Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death for children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats as long as possible; (2) forward-facing car safety seats from the time they outgrow rear-facing seats for most children through at least 4 years of age; (3) belt-positioning booster seats from the time they outgrow forward-facing seats for most children through at least 8 years of age; and (4) lap and shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health supervision visit.
Improved vehicle crashworthiness and greater use of child restraint systems have significantly affected the safety of children in automobiles. Major shifts in child restraint use, particularly the use of booster seats among older children, have occurred in response to public education programs and enhancements to child restraint laws in nearly every state.1,–3 In addition, there has been a substantial increase in scientific evidence on which to base recommendations for best practices in child passenger safety. Current estimates of child restraint effectiveness indicate that child safety seats reduce the risk of injury by 71% to 82%4,5 and reduce the risk of death by 28% when compared with children of similar ages in seat belts.6 Booster seats reduce the risk of nonfatal injury among 4- to 8-year-olds by 45% compared with seat belts.7 Despite this progress, each year, nearly 1000 children younger than 16 years die in motor vehicle crashes in the United States.8
The American Academy of Pediatrics (AAP) strongly supports optimal safety for children and adolescents of all ages during all forms of travel. This policy statement provides 5 evidence-based recommendations for best practices to optimize safety in passenger vehicles for all children, from birth through adolescence (summary of recommendations in Table 1):
All infants and toddlers should ride in a rear-facing car safety seat (CSS) as long as possible, until they reach the highest weight or height allowed by their CSS’s manufacturer. Most convertible seats have limits that will 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 CSS should use a forward-facing CSS with a harness for as long as possible, up to the highest weight or height allowed by their CSS’s manufacturer.
All children whose weight or height is above the forward-facing limit for their CSS 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.
Of note, the recommendation that all children be restrained in a rear-facing-only or convertible CSS used rear facing as long as possible represents a significant change from previous AAP policy and is based on data from the United States9 as well as extensive experience in Sweden.10,11 It is important to note that nearly all currently available CSSs have weight limits for rear-facing use that can accommodate children 35 to 40 lb.12
Certain considerations contained in this policy statement are relevant to commercial airline travel as well and are noted in the accompanying technical report. Additional AAP policy statements provide specific recommendations to optimize safety for preterm and low birth weight infants,13 children in school buses,14 and children using other forms of travel and recreational vehicles.15,–17 In addition, complementary AAP policy statements provide recommendations for teen drivers18 and for the safe transport of newborn infants19 and children with special health care needs.20,21
Pediatricians play a critical role in promoting child passenger safety. To facilitate their widespread implementation in practice, evidence-based recommendations for optimal protection of children of all ages in passenger vehicles are presented in the form of an algorithm (Fig 1) with an accompanying table of explanations and definitions (Table 2). A summary of the evidence in support of these recommendations is provided in the accompanying technical report.22 Because pediatricians are a trusted source of information to parents, pediatricians need to maintain a basic level of knowledge of these best practice recommendations and promote and document them at every health supervision visit. Prevention of motor vehicle crash injury is unique in health supervision topics, as it is the only topic recommended at every health supervision visit by Bright Futures.23 Pediatricians can also use this information to promote child passenger safety public education, legislation, and regulation at local, state, and national levels through a variety of advocacy activities, including aligning their state’s child passenger safety law with the best practice recommendations promoted in this policy statement.
Pediatricians are urged to keep abreast of the evolving and multifaceted guidance and resources on motor vehicle safety for children. In particular, many communities have child passenger safety technicians who have completed a standardized National Highway Traffic Safety Administration course and who can provide hands-on advice and guidance to families. In most communities, child passenger safety technicians work at formal inspection stations; a list of these 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 child passenger safety technician in your area via the National Child Passenger Safety Certification Web site at http://cert.safekids.org or via the National Highway Traffic Safety Administration Child Safety Seat Inspection Station Locator at http://www.nhtsa.dot.gov/cps/cpsfitting/index.cfm. Car Seat Check Up Events are updated at https://www.safekids.org/events/field_type/check-event. In addition, additional resources for pediatricians and families can be found at www.aap.org or www.healthychildren.org.
Drs Durbin and Hoffman were equally responsible for conception and design of the revision, drafting, and editing of the manuscript.
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.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements 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 statement 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 policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
FUNDING: No external funding.
Dennis R. Durbin, MD, MSCE, FAAP
Benjamin D. Hoffman, MD, FAAP
Council on Injury, Violence and Poison Prevention, 2018–2019
Benjamin D. Hoffman, MD, FAAP, Chairperson
Phyllis F. Agran, MD, MPH, FAAP
Sarah A. Denny, MD, FAAP
Michael Hirsh, MD, FAAP
Brian Johnston, MD, MPH, FAAP
Lois K. Lee, MD, MPH, FAAP
Kathy Monroe, MD, FAAP
Judy Schaechter, MD, MBA, FAAP
Milton Tenenbein, MD, FAAP
Mark R. Zonfrillo, MD, MSCE, FAAP
Kyran Quinlan, MD, MPH, FAAP, ex-officio
Stuart Weinberg, MD, FAAP, Partnership for Policy Implementation
Lynne Janecek Haverkos, MD, MPH, FAAP – National Institute of Child Health and Human Development
Jonathan D. Midgett, PhD – Consumer Product Safety Commission
Alexander W. (Sandy) Sinclair – National Highway Traffic Safety Administration
Richard Stanwick, MD, FAAP – Canadian Paediatric Society
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose.