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Families with children crossing in a crosswalk

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Speed, technology, road design are key factors in reducing pedestrian injuries: AAP

June 20, 2023

One of the favorite questions Brian D. Johnston, M.D., M.P.H., FAAP, asks pre-kindergartners at their well-child visit is, “What are you supposed to do when you cross the street?”

Most kids will answer: “Look both ways.”

“And that makes most parents very proud,” Dr. Johnston said. “But then when you ask the child, ‘What are you looking for?’ you get all kinds of answers: ‘my friends, money,’ etc.” he said.

Many children have internalized safety advice but may not be ready for prime time, said Dr. Johnston, a lead author of an updated AAP policy statement and new technical report from the AAP Council on Injury, Violence and Poison Prevention.

The policy Child Pedestrian Safety and the technical report Epidemiology and Prevention of Child Pedestrian Injury are available at and and will be published in the July issue of Pediatrics.

Pediatricians will find evidence-based advice for families about the risks and safety precautions to consider for child pedestrians at different ages as well as the benefits of “active transport” — travel by walking or bicycling.

Studies have shown that younger kids can do a good job completing pedestrian safety education in a structured environment like Safety Town, Dr. Johnston said. “But if you follow these same kids home from school, it doesn’t translate into other traffic environments where they have to make the same sort of decisions.”

Anticipatory guidance

Traffic environments are complex, and the policy emphasizes that most children under age 10 probably can’t apply all the skills needed to be safe pedestrians on their own.

Adults consider many issues when they are negotiating road environments, Dr. Johnston said, “…and kids don’t have that database of knowledge and experience, in general.”

The policy recommends advising parents to provide ongoing, active instruction on pedestrian safety, including the risk of distracted walking (especially while using cellphones or other devices).

Children with limited mobility or other disabilities require extra time for counseling.

Young children should not be allowed to play in driveways and adjacent, unfenced yards due to the risk of not being seen by drivers backing their vehicles.

Rising mortality, need for advocacy

Although pedestrian deaths have been dropping consistently over most of the last three decades, child pedestrian mortality has increased 11% since 2013. This is a result of increases in deaths of 10- to 14-year-olds and 15- to 19-year-olds, a trend that was evident even before the pandemic.

Pedestrian injuries/deaths also rose during the pandemic across all ages, despite fewer people on the roads.

Advocacy to address environmental and urban design factors has the greatest potential to reverse these trends, according to the policy. Pediatricians can advocate for improvements that address technical issues like vehicle speed, car technology and road design.

“Probably, the most important point we wanted to convey to pediatricians is that your role in preventing child pedestrian injury is more closely tied to your role as an advocate, as a trusted voice in child health, as a member of your community advocating for specific policies — urban planning decisions, speed enforcement, things that go beyond the walls of the exam room — and less having to do with what you can counsel individual children and families to make themselves safer,” Dr. Johnston said.

Vehicle automation technologies and safety features must protect children as well as adults, yet many algorithms are based on the detection and behavior of adult pedestrians, he added.

Risk factors, equity issues

Death rates in Black and American Indian pedestrians under age 19 are 1.8 times higher than in White children, and Hispanic children are 1.2 times more likely to die than non-Hispanic children.

“Injury risk correlates closely with socioeconomic status in the neighborhood where you live,” said Dr. Johnston, “and poor neighborhoods are just less likely to have the amenities that make it safe and appealing for people to walk.”

There are disparities in access to public transportation and in sidewalk and road designs that increase the chance of pedestrian injury. Systemic and historical racism is reflected in zoning laws and policies.

Other findings in studies of pedestrian injuries include the following:

  • Most pedestrian fatalities occur mid-block not at intersections.
  • Although lower extremities are the most common site for pedestrian injuries, traumatic brain injury is diagnosed in 55% of deaths.
  • Alcohol-impaired drivers are implicated in nearly one-fourth of child fatalities.
  • Speed plays a major role. In a U.S. study, the average risk of severe injury to a pedestrian was 10% at an impact speed of 17 mph, 25% at 25 mph, 50% at 33 mph, 75% at 41 mph and 90% at 48 mph. Efforts to reduce vehicle speed in pedestrian environments are crucial.

Embrace safety programs

Public health/pedestrian safety programs like Complete Streets and Vision Zero, recommended in the AAP guidance, include multiple design features to slow traffic such as roundabouts, speed humps or narrow street width. These programs are built on the assumption that humans will make mistakes. Layers of safety help mitigate the outcome of those errors.

Enforcement activities also help. These include speed cameras in critical locations like school zones or 20 mph speed limits in areas such as residential and commercial districts.


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