Child Passenger Safety

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 those for 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, approximately 1500 children younger than 16 years die in motor vehicle crashes each year in the United States, nearly half of whom were completely unrestrained.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 (a summary of recommendations is listed in Table 1):

1. All infants and toddlers should ride in a rear-facing car safety seat (CSS) until they are 2 years of age or until they reach the highest weight or height allowed by the manufacturer of their CSS.

2. All children 2 years or older, or those younger than 2 years 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 the manufacturer of their CSS.

3. 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 feet 9 inches in height and are between 8 and 12 years of age.

4. 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.

5. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

It should be noted that the recommendation that all children younger than 2 years be restrained in an infant-only or convertible CSS used rear-facing represents a significant change from previous AAP policy and is based on new data from the United States⁹  as well as extensive experience in Sweden.^10,11  It is important to note that most currently available CSSs have weight limits for rear-facing use that can accommodate the new recommendations.¹² 

Certain considerations contained in this policy statement are relevant to commercial airline travel as well and are noted in the accompanying technical report.¹³  Other AAP policy statements provide specific recommendations to optimize safety for preterm and low birth weight infants,¹⁴  children in school buses,¹⁵  and children using other forms of travel and recreational vehicles.^16,–,18  In addition, complementary AAP policy statements provide recommendations for teenaged drivers¹⁹  and the safe transport of newborn infants²⁰  and children with special health care needs.^21,22 

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.¹³  Because pediatricians are a trusted source of information to parents, every pediatrician must 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, because 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 ensuring that their state's child passenger safety law is in better alignment with the best-practice recommendations promoted in this policy statement.

Because motor vehicle safety for children is multifaceted and will continue to evolve, all pediatricians should familiarize themselves with additional resources to address unique situations for their patients that may not be covered by the algorithm and to maintain current knowledge. In particular, many communities have child passenger safety technicians who have completed a standardized National Highway Traffic Safety Administration (NHTSA) 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 stations is available at www.seatcheck.org. If your community does not have an inspection station, you can find a child passenger safety technician in your area on the National Child Passenger Safety Certification Web site (http://cert.safekids.org) or the NHTSA child safety seat inspection station locator (www.nhtsa.dot.gov/cps/cpsfitting/index.cfm). Car seat checkup events are updated at www.safekidsweb.org/events/events.asp. In addition, additional resources for pediatricians and families can be found at www.aap.org or www.healthychildren.org.