This report supports policy recommendations in the accompanying policy statement “Child Pedestrian Safety” (www.pediatrics.org/cgi/doi/10.1542/peds.2023-62506). It reviews trends in public health and urban design relevant to pedestrian safety and provides information to assist practicing pediatricians discussing the benefits of active transportation and the specific risks and safety precautions to consider for child pedestrians at different ages. The report offers the evidence base for which programs and policies that, if implemented, could foster independent mobility for children while increasing pediatric pedestrian safety.
Since the previous policy statement was published in 2009, the field of pedestrian safety has advanced with new evidence related to pediatric pedestrian education, the risks of distracted walking, the benefits of design and programming in safe routes to school, and the emergence of the “Vision Zero” public health and safety initiatives to prevent all serious and fatal transportation injuries.
At some point in the day, almost everyone is a pedestrian, whether walking independently or with the support of an assistive device. Walking is the most fundamental mode of human transport and is a part of every trip, even those completed by driving or on public transit. For children, walking is especially important as it is often the only form of independent mobility accessible to them. In addition, walking is a component of an active and healthy lifestyle; features of the built environment that encourage walking are associated with physical and mental health benefits as well as improved social cohesion.1
Pedestrians become vulnerable to injury when walking routes force pedestrians into close proximity with vehicles, especially when vehicle speeds are high. The field of pedestrian safety has advanced, with new evidence related to the benefits of pedestrian-friendly transportation policies, safe routes to school, and “Vision Zero” public health and safety initiatives to eliminate serious and fatal transportation injuries. Additional research has examined the risks of distraction when pedestrians and vehicles mix as well as the promise and limitations of pediatric pedestrian education. Implementation and dissemination of these new approaches through pediatric practice, public policy, and advocacy can ensure that all children experience the anticipated health benefits of walking safely.
Although there is no consensus definition, most data sets identify pedestrians as those walking, running, standing, or lying on a road, right of way, or parking lot. People on bicycles, skateboards, and other nonpowered conveyances are not considered pedestrians for the purposes of this report. Pedestrian injury data are often stratified into “traffic” data, which include those injured or killed while on the roadway, and “nontraffic” data involving those struck on driveways or private lots, an important subset of the injured among younger children.2
Deaths and Injury
In the United States, 16% of children killed in traffic crashes are pedestrians.3 In 2020, 235 child pedestrians (0–14 years old) died in traffic crashes, whereas another 81 died in nontraffic incidents. Older teens (15–19 years old) accounted for another 245 pedestrian deaths.4 Although pedestrian deaths decreased consistently over most of the last 30 years, child pedestrian mortality has shown a worrisome increase of 11% since 2013 because of increases among 10- to 14-year-olds and 15- to 19-year-olds (Fig 1).5 These population-based measures cannot discriminate how much of the increase in pedestrian injury is attributable to a true increase in pedestrian “risk” per mile walked or greater pedestrian “exposure”—an increase in pedestrian activity. A more meaningful measure of child pedestrian risk would be incidence density, measuring death per person mile traveled or per trip. Unfortunately, exposure data for child pedestrian activity are not systematically collected, despite emerging availability of efficient statistical estimation models6 and the use of global positioning satellite and accelerometer data from smart devices.7
Fatality data suggest that evenings (from 6:00–9:00 pm) are the riskiest times of day for child pedestrians. Sixty-four percent of deaths occur in daylight hours or at dusk,3 and most (62%) child pedestrian fatalities occurred midblock, rather than at intersections (18%).3 Alcohol-impaired drivers were implicated in 22% of child pedestrian fatalities.3
According to data from the National Electronic Injury Surveillance System All Injury Program, an estimated 31 006 pedestrians ages 0 to 19 years were treated for injury in US emergency departments in 2018.8 Pedestrian injuries are generally more severe than those experienced by motor vehicle occupants.9 Lower extremity injuries are the most common sequelae of pedestrian crashes, but traumatic brain injury is diagnosed in 6% of pedestrian emergency department visits and is implicated in 55% of pedestrian deaths.10 Up to 72% of children injured as pedestrians will have functional limitations 6 months after their injury.11
The burden of pedestrian injuries differentially impacts certain populations of children (Fig 2). As with most mechanisms, males are more likely to be injured as pedestrians than are females.4 The risk of child pedestrian death is greater in rural (0.85 of 100 000) than urban (0.66 of 100 000) areas.4 Preschool-aged children have a higher pedestrian death rate (typically from nontraffic incidents in driveways or parking lots) than do school-aged children. Rates climb again in the teen years when more children become independently mobile as pedestrians.
Children with disabilities are also at disproportionate risk of pedestrian injury.12 People who use wheelchairs experience well-documented pedestrian mortality disparity.13 Although children with physical impairments may be challenged to safely navigate standard road environments, those with intellectual disability or neurodevelopmental differences are challenged by the cognitive tasks of pedestrian mobility.14 Individuals with attention-deficit/hyperactivity disorder15 and autism spectrum disorder16 are also known to have a higher risk of death from injury, with elopement and exposure to traffic danger especially prevalent among children with autism spectrum disorder.17
The rate of death of Black and American Indian pedestrians younger than 19 years of age is 1.8 times that of white children, whereas the risk to Hispanic children is 1.2 times the risk to non-Hispanic children.4 Factors underlying these inequities include the pervasive impact of poverty for families with children, economic disparities in access to public transportation, systemic racism perpetuated through zoning laws targeted at racial and religious minorities, and disparities in the investment of transportation safety measures, such as sidewalks, to separate pedestrians from vehicles.18,19 Low-income areas often have interrupted sidewalk networks and larger roads with a higher traffic burden, which both increase the likelihood of traffic conflicts between pedestrians and vehicles.20 Individual racism may also affect drivers’ behavior. In studies of adults crossing at a crosswalk, Black pedestrians waited longer than white pedestrians before cars yielded, and more cars passed them while in the crosswalk.21
Exposure to Walking
Increases in population-based pedestrian injury rates may be attributable to changes in pedestrian risk or to an increase in walking. Conversely, much of the reduction in child pedestrian injury over the 1990s may have resulted from declines in child pedestrian activity and an increase in sedentary behavior.22 Recent public health campaigns to promote physical activity and active transport to school may have reversed that trend. Across all age groups, children 5 to 15 years old have the highest proportion of daily trips made by walking.23 Nationally, 10.4% of children travel to school as pedestrians, a proportion that increases dramatically when considering only those living within 0.5 mile (56.1% walk) and within 0.25 miles of their school (80.9% walk).23
Active transport to school (defined as travel by walking or bicycling) has theoretical benefits in both health and educational outcomes. Active transport is associated with greater total physical activity24,25 and may improve body composition and cardiovascular fitness. Walking for transport is also associated with improved mental health,26 but the best data on school outcomes are still inconclusive.27 Interventions to promote active transport to school have shown success in a variety of settings.28
Nevertheless, not all children who could walk to school will actually do so.29 In some cases there are barriers to walking imposed by urban form and street configurations.30 Extremes of climate can also discourage walking and school policies may encourage or hinder active transport.31 Real and perceived injury risk, related to traffic and to interpersonal danger, is a strong predictor of parental decisions about active transport.32
The safety of commuting to school on foot is integrally related to measures that separate walkers from vehicles and slow vehicle speeds. Compared with automobile passengers, child pedestrians experience double the risk of injury or fatality whether measured per trip or per mile traveled.33 Because children from lower socioeconomic backgrounds are more likely to travel as pedestrians, disparities in risk and exposure contribute to inequities in health outcomes.34,35 Interventions to increase pediatric pedestrian safety are required for children to realize the full benefit of active transport and independent mobility.
Child pedestrian injury prevention can be characterized as a spectrum from active programs, designed to educate or train individuals to change their behavior, to passive interventions that increase the safety of products or environments in a manner that impacts all users.36 These passive interventions tend to be more costly and difficult to implement but are also more likely to result in real and sustained reductions in injury incidence.37,38
Although it is important to acknowledge the tension between interventions focused on child pedestrian education and those directed more broadly at environmental modification, the optimal solution need not be an “either/or” decision.39 Most “passive” interventions still require an element of active participation or behavioral alignment,40 and many environmental approaches start with advocacy and education to change the behavior of community members and their leaders. All interventions should be examined in terms of their documented efficacy in reduction of child injury morbidity and mortality, their acceptability and scalability in practice, and their impact on equity in meaningful outcomes.
Pedestrian Safety: Urban Form and Policy
Road environments should safely accommodate the needs of all users. Although streets were used for all manner of social activity until the advent of the automobile, the early 20th century saw a cultural change wherein roads were viewed as solely for the rapid conveyance of motorized traffic.41 This perspective was actively encouraged by campaigns that characterized pedestrian injury as the result of irresponsible individual behavior.42 This focus on the behavior of the victim obscures the fact that speed, technology, and road design create the context in which these injuries occur. Planning and policy can be used to make the streets safer for all users, regardless of their age or ability.
Traffic Calming to Reduce Speed
Vehicle speed is arguably the most important risk factor for pedestrian injury.43 Because it takes longer to brake a fast-moving vehicle, speed is related to the risk of pedestrian crash. Slower vehicle speeds are associated with fewer crashes. In addition, when a crash occurs, vehicle speed is highly predictive of the risk of injury or death. In a study of US pedestrian crashes, the average risk of severe injury to a pedestrian increased from 10% at an impact speed of 17 mph to 25% at 25 mph, 50% at 33 mph, 75% at 41 mph, and 90% at 48 mph (Fig 3).44
Traffic-calming measures, such as roundabouts and speed bumps, are engineering approaches designed to reduce vehicular speed and, thus, decrease the number of pedestrian crashes and associated injuries.45 The redesign of intersections, including installation of a median to form pedestrian refuge islands and expansion of the curb to create pedestrian plazas, have been found to decrease pedestrian injuries in some areas.46 Not only is traffic calming associated with absolute reductions in pedestrian injury, its application can be prioritized in deprived areas to reduce the relative socioeconomic inequities in child pedestrian injury rate.47
Speed reduction is also achieved through automated enforcement, such as speed cameras. Lower vehicle speed limits around schools, coupled with photo enforcement, effectively reduce vehicle speeds.48 Although speed cameras have been used sporadically in the United States, other countries have seen dramatic benefit from more extensive networks.49 There is evidence that speed reductions attributed to camera enforcement extend beyond the immediate vicinity of the area under enforcement.50
The built environment is defined as “man-made structures, features, and facilities viewed collectively as an environment in which people live and work.”51 There are many aspects of the built environment that impact both pedestrian activity and pedestrian risk.52 The balance of increasing walkability while maintaining pedestrian safety can be challenging. In a comprehensive review of built environment approaches to pediatric pedestrian safety, only traffic calming and the creation of dedicated playgrounds or recreational spaces were associated with both an increase in walking and a decrease in child pedestrian injury.45
Some common environmental features, such as the presence of multifamily dwellings, mixed-use neighborhoods, and marked crosswalks not at controlled intersections, are associated with more walking but also a higher risk of injury.45 Transit stops, areas with high pedestrian activity, when placed on the near side of an intersection, result in more drivers failing to yield to pedestrians and passing stopped vehicles.53
Streets designed to be narrower and for slower speeds experience the lowest rates of vehicle-pedestrian crashes, and those with wide lanes and higher operating speeds experience the highest rates.54 Swift and colleagues examined 13 built environment characteristics and found street width to be correlated most highly with pedestrian collision rates,55 even when controlling for changes in traffic volumes.56 Effective countermeasures include sidewalks, pedestrian-only signal phasing, and optimal roadway lighting.57 Other technologies, including advance stop lines and in-pavement flashing lights, have been evaluated on a more limited basis.58
Focused on the unique vulnerabilities of child pedestrians on the daily trip to and from school, the Safe Routes to School (SRTS) program began in the 1970s in Denmark and was initiated in the United States in 2005. The US SRTS program funded state agencies to encourage children to walk and bike to school by making school travel safer. Funds were used to improve sidewalks and bicycle lanes, build traffic-calming infrastructure in school zones, improve signage, and provide pedestrian education. Evaluation of this program at 124 New York City schools showed that the annual rate of school-aged pedestrian injury during school-travel hours decreased 44% in census tracts with SRTS interventions but remained unchanged in census tracts without SRTS interventions.59 Economic modeling based on these results showed that SRTS interventions were cost-saving over time.60
Urban Form and Planning
Urban planning at the largest scale also affects pedestrian injury. Sprawl is characterized by low-density residential development with rigid zoning, few centers of activity, and a road network with large block sizes and long, wide streets that encourage excessive speed. In the United States, the sprawling urban environments of the South and West have the highest rates of pedestrian injury.61 These environments are simultaneously uninviting and underused by pedestrians but also especially dangerous for those who must walk there. When “sprawl” is explicitly modeled using an index, each 1% change in the index (meaning the city is more sprawling) is associated with a 3% increase in pedestrian fatality rates, even after adjusting for changes in exposure.62
US federal legislation provides planning tools and requirements for reducing the disparity experienced by pedestrians with disabilities.63 The Federal Highway Administration and its local transportation partners are required to provide accessible transportation facilities under the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 (Section 504). These statutes mandate that the agency must provide access to streets and sidewalks for persons with disabilities whenever a pedestrian facility exists. These standards include accessible features such as curb cuts, ramps, continuous sidewalks, and detectable warnings.
Policy and Advocacy
One of the pillars of injury prevention is legislation to further enforce safety-oriented behaviors. Because much of the legislation on speed limits, changes to the built environment, and pedestrian laws are based in county and city level jurisdictions, it is important that advocates partner with local politicians for the creation of protective laws. Research has found that if lawmakers are educated and informed on issues such as pedestrian safety, they are more interested and supportive of advocacy efforts.64
Speed limits in the United States have traditionally been set using an approach based on traffic studies to determine the speed of the 85th percentile in free-flowing conditions.65 These speeds do not consider safety, and many municipalities have experimented with reductions in the default speed limit on city streets. Area-wide 20 mph zones in residential or commercial zones are increasingly common. These interventions have been shown to reduce measured vehicular speeds66 and are associated with fewer crashes and pedestrian injuries.67 In London, 20 mph zones reduced pedestrian crashes and injuries by an average of 40%, with the greatest benefit seen in children younger than 15 years.68 To realize the safety benefits of urban slow zones, however, state law must allow cities to set these lower default speed limits.69
Daylight saving time adds an hour of light to the afternoon and increases the visibility of both vehicles and pedestrians, and modeling research has found that implementing daylight saving time year-round could help prevent pedestrian deaths and injuries.70,71 Policy supporting the implementation of year-round daylight saving time has been introduced in various US legislative bodies, but has not (as of publication of this statement) been passed.72
Complete Streets policies promote the development and use of roadways with all forms of transportation and people in mind, including motor vehicles, pedestrians, bicyclists, and people of varying abilities, developmental levels, and ages.73 Complete Streets are not centered on just transportation within cars (as has been the traditional focus of street design), and may include various types of design to incorporate different modes of travel, including bike lanes, median islands, roundabouts, sidewalks, crosswalks, specific bus lanes, and others. Complete Streets policies are most effective when implemented in conjunction with land use development with all forms of transportation in mind, and education, enforcement, and technology use. This type of coordination requires a multidisciplinary effort including policy makers, city planners, architects, and developers.74
“Vision Zero” is another effort focused on the reduction of traffic fatalities and severe injuries. Vision Zero is built on the premise that traffic injuries are a public health problem in which human error is assumed and expected, and solutions are created with that assumption at the foundation.75 This effort has shifted the focus away from individual behavior and toward system-wide change created with human error in mind. In the United States, more than 30 cities have adopted Vision Zero initiatives.76 Vision Zero activities include the use of automated enforcement cameras and roundabouts for speed reduction; street design, such as curb extensions and separate bike lanes, to accommodate mistakes and provide a safe, efficient, connected infrastructure for people walking; and traffic signal calibration to allow pedestrians time to cross before traffic can turn onto the street, or allow pedestrians to finish crossing before oncoming traffic flows into the crosswalk. Vision Zero campaigns may also include public education to promote awareness and safer behaviors, as well as investments in trauma care systems to mitigate the human toll of inevitable crashes.
Importantly, Vision Zero and Complete Streets have both included equity in their work. Vision Zero prioritizes changes in areas disproportionately affected by traffic fatalities and involves those communities in decisions about the changes.75 Complete Streets is now using diversity and equity outcomes in their framework for grading.77,78
Pedestrian Safety: Product Modification
Automobiles are consumer products. Modifications in product design are integral components of many injury prevention campaigns.
Because most pedestrian crashes are front-end, modifications can be made to the front of the vehicle to mitigate the severity of injuries.79 Design features can include soft bumpers, an active hood mechanism to provide a more forgiving crumple-zone, and pedestrian airbags to protect from impacts on the windshield or rigid structures in the frame.80 Most consumers are unaware of these options.
Sport utility vehicles, vans, and light trucks represent an increasing proportion of the US vehicle fleet. These designs account for more than 70% of the new car market81 and are heavier, stiffer, and more blunt at the front end than are passenger cars. As a result, they are associated with a two- to threefold increase in the risk of pedestrian death.82
Larger vehicles also have a larger rearward blind spot,83 increasing the risk of backover injuries to young pedestrians.2 Newer vehicles may be equipped with technologies to address this blind spot or to sense and intervene when an object is detected in that space. Recent studies suggest that a rear-facing camera is effective at reducing the risk of backover crashes, whereas a sensor or alarm, alone, is not.84 More sophisticated, rear, automatic braking can prevent up to 78% of these incidents.85
Technological improvements in vehicle function include increasingly prevalent crash avoidance systems. The Insurance Institute for Highway Safety now rates pedestrian safety of vehicles based on an autobrake system designed to detect pedestrians and avoid or mitigate a crash through early braking and driver notification.86
As the technology and use of autonomous vehicles (AVs) continue to advance, the ability of AVs to detect and avoid pedestrians has been one source of concern. AVs depend on prediction software, cameras, and a collection of sensors to detect the environment (including pedestrians).87 Child pedestrians are smaller and less predictable in their roadside behavior and may not be well-served by algorithms that are adequate for adults. Thus, although AVs have the potential to decrease pedestrian crashes, the technology might impact age-related disparities by reducing adult injuries primarily.88,89
More broadly, AVs represent a disruptive technology that could lead to shifts in mobility patterns and urban development. Most planning scenarios envision a dramatic reduction in the need for urban parking spaces, allowing land currently allocated to that use to be repurposed as greenspace or mobility corridors for other forms of transport.90 Aggressive attention to the needs of child pedestrians will be required as this transition unfolds.
Pedestrian Safety: Education and Behavior
Although changes in policy, planning, and the built environment have the greatest potential to improve pedestrian safety, many of the most commonly promoted strategies to address pedestrian risk focus on individual-level interventions to improve the skills or behavior of child pedestrians, their adult guardians, or the drivers with whom they interact.
Learning Pedestrian Skills
Eventually, all individuals must learn how to be a pedestrian. Rather than thinking of pedestrian safety as a body of knowledge to absorb, it is most useful to characterize it as a series of cognitive, perceptual, and motor skills that must be mastered to navigate the road traffic environment.91,92 Crossing the street is a complex task that requires the ability to identify a safe place to cross, recognize the relative speed of a moving car, judge the distance of the automobile, and quickly make a decision about whether it is safe to enter the roadway.93 Various techniques have been used to teach these skills, including classroom curricula, video or web-based instruction, real life practice with adult supervision and instruction, and internet and smart phone-based virtual reality (VR) training.94–97 To date, no standardized educational intervention has demonstrated effectiveness at preventing pedestrian injury; the relative costs and benefits of these intensive programs is an important consideration when evaluating prevention measures. Despite the appeal of these programs, a Cochrane review in 2002 concluded that “Pedestrian safety education can change observed road crossing behavior, but whether this reduces the risk of pedestrian injury in road traffic crashes is unknown.”98
In a rare randomized controlled trial, Schwebel and colleagues showed that, for 7- and 8-year-old children, either direct, street-side instruction or training in a VR pedestrian environment resulted in improvement of at least some safety behaviors when compared with standard video instruction.99 Intensive education approaches have demonstrated that younger children can learn crossing skills.100,101 Evaluation of the Kerbcraft program in the United Kingdom, for example, found improvements in 3 targeted crossing skills.101,102 However, taking these intensive programs to scale is daunting.103
Using available VR technology, pedestrian training in virtual environments could theoretically be delivered without adult supervision and with the option for repetition and practice until a threshold competence is achieved.99 Access to VR technology remains a barrier, and it is unclear which pedestrian skills are best suited to this form of instruction.
Thus, although there are promising techniques for improving the skills needed to navigate roadways and intersections, these require careful attention to implementation and may not be adequate to ensure the safety of child pedestrians.91,95 The literature does suggest that pedestrian safety hinges on skills that can be actively learned and which, at some point, can reliably be taught. However, the abilities and developmental level of the individual child are important, and it is unlikely that most children can be taught to safely navigate diverse traffic environments earlier than 10 years of age.104
Adult supervision is associated with a decreased risk of child pedestrian injury. Roberts et al demonstrated a 64% reduction in the risk of child pedestrian injury when adults accompanied children on the walk to or from school.105 Subsequent studies have confirmed this association but also highlight parental overestimation of their children’s ability to walk safely without supervision.106 This overestimation is also seen in deficits in parental modeling of appropriate pedestrian behavior and poor parental instruction of their children in pedestrian skills.107
The “walking school bus”—a group of children walking to school with an adult chaperone—is a form of adult supervision for child pedestrians. In addition to promoting active commuting and physical activity, the walking school bus provides the safety benefit of adult oversight. Limited studies to date suggest an improvement in some safety behaviors while participating in a walking school bus.108
Pedestrian and driver distraction are 2 factors that increase the risk of a pedestrian being struck. Almost 500 000 people drive daily while using cell phones,109 and up to 14% of those injured by distracted drivers are pedestrians.110 Interventions to combat distracted driving have been reviewed elsewhere.111,112
Pedestrians can also be distracted.113,114 Observational data show that when using smart phones and other devices, both children and adults are less likely to follow basic safety measures when crossing the street.115–117 An optimally designed pedestrian infrastructure would anticipate and protect the distracted pedestrian. Potential interventions to reduce distracted walking behavior have been evaluated, including visual stenciled warnings on the sidewalk,118,119 virtual reality training, and campaigns for community-wide change.120 Although studies are ongoing, few to date have found sustained change in behaviors.
Intervention With Drivers
Interventions with drivers include those designed to increase awareness of pedestrians and to decrease drivers’ speed. Advanced yield markings, curb extensions, and parking restrictions have been found to impact drivers’ self-reported behavior when near pedestrian crossings.121 Although laws vary, most states require at least yielding to pedestrians in a crosswalk.122 Various advances in pedestrian-detection technology within motor vehicles may assist in the effort to detect pedestrians early. These include forward collision warning systems and automated emergency braking,123,124 although studies suggest that many drivers are unfamiliar with the purpose and limits of the technology on their vehicle.125
Certain characteristics of the driver have been associated with a higher likelihood of pedestrian injury, including impairment attributable to drugs or alcohol.126 The Driver Alcohol Detection System for Safety Program, along with car manufacturers, is working to develop a passive alcohol detection system within vehicles to reduce the incidence of drunk driving.127,128
Walking is the most fundamental mode of human locomotion and, for children, the primary source of independent mobility. Active transport is associated with physical and mental health benefits and is the focus of public health campaigns to increase physical activity and reduce obesity. However, when pedestrians share the roadway with vehicular traffic, they face real risk of injury or death. Child pedestrian mortality decreased for the last 3 decades but has started to trend up again in recent years, with disproportionate impact on families living in low-income communities and those who identify as Black, American Indian, and Hispanic.
There is no definitive age at which children can safely navigate streets independently, although children younger than 10 years generally require supervision. Anticipatory guidance on the safe navigation of streets while walking, as well as educational interventions with the purpose of increasing pediatric pedestrian’s knowledge and skills, are important; however, the most important interventions to address pedestrian safety involve urban planning and street design to safely accommodate all users. The Vision Zero initiative assumes that a target of no pedestrian fatalities or serious injuries is realistic with appropriate design and infrastructure investment. The development of autonomous vehicles presents urgent new opportunities to enhance child pedestrian safety.
These initiatives, with continued innovation and rigorous testing of educational interventions to help parents and communities safely train young pedestrians, will allow us to significantly reduce the significant morbidity and mortality of pediatric pedestrians.
Sadiqa Kendi, MD, FAAP
Brian D. Johnston, MD, MPH, FAAP
Council on Injury, Violence, and Poison Prevention Executive Committee, 2020–2021
Benjamin Hoffman, MD, FAAP, Chairperson
Phyllis F. Agran, MD, MPH, FAAP
Alison Culyba, MD, MPH, PhD, FAAP
James Dodington, MD, FAAP
Brian Johnston, MD, MPH, FAAP
Sadiqa Kendi, MD, FAAP
Lois K. Lee, MD, MPH, FAAP
Terri McFadden, MD, FAAP
Kathy Monroe, MD, FAAP
Milton Tenenbein, MD, FAAP
Kyran Quinlan, MD, MPH, FAAP, Immediate Past Chairperson
Suzanne Beno, MD – Canadian Pediatric Society
Cinnamon Dixon, DO, MPH, FAAP – National Institute of Child Health and Human Development
Laura Dunn, MPH, CPST-I – National Highway Traffic Safety Administration
Jonathan D. Midgett, PhD – Consumer Product Safety Commission
Bethany Miller, MSW, Med – Health Resources and Services Administration
Judith Qualters, PhD – Centers for Disease Control and Prevention
Drs Kendi and Johnston together conducted the literature review, drafted the report, and formulated all recommendations; and both authors approve of the final manuscript.
Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-062506.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.