Objective. Motor vehicle crashes remain the leading cause of death among US children 1 year of age and older. Although age-appropriate child passenger restraint use and back seating position are effective injury prevention strategies, many children 12 years of age and younger ride inappropriately restrained and seated in the front seat. In Georgia and in most states, surveillance of child passenger restraint use is less than optimal. Although child safety seat legislation is 1 of the most effective mechanisms for increasing correct restraint use and back seating position, Georgia's child occupant restraint law, like the laws in most states, falls short of practices recommended by government and child advocacy safety groups. The objective of this study was to document child passenger restraint use and seating position among children aged 0 to 12 years in Georgia and to use these study results to evaluate the efficacy of Georgia’s child restraint surveillance and legislation.
Methods. In May and June 2001, police roadblocks were used to collect information about child passenger age, restraint use, and seating position.
Results. Data were collected on 1858 children who were riding in 1221 vehicles in 24 different Georgia counties. Results showed that 56% of children were inappropriately restrained and/or in the front seat. The most problematic age groups included infants who were in forward-facing child safety seats (28%) and/or in the front seat (22%); children who were 5 to 8 years of age in car seat belts alone (88%), rather than age- and size-appropriate child safety seats (6%); and children who were 9 to 12 years of age and riding in the front seat (39%). We compared our results with the existing Georgia passenger restraint surveillance system and found that it would have missed 77% of the children in our study who were inappropriately restrained and/or riding in the front seat. In a similar comparison, Georgia's restraint law did not cover over 74% of the children in our study who were riding at risk.
Conclusion. The results of this study highlight 3 important areas for improving child passenger safety: targeted interventions to promote booster seat use and riding in the back seat, expanded child passenger restraint and seating position surveillance, and expanded legislation to mandate booster seat use and back seating position.
In the United States, motor vehicle crashes continue to be the leading cause of death among children after their first birthday.1 Every year, >1000 motor vehicle passengers who are 0 to 12 years of age are killed in crashes.2 For each death, there are well over 100 injuries.3 Most of the child passengers killed in 1999–2000 were unrestrained (52%), incorrectly restrained (18%), and/or riding in the front seat (35%).2
Many of these injuries could have been prevented by age-appropriate restraint use and by placing children in the back seat. The definition of age-appropriate restraint from the American Academy of Pediatrics (AAP)4 and the National Highway Traffic Safety Administration (NHTSA)5 includes 4 components. First, infants should ride in rear-facing seats until they are at least 1 year of age and at least 20 pounds. Some rear-facing seats can accommodate children up to 30 or even 35 pounds. Second, children who have outgrown their rear-facing seats should be placed in forward-facing seats with internal harnesses until they are 40 pounds. Most children reach 40 pounds at 4 or 5 years of age.6 Third, children who weigh >40 pounds should ride in belt-positioning booster seats until they fit well in car seat belts alone. Children generally do not fit well into car seat belts until they are ∼9 years of age. Shield boosters are not considered appropriate restraint at any age. Last, all children who are 12 years of age and younger should ride in the back seat.
Age-appropriate restraint is very effective in preventing injuries. Rear-facing infant seats reduce the risk of fatal injury by >70%.7 Rear-facing seats are important for infants because their proportionally large heads and weak necks make them more prone to head and neck injuries when placed in forward-facing seats.8,9 Forward-facing convertible car seats reduce the risk of nonfatal injury more than 3-fold when compared with car seat belts alone.10 Riding in a belt-positioning booster seat improves seat belt fit and reduces the risk of injury by more then half when compared with seat belt use alone.10 Belt-positioning booster seats are particularly effective in preventing injuries of the head, abdomen, spine, and lower extremities.10–13 Riding in the back seat places children in the safest part of the vehicle and reduces the risk of fatal injury by >35% in vehicles without front passenger-side airbags and by 46% in vehicles with front passenger-side airbags.14 Infants are particularly prone to injury and death when riding in the front seat of a vehicle with a passenger-side airbag.4,5
Although age-appropriate restraint and back seating position are known to be effective interventions for injury prevention, some children are not appropriately restrained and positioned. To guide prevention activities, periodic surveillance is needed to identify gaps in restraint use and seating position and to follow these trends over time.
Child passenger safety practices in Georgia are currently assessed by the Georgia Statewide Use of Occupant Restraint Survey. This study consists of an annual direct observation survey of children who are estimated to be 0 through 4 years of age and a seat belt study of people who are estimated to be 5 years of age and older. Georgia surveillance follows the guidelines used by the NHTSA in their nationwide survey. The survey notes whether children 0 through 4 years are restrained in a child safety seat (CSS) or seat belt or are not restrained. Although useful, the survey methods are not optimal. The gaps in this surveillance system include that CSS type is not specified and that CSS use as well as seating position among children who are older than 4 years is not recorded.15 The surveillance in most states has similar limitations.
Part of the reason that many children are not correctly restrained and riding in the back seat is that these interventions are not required by law; CSS legislation is 1 of the most effective mechanisms for increasing correct restraint use and back seating position.16,17 At the time of this study, Georgia state law required that children 4 years and younger be in a federally approved CSS, used according to manufacturers' instructions. Children 5 to 18 years of age were required to use at least a car seat belt. The law did not address booster seat use, and it did not mandate that children ride in the back seat. Georgia's law, like most state laws, fell short of recommended practices.18 (Please note, since the conclusion of this study and in part secondary to study findings, Georgia's Child Restraint Law has been up graded. Starting July 1, 2004, Georgia's law requires children 5 years of age and younger to ride in a CSS. Children 5 years of age and younger are also required to ride in the rear seat when available.18) The objectives of this study were 3-fold: (1) to document child passenger restraint use and seating position among children 0 to 12 years of age in Georgia, (2) to assess the gaps in Georgia's current child restraint surveillance, and (3) to evaluate the coverage of Georgia's child passenger safety legislation.
This cross-sectional study was conducted at police roadblocks, using a convenience sample, during May and June 2001. Roadblocks are set up quarterly across the state of Georgia to check for vehicle registration, passenger restraint use, and driving under the influence. This setting was particularly conducive to collecting the information needed for this study because vehicles were stopped. This enabled both interview data (age and weight) and observational data (restraint type and seating position) to be collected.
Data Collection by Volunteers
There are 3 groups involved in promoting child passenger safety at police roadblocks in Georgia. First, police officers from 60 precincts across the state partnered with the Georgia Division of Public Health to educate parents about child passenger safety at roadblocks. Officers from these precincts were invited to participate in data collection; 38 police officers from 30 precincts chose to assist in data collection. SAFE KIDS, a national organization dedicated to preventing unintentional childhood injury, has active coalitions in 53 Georgia counties. Coalition coordinators were invited to assist with data collection, and 4 chose to participate. Three staff members from the Georgia Department of Human Resources and 4 from the Centers for Disease Control and Prevention also collected data.
Because roadblocks are busy events, a checklist was designed to maximize speed of observational and interview data collection on child passenger restraint use and seating position. All 49 volunteers were uniformly trained to use this survey instrument. The following 4 survey items were recorded about children 0 to 12 years of age as their vehicles passed through a participating roadblock. The age and weight of each child passenger were obtained from the driver. The seating position (front or back seat) and child restraint type (rear-facing CSS, forward-facing CSS, shield booster seat, belt-positioning booster seat, car seat belt, no restraint) were determined by looking into the vehicle. For children who were seated in the front seat, this survey did not evaluate whether a back seating position was available. This survey also did not evaluate whether children were properly strapped into the CSSs or whether the CSSs were installed properly into the vehicles; it recorded only the type of CSS used by the children. The survey also documented the number of children who were aged 0 to 12 years in each vehicle, as well as the location, time of the day, and date of each roadblock.
Data Management and Analysis
Initial analysis examined the proportion of children who were riding appropriately restrained and the proportion who were riding in the back seat. Appropriate restraint was defined on the basis of the NHTSA and AAP guidelines, previously discussed, using age and weight characteristics. However, because weight information was frequently missing from our data, because parents often incorrectly estimate the weight of their children, and because children frequently ride in CSSs that are too big for their size yet infrequently ride in CSSs that are too small,19 the recommended guidelines were slightly modified in our operational definition of correct restraint (Appendix 1).
This study, like almost all current child passenger surveillance in the United States, is compromised because weight is estimated. In this study, weight estimates are based on information from parents and on the child's age. Given these handicaps, the operational definition is not perfect; there are several areas in which children may be misclassified. The operational definition purposely errs on the side of underestimating incorrect use so that reported misuse rates were not falsely high. For example, it classifies all children who are younger than 2 years, in a rear-facing seat, as restrained correctly. In reality, some of these children are probably too heavy for rear-facing seats, especially seats with 20-pound limits. Similarly, the operational definition classifies all 4- and 5-year-olds, in belt-positioning booster seats, as restrained correctly, although approximately half of all 4- and 5-year-olds have not yet reached 40 pounds. That being said, 1 small area in which incorrect use may be overreported by this definition is 3-year-old children in booster seats. The operational definition classifies all 3-year-olds in booster seats as incorrect; 5% to 10% of 3-year-old children do weigh 40 or more pounds and thus are restrained correctly in booster seats.6
Additional analyses of appropriate restraint use and seating position were performed using the following variables: number of children in a vehicle, time of day, weekend versus weekday, and urban versus rural.20
Because some of the children included in this study were riding in the same vehicle, there was not full independence in sampling. Children within a given car may have some degree of dependence with respect to proper restraint use and proper seating position. To correct for this, we used a cluster sampling model to properly calculate variances of statistical estimates. Means, variances, and confidence intervals were calculated using the SURVEYMEANS procedure in the Statistical Analysis System (SAS) software package, Version 8.21 This procedure permits explicit specification of a clustering factor, in this case a vehicle ID (sequentially assigned numbers in this study). For each estimated proportion (or, equivalently, each percentage), the SURVEYMEANS procedure provides an estimated SE incorporating any effect of clustering. Using these estimated proportions and SEs, 95% confidence intervals that were based on a normal approximation (proportion ± 1.96 × SE) were also calculated.
Data were also used to calculate the proportion of children who were riding at risk and would have been overlooked using Georgia's annual surveillance system: (a) children riding at risk and identified by Georgia's surveillance = 0 to 4 years of age not using a CSS and/or in the front seat + unrestrained children 5 to 12 years of age; (b) all children riding at risk (current study) = this study's definition of incorrect restraint and/or children in the front seat; and (c) of children riding at risk, the proportion not detected by Georgia's Surveillance System = 1 − a/b.
Similarly, the ability of Georgia's passenger restraint law to identify at-risk child passengers was evaluated: (d) children riding not in compliance with Georgia's State Law = 0 to 4 years of age not using a CSS + unrestrained children 5 to 12 years of age; (e) all children riding at risk (current study) = this study's definition of incorrect restraint and/or children in the front seat; and (f) of children riding at risk, the proportion not identified by Georgia's State Law = 1 − d/e.
From May 21, 2001, to June 8, 2001, police roadblocks were conducted and information was collected at 83 sites in 24 of Georgia's 159 counties on 1858 children in 1221 vehicles. Figure 1 shows the location of the 86 counties that were invited to participate in the study, the 24 counties that did participate in the study, and the number of children who were surveyed in each participating county. A total of 431 (23%) children were surveyed in 10 urban counties, and 1427 (77%) children were surveyed in 14 rural counties. Forty-four percent of our study data came from only 2 of the 24 counties, yet when data from these 2 counties (Clinch and Elbert) were compared with data from the other 22 counties, no meaningful differences in appropriate restraint use or seating position were seen (correct restraint percentage estimates and the back seat percentage estimates from Clinch County, Elbert County, and the combined 22 other counties were not significantly different from one another, with α < .05).
Children who were 0 to 4 years of age made up 45% of the study population (Table 1). Data were collected at different times of the day and days of the week. More than half of the children were riding in a vehicle with another child. Data were complete for 96% to 100% of the children for each variable except weight, which was recorded for 58%.
Overall, 58% of the children were restrained in age- and size-appropriate systems, but this percentage varied greatly by age group (Table 2). Although 99% of the infants were in car seats, only 71% were restrained appropriately because 28% were positioned incorrectly in forward-facing seats. Eighty-eight percent of children who were aged 1 and 2 years were restrained appropriately in rear-facing infant seats (14%) or forward-facing convertible car seats (74%). The remainder were in booster seats (4%), were in just a seat belt (5%), or were completely unrestrained (3%). Fifty-five percent of the children who were 3 and 4 years of age were restrained correctly; however, 3% were riding in shield boosters, 7% were 3-year-old children probably using booster seats prematurely, 33% were using only a seat belt, and 3% were completely unrestrained. Only 11% of 5 and 6 years and 1% of those 7 and 8 years of age were restrained correctly. Among children who were 9 to 12 years of age (for whom only seat belts are recommended), 97% were restrained appropriately.
The 3- to 8-year combined age group had the highest rates of inappropriate restraint use. Figure 2 shows this age group in more detail presenting the data by each year of age and by restraint type. Sixty percent of children who were 3 years of age were restrained appropriately, but 12% were placed prematurely in belt-positioning booster seats and 21% were restrained only by a seat belt. Forty-eight percent of the children who were 4 years of age were in age-appropriate CSSs, but 48% were restrained only by a seat belt. Only 6% of the 5- to 8-year age group used age- and size-appropriate restraints; 88% of these children were restrained by only a car seat belt.
Overall, 75% of children who were 0 to 12 years of age were seated in the back (Table 2). Seventy-nine percent of infants rode in the back seat. Children who were 1 and 2 years of age had the highest rates, with 92% of this age group in the back seat. From here, there is a general decline in back seating position as age increases. Eighty-eight percent of the children who were riding in the front seat were in vehicles that were carrying at most 2 other child passengers and thus in theory had a back seat position available.
Merely 44% of the children were in age-appropriate restraints and in the back seat (Table 2). Fifty-six percent of children were restrained and/or positioned inappropriately in the front seat. Fourteen percent were in the front seat and restrained appropriately, 11% were in the front seat and restrained inappropriately, and 31% were in the back seat and restrained inappropriately. Urban versus rural counties, time of day, and time of the week (weekday or weekend/holiday) had no appreciable effect on correct restraint use and seating position (Table 3).
The proportion of correct restraint use (without regard to seating position) decreased as the number of child passengers in a vehicle increased. However, the proportion of children who were seated in the back seat generally increased as the number of child passengers in a vehicle rose.
A comparison of the study results with the Georgia Statewide Use of Occupant Restraint Survey, the current annual surveillance system, found that the current Georgia surveillance system would have missed 589 (77%) of the 765 children identified in this study as restrained inappropriately. The current surveillance system documents restraint information (CSS, seat belt, or no restraint) for children who are aged 0 to 4 years. It does not collect information about CSS type (rear-facing, forward-facing, booster seat) or about CSS use for children who are 5 years of age and older. These 589 missed children included 43 infants who were in forward-facing seats, 31 children who were 1 to 3 years of age and in belt-positioning booster seats, 17 children who were in shield boosters, and 490 children who were 5 to 8 years of age and using only seat belts. The current surveillance system documents seating position (front seat or back seat) for children who are 0 to 4 years of age only. It would have missed 331 (74%) children (5–12 years of age) of the 446 children in our study who were seated in the front seat. Combining inappropriate restraint and front seating position, the Georgia Statewide Use of Occupant Restraint survey would have missed 77% of the children who were riding at risk.
Similarly, the Georgia restraint law did not cover most of the children who were found to be riding at risk in our study. The law required that children 4 years and younger be in a federally approved CSS, used according to manufacturers' instructions. Thus, it was legal yet suboptimal for children to ride in shield boosters and for children 5 through 8 years to ride without a booster seat and be restrained only by a seat belt. Georgia's law did not mandate that children ride in the back seat. Of the 765 children who were riding at risk (restrained inappropriately and/or riding in the front seat), 199 (26%) were riding illegally by the current law, but 566 (74%) of the children in our study who were riding at risk were riding legally.
Because of ongoing safety research, recommended practices for proper restraint of children in passenger vehicles have changed in the past several years and will continue to evolve. Two of the most recent changes, the use of booster seats and that children who are aged 12 and younger be seated in the rear are, not surprising, the areas in which misuse is most pronounced. Educating caregivers about rapidly changing recommendations and updating surveillance systems and state laws to reflect current recommended practices are ongoing public health challenges.
Findings of this study revealed critical gaps in child passenger safety practices, surveillance, and legislation in the state of Georgia. The majority of children in our study were not restrained adequately and riding in the back seat as they should. All age groups needed improved protection. Infants were frequently in forward-facing seats (28%) and in the front seat (21%), the 5- to 8-year-olds were not in booster seats (94%), and the 9- to 12-year-olds were frequently in the front seat (39%). Similar rates of inappropriate restraint use and front seating position have been reported at the national level.11,19,22,23
Many children ride in restraint systems that are designed for older children: almost one quarter of infants are being placed in forward-facing seats before their first birthday; some children who are 1 to 3 years of age ride prematurely in booster seats; approximately one third of children who are aged 3 to 4 years ride restrained only by a seat belt; and most children who are aged 5 to 8 year are placed in car seat belts rather than belt-positioning booster seats. Continued efforts to increase age-appropriate restraint use, particularly efforts to promote belt-positioning booster seat use in the 5- to 8-year age group, are key for reducing child passenger injuries.
Our data show that one quarter of children continue to ride in the front seat, although riding in the back seat is 1 of the most effective means of decreasing fatal injuries.14 Because information about vehicle type (truck, sedan, minivan, etc) was not collected, our data cannot determine the exact percentage of children who were riding in the front seat and could have been placed in the back. However, other studies that took vehicle type into account found that ∼90% of children who were seated in the front seat could have been seated in the back.22,24 Previous research suggests that <4% of private vehicles that carry children have only a front seat.24 Decreasing the number of children who ride in the front seat should be a priority in child passenger safety efforts.
Limitations of this study are at least 3-fold. First, the survey data constitute a convenience sample. However, results are very similar to those of other recent studies of age-appropriate restraint use and seating position.11,19,23,25 The 1 area in which our results did not closely parallel other observational surveys is the percentage of unrestrained children. We found only 3% of children to be completely unrestrained, whereas other recent studies reported >10%.19,23 We suspect that our numbers are uncharacteristically low because drivers, seeing an upcoming roadblock, quickly buckled previously unrestrained children. Several police officers commented that they frequently notice unrestrained passengers buckling their seat belts as they approach a road block. Second, children's weights were estimated using parents' knowledge and children's ages. Weighing child passengers would make studies of child passenger restraint more labor intensive and intrusive, so most studies do not collect weight data, although weight is a key factor in determining correct restraint. Third, information was not collected on vehicle type; thus, we do not know what proportion of children who were seated in the front seat were in vehicles without back seats.
Surveillance of restraint use and seating position is important because it highlights restraint problem areas and helps to monitor change over time. This is particularly relevant because child restraint practices continue to change.25 Surveillance also provides a measure of public health intervention effectiveness, such as changes in restraint use after new child restraint legislation. Improved state-specific surveillance systems are particularly important at this time because many states have recently upgraded or are about to upgrade their child restraint laws. Individual states vary in the amount of child passenger safety surveillance information obtained, yet most states have very limited surveillance that does not include information about booster seat use or seating position among older children. Thus, surveillance in most states, like that in Georgia, fails to detect the majority of children who are traveling at risk.
Ideally, each state would have regular child passenger safety surveillance for children who are 0 to 15 years of age. This surveillance should include the specific type of restraint (forward-facing CSS, rear-facing CSS, booster seat, seat belt, and no restraint). For children who are 12 years of age and younger, surveillance should include data on front or back seating position and should document whether the vehicle has a back seat. Depending on the public health resources and child passenger injury rates of each state, measuring the height and the weight of participating children, collecting associated demographic data and information about CSS installation, and linking child passenger safety information with crash reports and medical records should be considered. A number of child passenger surveillance systems at the national level could provide valuable examples to assist states in developing and improving their surveillance programs.23,26–28
Improved child-specific surveillance systems are key in creating and monitoring new child restraint legislation. Appropriate CSS legislation is important for at least 3 reasons. First, it is 1 of the most effective mechanisms for increasing correct restraint use and back seating position.16,17 Second, 9 of 10 parents believe that if their children are riding legally, then they are restrained appropriately.29 Thus, laws that support recommended practices can help to ensure that recommended safety practices are followed. Last, most parents are in favor of expanded legislation to mandate appropriate restraint and back seating position.30,31
All 50 states have child passenger restraint laws, but 17 states require a CSS only for children who are 3 years of age and younger. An additional 6 states require CSSs for children who are 4 years of age and younger. Of states with booster seat legislation, most (15 states) require booster seats only for children who are 4 and 5 years of age but not for children who are 6 to 8 years of age (11 states). Only 7 states have laws mandating that children ride in the back seat if the vehicle has a back seat. Where such legislation exists, the age cutoff for back seating position varies from 1 to 11 years. In addition, 12 states allow older children to ride completely unrestrained if they are in the back seat.18,32 All states require children who are younger than 16 years to be restrained when riding in the front seat. Strengthening child passenger safety laws is an important and effective way to decrease child passenger injury.
Most children in Georgia are not using age-appropriate restraints and riding in the back seat. Improved state-specific surveillance of child passenger restraint use and seating position combined with stronger legislation is key for improving child passenger safety practices and should be a public health priority. Closing these gaps will prevent many fatal and nonfatal injuries. Because most states have child passenger safety surveillance programs and laws similar to those in Georgia, conclusions from this study may have important implications for most states.
We thank the many dedicated police officers and SAFE KIDS members in Georgia who made this study possible and the families who participated. We also thank our colleagues who generously gave of their time and expertise: David Sleet, Malcolm Washington, Tasha Gill, Jairam Lingappa, Dionne White, Tuwana Morris, Brian Michaluk, Reshma Mahendra, Sevena Quattlebaum, Joanna Taliano, Steve Leadbetter, Megan Davies, John Horan, and Christine Branch. Last, we thank experts in the field of child passenger restraint surveillance who took the time to discuss current activities in this area: David Eby, Larry Decina, Donna Glassbrenner, Dennis Utter, Alan Block, Mark Freedman, Sally Thorenson, Sandy Sinclair, Bill Hall, and Beth Ellen Cody.
- Accepted July 12, 2004.
- Address correspondence to Catherine Staunton, MD, 622 11th Ave E, Seattle, WA 98102. E-mail:
No conflict of interest declared.
Dr Staunton’s current affiliation is: Seattle–King County Department of Public Health, Seattle, Washington.
PEDIATRICS (ISSN 0031 4005). Published in the public domain by the American Academy of Pediatrics.
NEONATAL MORTALITY IN THE UNITED STATES, 1989–2001
“During 1989–2001, neonatal mortality in the United States declined 25%, from 6.0 deaths per 1000 live births to 4.5 … In 1989 and 2001, preterm infants accounted for approximately 70% of all neonatal deaths. In 2001, preterm infants accounted for 84% of black neonatal deaths and 72–75% of deaths among infants of other races/ethnicities. Extremely preterm infants accounted for 49% of neonatal deaths overall in 1989 and 58% in 2001.”
Noted by JFL, MD
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- Copyright © 2005 by the American Academy of Pediatrics