Abstract
Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of 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 for most infants up to 2 years of age; (2) forward-facing car safety seats for most children through 4 years of age; (3) belt-positioning booster seats for most children through 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 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):
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.
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.
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.
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.
Summary of Best-Practice Recommendations
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.
Explanations of Decision Points and Additional Resources
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.
Lead Author
Dennis R. Durbin, MD, MSCE
Committee on Injury, Violence, and Poison Prevention, 2008–2010
H. Garry Gardner, MD, Chairperson
Carl R. Baum, MD
M. Denise Dowd, MD, MPH
Dennis R. Durbin, MD, MSCE
Beth E. Ebel, MD
Michele Burns Ewald, MD
Richard Lichenstein, MD
Mary Ann P. Limbos, MD
Joseph O'Neil, MD, MPH
Elizabeth C. Powell, MD
Kyran P. Quinlan, MD, MPH
Seth J. Scholer, MD, MPH
Robert D. Sege, MD, PhD
Michael S. Turner, MD
Jeffrey Weiss, MD
Contributor
Stuart Weinberg, MD
Partnership for Policy Implementation (PPI)
Liaisons
Julie Gilchrist, MD
Centers for Disease Control and Prevention
Lynne Janecek Haverkos, MD
Eunice Kennedy Shriver National Institute of Child Health and Human Development
Jonathan D. Midgett, PhD
Consumer Product Safety Commission
Alexander S. Sinclair
National Highway Traffic Safety Administration
Natalie L. Yanchar, MD
Canadian Paediatric Society
Staff
Bonnie Kozial
dshp{at}aap.org
Footnotes
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.
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.
- AAP =
- American Academy of Pediatrics •
- CSS =
- car safety seat
REFERENCES
- Copyright © 2011 by the American Academy of Pediatrics
