WHEREAS less than half of lower- and middle-income countries have child restraint system laws, and
WHEREAS motor vehicle crashes are a leading cause of death for children even in high-income countries that have child restraint system laws, and
WHEREAS most children who were killed in car crashes were unrestrained or using an inappropriate child restraint system, and
WHEREAS primary enforcement of restraint laws is more effective than secondary enforcement laws in increasing restraint use and decreasing injuries [See Restraints Position Statement], and
WHEREAS industry standards and national and international regulations have been developed to define best practices for child restraint system performance, and
WHEREAS appropriate child restraint systems based on the child’s development are effective in reducing crash fatalities and serious injuries, and
WHEREAS community services are available to parents and other caregivers to provide appropriate fitment between the child restraint system and their vehicle(s) as well as education on appropriate seatbelt fit on the child to prevent misuse,
BE IT RESOLVED that parents and other caregivers use the following sequence of restraint systems based on the child’s individual development and immediately transition to the next stage after reaching the manufacturer’s recommended maximum height OR weight:
- Rear-facing car seat with five-point harness
- Forward-facing car seat with five-point harness
- Belt-positioning booster seat
- Lap and shoulder belt (must be at least 57 inches tall)
BE IT FURTHER RESOLVED that primary enforcement laws should reflect this progression of appropriate child restraint use and be consistently applied in all states, regions, and countries and that community resources continue to exist to educate parents and other caregivers on proper child restraint use.
Adopted: August 2020
Less than half of middle- and low-income countries have child-restraint laws. A 2018 World Health Organization (WHO) report found that only 9% of the world’s population meet the overall best practice criteria for child-restraints, which includes the presence of national laws, requirements for children under the age of 10 or under 135 cm in height to use a child-restraint, age and height restrictions on riding in the front seat, and references to specifications or standards for the restraint systems themselves. Among countries with laws meeting best practice, just 15% are middle-income and none are low-income. An earlier 2013 WHO report found that at the time, only 43% of middle-income countries and 30% of low-income countries even had child-restraint laws. The 2018 WHO report also cited that “despite the prevalence of motorcycles in low-income settings … only 63 countries representing 33% of the world’s population, restrict child passengers on motorcycles.”
Motor vehicle crashes are still a leading cause of death of children even in high-income countries with child-restraint laws. The 2018 WHO report found that road traffic injuries are the leading cause of death in children and young adults globally.1 A 2016 study also found that motor vehicle crashes were the leading cause of death of young children and adolescents in the United States, accounting for 20% of all deaths, though the per capita death rate had reduced by approximately half from 1999 to 2016. The child fatality rate in the United States was triple that of other high-income countries studied, with researchers partially attributing lower fatality rates in other countries to government investment in road-traffic safety, such as the Vision Zero policy in Sweden. The National Highway Traffic Safety Administration (NHTSA) published its annual “Traffic Safety Facts” in May 2019 with some specific 2017 data on traffic crashes involving children. In the United States, while children account for 19% of the total population of the United States, children accounted for approximately 3% of over the 37,000 motor vehicle traffic fatalities, with nearly 75% of those child fatalities being vehicle occupants. While all 50 states of the United States have had a child restraint system law since at least 1985, wide variation among states, exemptions, and the wording of some laws still creates confusion and a lack of knowledge, potentially leading to lower compliance, as well as circumstances in which some children are still not covered by any law.,
Most children killed in car crashes were unrestrained or using an inappropriate child restraint. The 2017 NHTSA data on children indicated that among the infants (<1 years old) involved in fatal crashes, 60% of those who were known to be unrestrained being killed, while only 19% of those who were known to be restrained were killed. For all one- to three-year-olds, 31% of unrestrained one- to three-year-olds being killed and just 13% of restrained one- to three-year-olds being killed. Among all four- to seven-year-olds, 31% who were unrestrained were killed versus 9% of those who were restrained were killed. For children aged 8-12, 38% of those who were unrestrained were killed versus just 8% of those who were restrained were killed. These data plainly demonstrate the importance of using restraints, particularly for infants, who are the smallest and most vulnerable to the forces sustained in vehicle impacts.
Data were also provided based on restraint type (when known). Among the 51 children less than one year old who were killed in passenger vehicles, 35% were unrestrained and another 8% were in restrained with something other than a rear-facing car seat. Among the 101 one- to three-year-olds who were killed, 32% were unrestrained and an additional 65% were restrained by something other than a rear-facing car seat, leaving just 3% who were utilizing a rear-facing car seat. Based on Centers for Disease Control (CDC) growth chart data and most rear-facing car seat manufacturers’ recommendations, it should be noted that the vast majority of rear-facing car seats support nearly all children up to and beyond the age of three. Among the 146 four- to seven-year olds who were killed, 44% were unrestrained and 25% were wearing some combination of a lap and/or shoulder belt instead of using a car seat or booster seat. Again, based on growth chart data and manufacturer recommendations, most booster seats support nearly all children up to and well beyond the age of seven. Just under half of the 207 children aged 8-12 that were killed in passenger vehicles in 2016 were unrestrained. These data further support the use of appropriate child restraint systems based on the child’s height and weight and the manufacturer’s corresponding recommendations.
Appropriate child restraint use must be habitual for it to be effective. A 2016 motor vehicle occupant safety survey specifically addressed child passenger safety in one of its reports. It found that just 61% of drivers would place children under 13 who lived in their home in a car seat or booster seat “all of the time,” while 32% stated the child “never” would ride in a car seat or booster seat. The 2017 NHTSA data also analyzed driver restraint use in fatal crashes. Looking at all children and limiting the data to when the restraint use was known, when the driver was restrained, the child in that same vehicle was also restrained 74% of the time. When the driver was unrestrained, the child in that same vehicle was restrained just 29% of the time. This is evidence that restraint use is a habit, and AAAM encourages restraint use for all vehicle occupants [See Restraints Position Statement for more information].
Industry standards and national and international regulations have established child restraint system performance criteria. There are many Federal Motor Vehicle Safety Standards (FMVSS) promulgated by NHTSA, including FMVSS 213 on child restraint systems. This standard specifies requirements for child restraint systems used in motor vehicles and aircraft. It provides clear definitions and testing requirements for both methodology and results of the individual restraint system components as well as its performance overall. There are also well-defined criteria for the warnings that need to accompany these car seats. The Economic Commission for Europe of the United Nations has also established Regulation No. 44 on child restraint systems and categorized the restraints into five groups by child mass. A newer European standard, known as i-Size, runs alongside this current regulation. Other innovations, such as ISOFIX and LATCH, have helped to standardize a system for securing car seats to vehicles.
Appropriate child restraint systems based on the child’s development are effective in reducing crash fatalities and serious injuries. Young children need to have their posterior torso, neck, head, and pelvis supported and distribute the crash forces over the entire body. For those in a five-point harness, the buckles should all be securely latched, and the belts should be tight to the body with the chest clip near the armpits. Children in a belt-positioning booster or traditional lap and shoulder belt should have the lap belt low across the hips and pelvis rather than the abdomen, and the shoulder belt should lie across the middle of the chest and shoulder rather than the neck or face. Heavy clothing should be removed if it interferes with tight securement of the restraint.
In late 2018, the American Academy of Pediatrics (AAP) released its updated policy statement on child passenger safety. The 2018 update listed five best practice recommendations that cover children from newborns up through the time they can wear a lap and shoulder belt like adults. The AAAM strongly supports these 2018 recommendations. The technical report that accompanied the 2018 AAP policy statement pointed to numerous lab and field studies that have tested child restraint systems and analyzed usage patterns in real crashes. Newborns and young infants simply do not have the strength to sit upright, so the reclined rear-facing car seat places them in a safer position that matches the rear seat geometry of a passenger vehicle. In a frontal impact, the crash forces are then transmitted throughout the back, and the head and spine are held in place. While car seats are designed to meet FMVSS 213 standards (which test frontal impacts only), research on one- and year-old anthropomorphic test dummies has shown that rear-facing car seats are able to mitigate crash loads below the injury thresholds of FMVSS 213 in moderate severity rear impacts, too. Forward-facing car seats have also been shown to be “highly effective in preventing serious injuries and hospitalizations” compared to seat belts. For children who have outgrown their forward-facing car seats but are not able to properly wear a lap and shoulder belt can greatly benefit from a belt-positioning booster seat. A comprehensive longitudinal survey found that children aged four to eight restrained by a belt-positioning booster “were 45% less likely to sustain injuries than similarly aged children” using a lap and shoulder belt, with no differences seen between backless and high-back boosters.
Beneficial community resources exist to educate and assist parents and other caregivers on proper child restraint use. A variety of resources are available to help with child restraint system installation and inspection. Safe Kids Worldwide has over 43,000 certified Child Passenger Safety Technicians globally that provide hands-on assistance. Many police stations, fire stations, hospitals, and automotive dealers can also provide guidance on appropriate child restraint system use. The 2016 survey of caregivers found that nearly half of respondents cited police or other law enforcement agencies and doctors or nurses as their information sources on car seats. Numerous websites provide basic knowledge on how to install car seats and ensure proper seat belt fit. The owner’s manuals provided with the child restraint systems are also a fundamental source for detailing exactly what size children are appropriate for their equipment and typically offer diagrams and thorough instructions on proper installation and seat belt fit to maximize safety. Maintaining awareness of these various resources is critical to educating the public on proper child restraint system use.
 World Health Organization. (2018). Global Status Report on Road Safety.
 World Health Organization. (2013). Global Status Report on Road Safety.
 Cunningham, R.M., Walton, M.A. & Carter, P.M. (2016). The Major Causes of Death in Children and Adolescents in the United States. The New England Journal of Medicine. 379: 2468-2475.
 National Highway Traffic Safety Administration. (2019). Traffic Safety Facts: Children.
 Bae et al. (2014). Child Passenger Safety Laws in the United States, 1978–2010: Policy Diffusion in the Absence of Strong Federal Intervention. Social Science and Medicine. 100: 30-37.
 Centers for Disease Control. Clinical Growth Charts. https://www.cdc.gov/growthcharts/clinical_charts.htm
 Martin, K. & Block, A. (2020). Motor Vehicle Occupant Safety Survey; Volume 3: Child Passenger Safety Report.
 Durbin, D.R. & Hoffman, B.D. (2018). Technical Report – Child Passenger Safety. Pediatrics. 142(5).
 Mansfield, J., Kang, Y. & Bolte, J. (2018). Rear-Facing Child Restraint Systems in Rear Impact Sled Tests. SAE Technical Paper. 2018-01-1325.
 Arbogast, K.B. et al. (2004). An evaluation of the effectiveness of forward facing child restraint systems. Accident Analysis and Prevention. 36: 585-589.
 Arbogast, K.B. et al. (2009). Effectiveness of Belt Positioning Booster Seats: An Updated Assessment. Pediatrics. 124(5): 1281-1286.