INTRODUCTION

Background

Pedestrian traffic injuries represent a critical public health concern worldwide, particularly among vulnerable groups such as children [1]. Child pedestrian accidents are especially alarming, as they constitute a leading cause of death and can result in long-lasting consequences. These incidents frequently occur while children commute to and from school, leading to severe physical injuries, disabilities, and psychological trauma [1–3]. Consequently, the importance of implementing effective safety measures cannot be overstated.

In Korea, the pedestrian death rate per million children aged 0 to 14 years has been continuously decreasing, yet it remains the second highest among the Organization for Economic Co-operation and Development (OECD) countries [4]. Despite strengthened traffic safety efforts, such as the establishment of school zones, pedestrian accidents involving children persist [5]. This underscores the urgent need to reinforce road safety measures specifically for children and to comprehensively analyze the distinct characteristics of pedestrian injuries.

Preschoolers (aged 4–5 years) and early school-aged children (aged 6–7 years) are particularly vulnerable to pedestrian injuries, with developmental differences potentially influencing the incidence of pedestrian traffic accidents [6]. The preschool period involves rapid physical and cognitive development. During this phase, children increasingly explore their environments independently, yet their limited field of vision and underdeveloped ability to assess road hazards increase their susceptibility to pedestrian injuries [6]. Conversely, early school-aged children possess more advanced motor and cognitive abilities, but face new risks as they begin commuting to school through high-traffic areas [7]. They continue to exhibit risky behaviors, such as ignoring traffic signals when crossing streets or not waiting in designated safe zones [8].

Additionally, patterns of pedestrian injuries may differ depending on transportation methods and proximity to elementary schools and kindergartens. In Korea, the Rules on Decision, Structure, and Installation Standards for Urban Planning Facility mandate that elementary schools be situated within a 1.5 km radius of residential areas to ensure student accessibility [9]. However, no corresponding regulation exists for kindergartens. As a result, early school-aged children typically walk to elementary schools, whereas preschoolers often depend on school buses for transportation [10].

With a global focus on pedestrian injuries among children and adolescents aged 0 to 19 years, previous research has analyzed the prevalence, severity, and mortality of such injuries in various countries, including Australia [2], Japan [11], and Korea [5]. These studies indicate that pedestrian injuries are notably frequent among preschoolers and early school-aged children, often involving severe orthopedic injuries. However, limited research has specifically compared pedestrian injury characteristics between preschoolers and early school-aged children. Our study aimed to fill this gap by identifying the distinctive characteristics and circumstances associated with pedestrian injuries in these two age groups. Recognizing these differences is critical for the development of tailored interventions and effective safety measures that safeguard children from traffic-related hazards.

Objectives

This study aims to compare pedestrian injury characteristics between preschoolers (aged 4–5 years) and early school-aged children (aged 6–7 years) in Korea, identify temporal injury patterns, and examine the relationship between injury severity and mortality in both groups. By investigating these specific aspects, we seek to provide valuable insights to inform targeted interventions and policy development aimed at enhancing pedestrian safety for young children in Korea.

METHODS

Ethics statement

The study was approved by the Institutional Review Board of Konyang University (No. KYU 2024-06-001). The requirement for informed consent was waived due to the use of publicly available data.

Study design and setting

This cross-sectional study utilized secondary data from the 2020 Community-Based Severe Trauma Surveillance (2016–2020) [12]. This survey is conducted annually by the Korea 119 Emergency Services and includes all patients classified as seriously injured or involved in multiple casualty events. Its purpose is to continuously generate national health and medical statistics by identifying epidemiological characteristics such as disability and death resulting from injuries. Data collection involves collaboration with fire departments across 17 metropolitan cities and provinces, as well as over 700 hospitals. Trained investigators collect data using questionnaires by identifying participants through emergency activity records and obtaining medical records from hospitals.

Participants

The study initially identified 237,616 patients from 2016 to 2020. After three exclusion steps, a total of 413 patients (173 preschoolers and 240 early school-aged children) were included in the final analysis (Fig. 1). First, 234,460 patients were excluded for being younger than 4 years or older than 7 years. Second, 2,734 patients were excluded because their injuries were not pedestrian-related. Finally, nine patients were excluded due to unavailable injury information, out-of-hospital cardiac arrest, or prehospital death.

Variables

We collected data and categorized the variables into demographic characteristics, injury-related characteristics, and outcomes. Injury-related characteristics included the season of injury (spring, summer, autumn, winter), time of injury (00:00–05:59, 06:00–11:59, 12:00–17:59, 18:00–23:59), day of injury (Monday–Sunday), location of injury (home/residential institution/medical institution, school/educational area/sports venue, transportation area, other/unknown), activity when injured (education/recreational activity, daily activity, traveling unclassified, other), and Injury Severity Score (ISS; 1–15, 16–75, and out-of-hospital cardiac arrest/prehospital death) [13]. An ISS of 1 to 15 indicates minor trauma, while scores of 16 to 75 indicate severe trauma. We also recorded the level of the receiving hospital (regional trauma center, regional emergency center, local emergency center, local emergency facility). Outcome variables included functional outcomes after injury (severe disability, moderate disability, good recovery) and survival status (survival or death).

Statistical analysis

Time series analyses were conducted to examine temporal trends in pedestrian injuries within each age group. All statistical analyses were performed using IBM SPSS ver. 22.0 (IBM Corp), with statistical significance set at P<0.05. Variables were described using absolute frequencies and percentages. Cross-tabulation and chi-square tests were employed to explore relationships between categorical variables and to compare demographic and injury-related characteristics between age groups. Additionally, Fisher exact test was used to compare pedestrian injury outcomes according to injury severity intervals and between age groups. For detailed analyses by age group, distributions of pedestrian injury prevalence by time, day, and month were presented as counts and percentages. Multivariate logistic regression analysis was conducted to identify key factors influencing mortality. The optimal model was derived by incorporating the most significant variables, effectively explaining the variation in mortality among participants. Furthermore, due to mortality being the dependent variable, incidents involving out-of-hospital cardiac arrest and prehospital death were excluded from the ISS categories.

RESULTS

Demographic characteristics and pedestrian injury-related characteristics

Table 1 compares demographic and pedestrian injury-related characteristics. The variables "location of injury" and "activity when injured" showed statistically significant differences between the age groups. Early school-aged children had a significantly higher proportion of pedestrian injuries occurring in transportation areas compared to preschoolers (86.2% vs. 71.7%, P=0.002). Additionally, early school-aged children had significantly more pedestrian injuries during unclassified travel activities than preschoolers (85.8% vs. 67.0%, P<0.001).

Outcomes of pedestrian injury by injury severity interval and age groups

Table 2 presents a comparison of the outcomes of pedestrian injuries according to injury severity intervals and age groups. For both preschoolers and early school-aged children, the mortality rate tended to be higher in the severe trauma group (ISS, 16–75) compared to the mild or moderate trauma group (ISS, 1–15), although this difference did not reach statistical significance.

Distribution of pedestrian injury by age groups

Monthly variation

The distribution of pedestrian injuries varied distinctly by month (Fig. 2). Overall, early school-aged children experienced a higher incidence of pedestrian injuries than preschoolers. Preschoolers had the highest injury incidence in July (32 patients, 18.5%), followed by April (22 patients, 12.7%) and June (20 patients, 11.6%). For early school-aged children, June had the highest incidence (32 patients, 13.3%), closely followed by September (30 patients, 12.5%) and May (27 patients, 11.3%).

Daily variation

Pedestrian injuries also showed variation according to the day of the week (Fig. 3). For preschoolers, Saturday was the peak injury day (38 patients, 22.0%), followed by Thursday (35 patients, 20.2%). Among early school-aged children, Tuesday and Thursday were the peak days (each 43 patients, 17.9%), with Saturday as a secondary peak day (34 patients, 14.2%).

Hourly variation

Distinct hourly variations in pedestrian injuries were also observed (Fig. 4). Preschoolers experienced peak pedestrian injury occurrences at 5 ᴘᴍ (28 patients, 16.2%), with a secondary peak at 9 ᴀᴍ (27 patients, 15.6%). For early school-aged children, peak injury times were 5 and 6 ᴘᴍ (each 35 patients, 14.6%), with a secondary peak at 3 ᴘᴍ (34 patients, 14.2%).

Factors for mortality among preschoolers and early school-aged children

Table 3 shows mortality-related factors for pedestrian injuries. The severe injury group had a mortality rate 5.7 times higher compared to the mild/moderate injury group (odds ratio [OR], 5.65; 95% confidence interval [CI], 1.65–19.37; P=0.006). Mortality rates at local emergency centers were significantly higher compared to regional trauma centers (OR, 4.00; 95% CI, 1.38–11.60; P=0.011). Although mortality was also higher at local emergency facilities (OR, 3.00; P=0.160) and regional emergency centers (OR, 1.07; P=0.912), these findings were not statistically significant. Mortality at age 5 years (OR, 2.19; P=0.232) and 6 years (OR, 1.52; P=0.539) was higher than at the reference age of 4 years, though not significantly. Conversely, mortality at 7 years was lower, but this also lacked statistical significance (OR, 0.50; P=0.261). Higher mortality was observed during autumn, although this was not statistically significant (OR, 2.23; P=0.141). Variations in risk for summer (OR, 0.57; P=0.312) and winter (OR, 1.47; P=0.576) also did not reach statistical significance.

DISCUSSION

Our study revealed that preschoolers experienced fewer pedestrian injuries than early school-aged children. Previous studies on pedestrian injuries spanning preschool to adolescent age groups have indicated higher injury rates among school-aged children (31.3%–44.9%) compared to preschoolers (11.9%–40.4%), despite not specifically targeting the same age groups as our study [11,14]. This difference may stem from variations in school transportation methods. Preschoolers benefit from lower pedestrian accident rates because they typically commute to kindergarten using school transportation vehicles, reducing the need for independent walking compared to early school-aged children [15]. Conversely, early school-aged children experience higher pedestrian injury risks as they rely less on vehicles for school transportation and frequently walk to school with or without adult supervision [11,15].

We observed monthly variations in pedestrian injury rates between preschoolers and early school-aged children. For preschoolers, injuries peaked in July, coinciding with increased outdoor activities during summer vacation [1,16], when parents may be momentarily distracted, thereby heightening accident risks [17]. Conversely, early school-aged children experienced their highest injury incidence in June. This may be attributed to warmer weather facilitating more outdoor sporting events both in and out of school, thus increasing outdoor activity [16,18]. Additionally, pedestrian supervision may become less stringent during this time compared to the closer monitoring typical at the start of the school term in March and April.

The social skills of early school-aged children surpass those of preschoolers [19]. This developmental advancement allows early school-aged children to form new friendships upon entering elementary school, potentially leading them to engage in risky behaviors while walking, such as chatting or playing with friends on streets [19,20]. During winter months (January and February), both preschoolers and early school-aged children tend to participate less in outdoor activities due to colder weather, resulting in fewer accidents [1,16]. Consequently, our findings highlight the necessity for parents to exercise greater caution during outdoor activities to reduce pedestrian injuries. Additionally, as practiced in the United States and the United Kingdom, tailored training programs should be developed to enhance pedestrian safety among children [21,22].

Although there were variations in the timing of pedestrian injuries, both groups experienced peak injury occurrences between 3 and 6 ᴘᴍ, followed by 8 and 9 ᴀᴍ. This finding aligns with previous research examining injury trends by hour, which reported that 21.5% of injuries occurred between 3 and 6 ᴘᴍ and 21.0% between 6 and 9 ᴀᴍ [23]. This pattern likely reflects increased pedestrian activities during kindergarten and elementary school arrival and dismissal periods [24]. Additionally, afternoon periods coincide with after school activities, contributing to higher injury rates [14]. Moreover, longer commuting distances extending beyond typical school zones—which generally cover a radius of 300 m from kindergarten and elementary school entrances—pose additional risks for pedestrian accidents in Korea [25]. A prior study reported that elementary school students in Seoul had an average commuting distance of 727.6 m, with some traveling up to 3,200 m [25].

The higher incidence of pedestrian injuries during afternoon hours may be attributed to limitations of the "walking school bus" programs conducted by the Korean government, where children walk to school under adult supervision [26]. These programs are inadequately structured during school dismissal times [27]. Although school start times remain consistent, dismissal times can vary significantly due to after school activities. Studies have indicated difficulties in establishing effective support systems when dismissal times are extended [28]. Therefore, our study suggests policy recommendations aimed at enhancing child safety, such as expanding walking school bus programs and extending school zones. Previous studies corroborate these recommendations, indicating that walking school bus programs enhance child pedestrian safety and expanded school zones reduce pedestrian injury incidents [29,30]. In addition to protective policy implementation, it is essential to provide education on basic traffic rules and safe pedestrian practices to improve road safety behaviors among children and parents [31]. Moreover, awareness campaigns should target parents and teachers responsible for children's care to further improve pedestrian safety [32].

The observed higher mortality rates among child pedestrians treated at local emergency centers compared to regional trauma centers can be explained by several factors, despite regional trauma centers typically managing more severe injuries. Regional trauma centers are specifically designed and equipped to manage severe trauma, featuring specialized medical personnel and advanced facilities that improve patient outcomes [33]. In contrast, local emergency centers may lack such specialized resources, potentially leading to delays in critical interventions. These delays may result from insufficient trauma-specific training among medical staff, causing an inappropriate focus on less urgent diagnostic procedures and disrupting continuous trauma care [34]. Consequently, patients treated at local emergency centers may face higher mortality rates, even with comparatively less severe injuries. This disparity underscores the importance of specialized trauma care in improving pediatric patient outcomes [35]. Implementing dedicated pediatric trauma protocols and strengthening interhospital transfer systems are critical steps toward reducing mortality rates in this vulnerable population.

Limitations

This study has several limitations. First, the absence of key contextual variables—such as driver behaviors (e.g., speeding, distracted driving), parental supervision (e.g., caregiver presence, risk perception), and road infrastructure (e.g., crosswalk availability, traffic volume, road signage, lighting)—represents a significant constraint. The exclusion of these factors may oversimplify the complex dynamics involved in child pedestrian safety. Second, the limited availability of previous studies specific to this age group and injury mechanism within the Korean context constrains the interpretability and generalizability of our findings. Existing literature often addresses broader age ranges or aggregates traffic injury data, complicating efforts to contextualize our results within an established evidence base. Third, reliance on secondary data restricted the types of variables analyzed and limited the depth of the investigation. Important variables such as environmental conditions (e.g., weather, road surface) and socio-demographic disparities (e.g., household income, urban versus rural settings), which may meaningfully influence injury patterns and outcomes, were not included. Lastly, although descriptive and comparative analyses provided valuable initial insights, the statistical approaches used may not fully reveal complex interactions or causal relationships.

Conclusions

Our study identified differences in pedestrian injury rates and patterns between preschoolers and early school-aged children. Monthly pedestrian injury trends demonstrated distinct variations, with preschoolers experiencing the highest injury rates in July and elementary school children in June. Despite differences in injury timing, both groups exhibited peak accidents around school arrival and dismissal times, highlighting the necessity to educate children and parents using audiovisual materials on safe walking behaviors and indirect experiences of traffic accidents. Additionally, policies to enhance child safety should be implemented, including extending walking school bus program hours and broadening school zones beyond the current 500-m standard. Future research should employ larger samples and comprehensively analyze driver behaviors, parental supervision factors, and road infrastructure in relation to pedestrian injuries among preschoolers and early school-aged children. Further research is required to provide a more nuanced understanding of risk factors and regional disparities. Longitudinal data would be especially valuable for identifying trends over time and evaluating the impacts of interventions such as changes to school zone regulations and walking school bus programs.

ARTICLE INFORMATION

Author contributions

Conceptualization: all authors; Data curation: CYP; Formal analysis: all authors; Investigation: all authors; Methodology: CYP; Project administration: CYP; Visualization: all authors; Writing–original draft: HNJ; Writing–review & editing: CYP. All authors read and approved the final manuscript.

Conflicts of interest

Chan Yong Park is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are openly available from the Korea National Injury Information Portal (https://www.kdca.go.kr/injury).

Additional information

This study was presented at the 11th Pan-Pacific Trauma Congress (PPTC) on June 13–14, 2024, in Suwon, Korea.

Fig. 1.

Flowchart for the selection of preschoolers and early school-aged children with pedestrian injuries. ISS, Injury Severity Score.

Fig. 2.

Distribution of pedestrian injuries in preschoolers (aged 4–5 years) and early school-aged children (aged 6–7 years) according to month.

Fig. 3.

Distribution of pedestrian injuries in preschoolers and early school-aged children according to the day of the week.

Fig. 4.

Distribution of pedestrian injuries in preschoolers and early school-aged children according to the time of day.

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Figure & Data

References

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