TABLE 2

Explanations of Decision Points and Additional Resources

Does the child have significant health needs?Children with certain temporary or permanent physical and behavioral conditions such as altered muscle tone, decreased neurologic control, skeletal abnormalities, or airway compromise that may preclude the use of regular CSSs may require specialized restraint systems.
Consult complementary AAP Policy and other resources for best practice recommendationsThe AAP has a Policy Statement providing specific guidance on best practice recommendations for children with special health care needs (http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B104/4/988).
To locate a child passenger safety technician in your area with special training in special health needs, go to http://cert.safekids.org.
<4 yInfants and toddlers have relatively large heads and several structural features of their neck and spine that place them at particularly high risk of head and spine injuries in motor vehicle crashes. Rear-facing CSSs provide optimal support to the head and spine in the event of a crash.
Children who are small for their age may need to be evaluated like younger children. Consult a child passenger safety technician with enhanced training in special needs or other resources for assistance.
Has the child outgrown weight or height limit for seat?
Is weight or height less than rear-facing limit for convertible CSS?
Is weight or height less than forward-facing limit for convertible combination CSS?The AAP annually updates information on child restraint systems currently available in the United States (www.healthychildren.org/carseatguide). The weight thresholds provided in the algorithm are considered minimum standards. More recent products have higher weight limits and should be used when possible. In general, children should remain in a child restraint system until they outgrow the weight or height limits for its intended use.
4–8 yMost children 4–8 years of age are not large enough to fit properly in the vehicle seat belt and will require a CSS or booster seat for optimal restraint. A belt-positioning booster seat positions a child so that the lap and shoulder portions of the seat belt fit properly: the lap portion low across the hips and pelvis and the shoulder portion across the middle of the shoulder and chest.
8 yMost children under 4 ft 9 inches in height will not fit properly in vehicle lap and shoulder seat belts.
Does child fit properly in the vehicle seat belt, usually around 4 ft 9 inches in height?These 3 questions are an evaluation to determine whether a child is ready to be restrained by the vehicle seat belt without a booster seat. If the answer is “no” to any of these questions, the child should use a booster seat:
 1. Is the child tall enough to sit against the vehicle seat back with her knees bent at the edge of the vehicle seat without slouching and stay in this position comfortably throughout the trip?
 2. Does the shoulder belt lie across the middle of the chest and shoulder, not against the neck or face?
 3. Is the lap belt low across the hips and pelvis?