noncrash vehicle-related hazards
because these can also cause injury and death. (10)
On the basis of strong research evidence, teen drivers
are at higher risk for motor vehiclerelated crashes;
however, there are known effective strategies to
reduce injury crashes among this population. (4)

Key References
(additional references can be found online)
1. Durbin DR; Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):788793

vention. Child passenger safety. Pediatrics. 2011;127(4):e1050

e1066
3. Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control. Web-Based Injury Statistics Query
and Reporting System (WISQARS). 2010. http://www.cdc.gov/
injury/wisqars/index.html. Accessed January 6, 2014
4. Insurance Institute for Highway Safety, Highway Loss Data
Institute. Fatality facts 2011. http://www.iihs.org/research/fatality.aspx?topicNameChild-safety. Accessed December 16, 2013
5. Arbogast KB, Durbin DR, Cornejo RA, Kallan MJ, Winston FK.
An evaluation of the effectiveness of forward facing child restraint
systems. Accid Anal Prev. 2004;36(4):585589
6. Pickrell TM, Ye TJ. The 2011 National Survey of the Use of
Booster Seats. (Report No. DOT HS 811 718). Washington, DC:
National Highway Trafc Safety Administration; 2013
7. Elliott MR, Kallan MJ, Durbin DR, Winston FK. Effectiveness
of child safety seats vs seat belts in reducing risk for death in
children in passenger vehicle crashes. Arch Pediatr Adolesc Med.
2006;160(6):617621
8. Durbin DR, Elliott MR, Winston FK. Belt-positioning booster
seats and reduction in risk of injury among children in vehicle
crashes. JAMA. 2003;289(21):28352840
9. Bull MJ, Engle WA; Committee on Injury, Violence, and Poison
Prevention and Committee on Fetus and Newborn; American
Academy of Pediatrics. Safe transportation of preterm and low birth
weight infants at hospital discharge. Pediatrics. 2009;123(5):
14241429
10. Kids and Cars. National statistics from the kidsandcars.
org database, 1991-2011. http://www.kidsandcars.org/statistics.
html. Accessed January 6, 2014

Parent Resources From the AAP at HealthyChildren.org

http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seat-Checkup.aspx
Spanish: http://www.healthychildren.org/spanish/safety-prevention/on-the-go/paginas/car-safety-seat-checkup.aspx
http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-and-Obese-Children-

Suggestions-for-Parents.aspx
Spanish: http://www.healthychildren.org/spanish/safety-prevention/on-the-go/paginas/car-safety-seats-and-obese-

children-suggestions-for-parents.aspx
http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/First-Aid-Supplies-for-your-Car.aspx
Spanish: http://www.healthychildren.org/spanish/safety-prevention/on-the-go/paginas/first-aid-supplies-for-your-car.

aspx
http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Baby-Carriers-Always-Use-in-the-Car.aspx

(English only)
http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Air-Bag-Safety.aspx
Spanish: http://www.healthychildren.org/spanish/safety-prevention/on-the-go/paginas/air-bag-safety.aspx

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1. Which of the following best describes the use of car safety seats (CSSs) in the United States?
A. Only 65% of US children ages 4 to 7 years are properly restrained in a CSS or belt-positioning booster
(BPB) seat when they ride.
B. More than 30% of children ride completely unrestrained in motor vehicles.
C. The use of CSSs reduces the risk of serious injury to 1- to 4-year-olds in a crash by less than 50%.
D. Not all states require the use of CSSs for children.
E. CSSs decrease morbidity but not mortality.
2. Which states do not have booster seat laws in place for children who have outgrown their CSS?
A.
B.
C.
D.
E.

New York and Maine.

Idaho and Montana.
Florida and South Dakota.
Texas and Oklahoma.
Illinois and Oregon.

3. When should children stop using their BPB seat and begin to use the vehicles lap and shoulder belt?
A. When the parent is comfortable with the transition.
B. When the child is 6 years old.
C. When the child is 4 ft 9 in tall and 8 to 12 years of age.
D. When the child is tall enough to be able to look out the side window.
E. When the child can buckle and unbuckle the seat belt by themselves.
4. How long can a 2-year-old remain in a rear-facing CSS in the back seat?
A.
B.
C.
D.
E.

Until age 2 years.

Beyond age 2 years as long as the child fits the rear-facing height and weight restrictions of the CSS.
Until the child weighs 20 pounds.
Depends on state law.
Until the child can fit into a booster seat.

5. Which of the following is true about CSSs sold in the United States?
A. Federal safety standards for CSSs vary by state.
B. Low-cost CSSs meet the same federal safety standards as very expensive CSSs.
C. Used CSSs are suitable for resale for another childs use.
D. CSSs are designed to be used with bulky clothing, such as heavy coats and snowsuits.
E. Low-cost CSSs do not provide adequate protection from injury.

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Car Safety
Nichole L. Hodges and Gary A. Smith
Pediatrics in Review 2014;35;155
DOI: 10.1542/pir.35-4-155

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