Car Seats
Dr. Elizabeth Lehto
The most dangerous thing children do as part of their daily lives is ride in a car. Motor vehicle crashes are the leading cause of death of children over four in the United States, and more than 5,000 children die in motor vehicle crashes annually.¹,² For every fatality, approximately 18 children are hospitalized, and more than 400 receive medical treatment following a car accident.¹
Over the past 20 years the number of children who died in motor vehicle accidents in the United States declined by 55%.² Much of the improvement in childhood injuries and fatalities due to motor vehicle accidents has been attributed to increased attention to age-appropriate restraints and laws regarding their use.³
Restraint systems decrease injuries and fatalities through several mechanisms:³
Reduce risk of ejection during a crash
Distribute energy load of a crash through structurally stronger bones rather than soft tissue
Prolong the time of deceleration, limiting the force of the crash experienced
Limiting contact with interior vehicle structures
Types of Restraint Systems
There are several types of child restraint systems
Rear facing only—for infants and toddlers
Convertible seats—can be used with children of various sizes and can change from rear facing to forward facing
Combination seats—forward facing only that can initially be used with their 5-point harness and converted to a belt-positioning booster seat after the harness is outgrown
Integrated seats—booster seats built into some cars that pop out of the rear seat bench, raising the child in height to create a better fit for the seat belt
Travel vest—a wearable booster seat alternative that works by bringing the seatbelt down to the child’s level rather than boosting them up
Belt positioning booster seat—designed to raise the child up in the car and position the adult-sized seat belt in the correct location over the child’s body
What Types of Restraint System Should be Used?
At the time of this writing, the American Academy of Pediatrics has the following best practice recommendations regarding child safety restraint:⁴
All infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by the manufacturer. Most convertible seats can accommodate children up to 40 lbs and permit children to ride rear facing for 2 years or more.
All children who have outgrown the rear-facing weight or height limit for their car safety seat should use a forward-facing car safety seat with a harness for as long as possible, up to the highest weight or height allowed by their child safety seat’s manufacturer. All children under 4 should be in a forward-facing car seat as they are not developmentally mature enough for a booster seat.
All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle lap and shoulder seat belt fits properly, typically when they have reached 4 ft 9 inches in height and are between 8 and 12 years of age.
When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.
As height and weight recommendations vary by car seat manufacture, it is important that parents are familiar with recommendations for their car seat. Recommendations are often found on a sticker on the side of the car seat or can be found in the user manual. Also note that all seats are marked with an expiration date, and seats over 10 years old should not be used.
Appropriate Buckling
When a child is buckled in a car seat the harness should be snug against the child with the chest clip at armpit level to prevent the harness from slipping off the shoulders.
Extra padding, including shoulder padding and infant head support that did not come with the car seat should not be used. During winter, coats should be removed prior to strapping the child into the seat. Blankets can be placed on the sides, but should never interfere with the harness position.
When using a seat belt to secure a car seat, the seat belt must be latched in order to hold the car seat securely. When using the LATCH (Lower Anchors and Tethers for Children) method available in newer vehicles, the strap must be pulled tightly so that the seat does not move more than an inch in any direction. If the LATCH system is used, the unused seatbelt should be buckled behind the seat to prevent the child from reaching and becoming tangled in the unused seatbelt.
What if the Car Seat is Involved in an Accident?
In addition to making sure children are in the proper restraint system, it is important to replace the child safety seat when it is involved in a moderate or severe crash.⁵ Child safety seats do not need to be replaced following a minor crash.
A minor crash is defined as all of the following:⁵
The vehicle is able to be driven away from the crash site
The vehicle door nearest the car seat is not damaged
None of the passengers in the vehicle sustained any injuries
Airbags did not deploy
No visible damage to the car seat
Manufactures instructions may also provide additional guidance about replacement following an accident. Used car seats are not recommended as it is unknown if they have been in an accident or not.
How Can Car Seat Use be Improved?
Child restraint laws have played a large part in increasing the use of child restraint systems.³,⁶ All fifty states have child restraint laws, however there is variation between requirements, and they don’t always match best practice recommendations. ⁶,⁷
Studies have shown that caregiver targeted interventions have also been effective at improving proper use of child restraint systems.⁶ Education of families using verbal, video, and written materials has been shown to improve proper use of child restraint systems.⁸,⁹ Additionally, community based education events that offer inspection and fitting of car seats as well as events that provide free car seats have also been shown to improve proper use of car seats.¹⁰,¹¹
Call to Action:
If you have been inspired by this post, here are some suggestions for improving proper use of car seats:
Ask about use of car seats during health care visits
Screening shouldn’t be limited to our pediatric patients, adults should also be reminded about the importance of using seat belts when the car both for their own safety, and because in accidents were an adult was unrestrained, 54% of children were also unrestrained³
Find or create car seat check stations in your community and encourage parents to have their seats inspected to ensure proper instillation
A list of stations is available at https://www.nhtsa.gov/equipment/car-seats-and-booster-seats#install-inspection
If your community does not have an inspection station, you can find a technician in your area via the National Child Passenger Safety Certification Web site at http://cert.safekids.org or via the NHTSA Child Safety Seat Inspection Station Locator at http://www.nhtsa.dot.gov/cps/cpsfitting/index.cfm
Technicians with enhanced training in restraining children with special health needs, as well as those with Spanish language proficiency, can be identified at http://cert.safekids.org
Become familiar with local laws regarding car seats, and advocate for adoption of laws that follow current best practice guidelines
Additional resources for providers and families:
Elizabeth Lehto, D.O.
University of Louisville | UL · Department of Pediatrics | Doctor of Pediatric Emergency Medicine
Dr. Elizabeth Lehto is a Pediatric Emergency Medicine Attending at Norton Womens and Children’s Hospital. Dr. Lehto attended Midwestern University Arizona College of Osteopathic Medicine and completed her residency and fellowship at the University of Louisville.
REFERENCES:
Center for Disease Control and Prevention. Injury prevention and control, web-based injury statistics query and reporting system (WISQARS). www.cdc.gov/injury/wisqars/index.html.
National Highway Traffic Safety Administration. Fatality analysis reporting system (FARS) encyclopedia. http://www-fars.nhtsa.dot.gov/.
Durbin DR, Hoffman BD. Child Passenger Safety. Pediatrics. 2018;142(5):e20182461.
Durbin DR, Hoffman BD. Child Passenger Safety. Pediatrics. 2018;142(5):e20182460.
National Highway Traffic Safety Administration. Car Seat Use after a Crash. https://www.nhtsa.gov/equipment/car-seats-and-booster-seats.
Sartin E, Bell TR, McDonald CC, Mirman JH. Assessment of Caregiver-Targeted Interventions for Use of Motor Vehicle Passenger Safety Systems for Children: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(10):e1914180-e1914180.
Association GHS. Child Passenger Safety. 2020; https://www.ghsa.org/state-laws/issues/child%20passenger%20safety.
Cooper-Sood JB, Chan C, Cho CS. A Paper-Based Car Seat Safety Educational Intervention in the Pediatric Emergency Department. Pediatr Emerg Care. 2019.
Kuroiwa E, Ragar RL, Langlais CS, Baker A, Linnaus ME, Notrica DM. Car seat education: A randomized controlled trial of teaching methods. Injury. 2018;49(7):1272-1277.
Aitken ME, Miller BK, Anderson BL, et al. Promoting use of booster seats in rural areas through community sports programs. J Rural Health. 2013;29 Suppl 1(0 1):s70-s78.
Gittelman MA, Pomerantz WJ, Laurence S. An emergency department intervention to increase booster seat use for lower socioeconomic families. Acad Emerg Med. 2006;13(4):396-400.
