4 0 6 A N N A L S O F E M E R G E N C Y M E D I C I N E 3 7 : 4 A P R I L 2 0 0 1

Children in Car Seats and in the Backseat

National Highway Traffic Safety Administration

Commentary: We Need to Give Children a

Boost Before We Buckle Them

Scott D. Berns, MD, MPH

The Injury Prevention Center

Hasbro Children’s Hospital

Brown University School of Medicine

Providence, RI

Federico Vaca, MD

University of California–Irvine

Center for Health Policy Research

Irvine, CA

Section Editors

Joan S. Harris

National Highway Traffic Safety Administration

Washington, DC

B. Tilman Jolly, MD

Department of Emergency Medicine

George Washington University

Washington, DC

Jeffrey W. Runge, MD

Department of Emergency Medicine

Carolinas Medical Center

Charlotte, NC

Knox H. Todd, MD, MPH

Rollins School of Public Health

Emory University

Atlanta, GA

Reprints not available from the editors.47/1/114203doi:10.1067/mem.2000.114203

that the child had graduated to using an adultseat belt.

• Nearly everyone (99%) reported thattheir infants were in a car seat all of the timeif they weighed less than 20 pounds or wereyounger than 2 years.

• Virtually all parents considered it veryeasy (71%) or somewhat easy (23%) to installthe car seat in the car.

• Most reported discontinuing their child’scar seat use by 3 or 4 years of age.

• The vast majority (90%) reported thechild most often sat in the car’s backseat.

• Almost all who were interviewed (98%)reported knowing that the backseat is thesafest seating location for children in a car.

• Despite this knowledge, 9% said thatthe child usually rode in the car’s front seat.

• When asked why the child rode in thefront, parents and caregivers reported thatthis is where the child preferred to ride (41%)or there was no other place (22%).

W H Y A R E S O M E C H I L D R E NN O T I N C A R S E A T S ?

The reasons most often given by part-timecar seat users (those who said they used a carseat but just not on every trip) were:

• The child did not like the seat (31%)• The seat was not available (30%)• They were only going to be in the car a

short time (29%)• Someone outside of the immediate

family had driven the child (44%)The children who never used car seats

were generally somewhat larger: about threefourths (76%) were 40 pounds or heavier. Theremainder weighed between 20 and 30pounds. The most frequent age at which par-

Children in Car Seats andin the Backseat

[National Highway Traffic Safety Admin-istration. Children in car seats and in thebackseat. Ann Emerg Med. April2001;37:406-407.]

I N T R O D U C T I O N

The National Highway Traffic Safety Admin-istration (NHTSA) conducts a national tele-phone survey every 2 years to monitor thepublic’s attitudes and behavior related tohighway safety. A recent report released byNHTSA summarizes the results of one of theserecently completed surveys that focused onchild safety seats. The survey consisted of 2questionnaires given to a randomly selectedsample of about 4,000 persons of driving age(≥16 years). Interviews took place betweenNovember 1998 and January 1999.

The survey selected a subgroup of driversto ask questions about their use of car seatsfor their children and their seating position inthe car. These drivers were most often par-ents and others (called “caretakers”) wholived in households with children youngerthan 6 years.

O V E R V I E W : R E S U L T S

• Most parents and caretakers (71%)reported their children used car seats all ofthe time.

• About one fifth (22%) reported theynever used a car seat.

• For those children who never used a carseat, the most common reason given was

National Highway Traffic Safety

Administration (NHTSA) Notes

N H T S A N O T E S

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ents and caregivers started placing childreninto booster seats was at age 3. About threefourths (76%) of parents and caregivers hadseen or heard about booster seats. Of these,slightly more than half (53%) said they usedthem occasionally for their children, whereasabout one third (30%) reported concernsabout booster seat safety.

P U B L I C A T T I T U D E S A B O U TC H I L D R E N ’ S S A F E T Y

Nearly all (94%) persons aged 16 and olderagreed that children who had outgrown carseats should be required by law to use a seatbelt; only 3% disagreed. The majority ofrespondents (60%) favor stringent childsafety enforcement, reporting that theybelieve police should cite a driver every timethey see a child not properly restrained in thecar. The public heavily favored fines for thecited drivers: 56% believed the fine should beat least $50, whereas another 32% wanted ahigher fine of $100 or more.

H O W T O O R D E R

For a complete copy of “1998 Motor VehicleOccupant Safety Survey, vol. 3: Child SafetySeat Report,” write to NHTSA (NTS-31), 400Seventh Street SW, Washington, DC 20590,or send a fax request to 202-366-7096. Thereport can also be downloaded from theNHTSA Web site at http://www.nhtsa.dot.gov/people/injury/research/.

Commentary: We Need toGive Children a BoostBefore We Buckle Them

[Berns SD, Vaca F. NHTSA NotesCommentary: We need to give children aboost before we buckle them. AnnEmerg Med. April 2001;37:407-410.]

Child restraint systems, ranging from childsafety seats (infant and convertible/toddlerseats) to booster seats and seat belts, havebeen proven to significantly reduce the risk ofinjury to children. As trauma care providers, itis no surprise to most of us that children travel-ing appropriately restrained in the backseat ofa car stand to be at significantly and indepen-dently decreased risk of serious injury or death

who were in child safety seats and boostersusually traveled in the backseat. By contrast,78% of children reportedly traveled in thebackseat in 1994. How did this change happenso fast? Public attention has substantiallyincreased regarding the significant risk tochildren who ride in the front seat, particularlyif the car is equipped with an air bag.3 Further-more, risk awareness has been raised byNHTSA and its partners including the Air Bagand Seat Belt Safety Campaign, the AmericanAcademy of Pediatrics, the American Collegeof Emergency Physicians, the National SAFEKIDS Campaign, auto manufacturers, insur-ance companies, and others. Awareness hasfurther increased through the media’s cover-age of a number of deaths as a result of youngchildren riding in the front seat of cars equip-ped with air bags. Finally and most impor-tantly, passage and enforcement of primaryseat belt laws* for children has undoubtedlyplayed a role. Some states (Delaware andRhode Island) have actually gone further andinstituted laws requiring children under aminimum age to ride in the backseat.

B O O S T E R S E A T U S E B E L O W1 0 %

Although the NHTSA report brings encourag-ing news about child safety seats, disappoint-ment lies in the findings regarding boosterseats and their use. The results reveal thatbooster seat use is still exceedingly low. Moststudies show booster seat use rates are farbelow 10%, with 1 study showing a use rateless than 1% in children older than 5 years.4

Is there a clear explanation for this underuti-lization of boosters? After all, safety profes-sionals recommend that children between 4and 8 years who weigh from approximately40 to 80 pounds (and until they are approxi-mately 4 feet 9 inches) should be in boosterseats until they are large enough to properlyfit into an adult seat belt.5

There is convincing evidence that childsafety seats and booster seats provide farbetter protection for children than seat beltsalone. In a study of injury risk as a result of

if involved in a serious crash.1 Between 1974through 1999, an estimated 4,500 lives weresaved by the use of child restraint systems.2

It is clear that child safety seats work tosave the lives of our young children, but manyexperts would argue that significant confu-sion exists among parents and health careproviders when it comes to selecting an age-and weight-appropriate safety seat. Clarifi-cation of appropriate child safety seatsselection begins with a newborn in an infantcar seat and the seat’s location and positionwithin the car. The infant seat should beinstalled in the middle location of the car’sbackseat. Additionally, it should be placed ina rear-facing position until the child is 1 yearof age and 20 pounds. The convertible seatcan be used similarly for infants but is alsosuitable for children older than 1 year of age(up to 4 years) and weighing between 20 and40 pounds. Once the child has exceeded thecritical period of 1 year of age and 20 pounds,this particular type of seat is used forward-facing with a recommendation that the rearmiddle seat location is the safest for travel-ing. As the child continues to grow, the nexttransition in child safety seat restraintsshould be graduation to a belt-positioningbooster seat. At this point, the child’s weightshould exceed 40 pounds. The fundamentalgoal of the booster is to provide appropriateanatomic positioning of the vehicle’s seatbelt around the child’s body in hopes of mini-mizing occupant displacement and or ejectionduring a crash. Finally, the last child restrainttransition is for the child to use the vehicle’sseat belts alone. This final transition shouldtake place when the child weighs more than80 pounds, which is usually around 8 years ofage. However, given the conclusions fromcurrent vehicle occupancy safety and crashinjury control literature, it is apparent that aneven greater amount of clarification and edu-cation needs to take place with regard tograduating children to booster seats andlater to seat belts.

C H I L D R E N I N T H E B A C K S E A T

As the accompanying NHTSA study illustrates,parents and caregivers are now reporting animpressive rate of children younger than 6years riding in the backseat (90%). In fact, in1998, 95% of parents with cars equippedwith a passenger air bag reported that children

*A law enforcement officer may issue a citation for fail-ure to comply with a primary, or standard belt law whenhe notices belts are not used. Under a secondary law, acitation for failing to use occupant restraints may only beissued after another infraction has occurred (eg, speed-ing, red light running).