Automobile crashes are a significant cause of morbidity and mortality among children. When used correctly, car seats will decrease mortality by 71 percent, however, there remains an incredibly high percentage of car seats that are misused. Health care professionals are frequently called on to answer questions about car seats and other child safety restraints. This article provides a basic overview of correct car seat use, addresses common problems that occur, and provides an update on some changes in child safety restraints.
General Child Safety
Parents should be encouraged to always use a car seat, starting with the baby's first ride home from the hospital. Consistency will help the child to form a lifelong habit of buckling up. To be effective, the harness must snugly restrain the child in the car seat and the seat belt must snugly hold the car seat in the car. Parents should be encouraged to look for a seat that is easy to use, to read the safety seat and motor vehicle manufacturer's instructions for correct installation and use, and to try the seat out in their car before purchase. They can test for a snug fit by pulling the base to either side and toward the front of the car. Only one inch of movement from side to side is acceptable.
Encourage parents to mail in the registration cards for new car seats. This allows the manufacturer to contact the purchaser in the event of a recall. The National Highway Traffic Safety Administration (NHTSA) operates a web site (www.nhtsa.dot.gov) to provide consumers with information on recalls.
All children are safest in the back, center seat, in a safety seat or seat belt. This position is the farthest away from both front and side impacts. Children are up to 29 percent safer riding in the back seat versus the front seat. Every child and adult should be buckled in a child safety seat, a booster seat, or with a lap/shoulder belt. Passengers riding loose can hurt those who are buckled in by being thrown up against them.
Parents should understand the various types of seats and which is appropriate for their child's size and development. Unfortunately, parents have a tendency to move their child out of a safety seat and into a lap/ shoulder belt too soon.
Babies
Infants up to 22 pounds and up to one year should always ride facing the back of the vehicle in the back seat of the car, van, or truck. Infants must never ride in the front seat of a car that has air bags or be held on someone's lap. Parents should avoid buying seats with a t-shield or tray until the child can sit upright with his head above the shield level.
Safety seats should recline at a 45-degree angle to keep the infant's head upright. If the vehicle seat slopes causing the infant's head to fall forward, the safety seat should be tipped back so that the base of the seat is horizontal. Some infant safety seats have tilt indicators to assist in proper positioning. To tilt the seat, a firm roll of cloth can be wedged under the base below the infants' feet. The seat should never be reclined more than 45 degrees.
The infant's buttocks and back should be flat against the back of the safety seat. Shoulder straps must be in the lowest slots; the harness must be snug, and the harness retainer clip at armpit level. If a head donut is to be used, it should not extend below the shoulder level. Either fold the back portion up behind the head or cut it off below the shoulder level. The infant should be secured into the seat and harness in one layer of clothing only. Do not swaddle the infant in blankets beneath the harness. Any additional layers of material between the infant and the seat can diminish the seats' ability to absorb crash forces and interfere with the proper securing and placement of the harness and buckle. Additional layers can be placed over the top for warmth once the correct infant placement is achieved.
Young Children
Some manufacturers are now making rear-facing seats for children up to 35 pounds. Otherwise, children over 22 pounds and at least one year of age can ride in a car seat that faces the front of the vehicle. They should continue to ride in the seat for as long as they fit comfortably. Children over 40 pounds should ride in a booster seat until the car's lap and shoulder belts fit right. They will be approximately 4-1/2 feet tall and weigh 80 pounds before the lap belt systems fit properly. The lap belt must fit low and snug on the child's hips. The shoulder belt must not cross their face or neck. The shoulder belt should never be placed behind their back or under their arm.
Safe Transportation of Premature Infants
Research has indicated that some infants, particularly premature, low-weight infants, may be subject to oxygen desaturation when placed in an upright position in car safety seats. The following guidelines can assist in proper positioning of small infants in car seats to minimize the risk of respiratory compromise and still provide protection for the infant in the event of a crash.
Correct selection of a restraint device is also important for newborn infants who have certain congenital conditions (spina bifida, hydrocephalus, Pierre Robin syndrome, osteogenesis imperfecta, and other neuromuscular conditions).
Misuse of Child Restraint Devices
In the state of Iowa, up to 97 percent of car seats are misused. The national misuse rate is 84 percent. Common errors that have been noted with car seats include:
While lack of parental effort may account for some of this misuse, it is more likely related to the complicated process of properly restraining children. Not all models of car seats fit all models of motor vehicles and many belt systems are incompatible with child restraints. There are up to 100,000 possible combinations of car styles, car seats, and seat belts!
In general, seat belts are built for the comfort of adults, not to secure a car seat correctly. Safety seats should be used only with safety belts that lock tightly and hold the seat firmly in place. Some lap/shoulder belts need a special locking clip to safely secure a child car seat. These locking clips come with all new car seats. Lap belts that exit forward of the seat crack and seat belts that are raised above the vehicle seat on a stiff stalk make it difficult to secure a child restraint tightly. Automatic shoulder and lap/shoulder belts cannot be used to secure car seats. Automobile dealers can install a special lap belt to lock the child restraint in place.
Many errors could be avoided if parents read the car seat and motor vehicle manufacturer's instructions for correct installation and use. Other errors are more challenging to correct due to the large variety of car seats available and the incompatibilities in vehicle seats and seat belts. Recognizing this challenge, many automobile dealers, police departments, fire departments, and other community agencies have developed checkpoints where parents can have their car seat installation checked out by local experts. Health care providers should be aware of what resources are available in their community and refer families to these resources.
Air Bags and Children
While dashboard air bags have saved an estimated 1,500 lives, they pose special hazards for children age 12 and under who ride in the front seat. As of late 1996, 31 children had been killed as the result of air bag deployment in low-speed collisions. Nine of these children were in rear-facing infant restraints. Eight more children were seriously injured as a result of air bag deployment, with five of these in rear-facing infant restraints. Air bags inflate at speeds up to 200 miles per hour. An infant's head in a rear-facing safety seat is directly in front of the air bag as it breaks through the dashboard and inflates. Even forward-facing child safety seats place the child within range of the air bag before it is fully inflated. Never put an infant in the front seat of a car with a passenger-side air bag. Infants must always ride in the back seat facing the rear of the car. If a baby has special health needs and requires full-time observation, another adult should ride with the baby in the back seat.
Air bags also pose hazards for children who ride unrestrained, or are improperly restrained in the front seat. Surveys indicate that as many as 35 percent of young children ride unrestrained. Pre-crash braking may throw a child against the dashboard at or near the air bag location and the inflating air bag can violently impact the child with such force that it can injure or kill the child. Drivers and adult passengers should also make sure they are properly belted and that their seat is moved back as far as practical from the air bag.
Vehicle owners can get on-off switches installed for their dashboard air bags through auto dealers and service outlets if they meet one of four eligibility requirements:
The safest place for all children is correctly restrained in the back seat of the vehicle. However, there is now concern about a recent manufacturing trend for side air bags in automobiles. NHTSA warns that side air bags can cause potentially serious or fatal injuries to children. They are particularly concerned about back seat air bags since they encourage seating children under age 13 in the back seat to avoid potential injury from dashboard air bags.
Children who are seated in close proximity to a side air bag may be at risk for serious or fatal injury, especially if the child's head, neck or chest is in close proximity to the air bag at the time of deployment. NHTSA has requested that manufacturers ship vehicles to dealers with the rear side air bags deactivated, unless the manufacturer determines that the air bags do not pose a significant risk. Shipping the cars with deactivated side air bags leaves the decision to activate the bags with the purchasers.
Head Protection Requirements
As of mid-1999, all forward-facing child restraints were required to meet new, more stringent head protection requirements. A top tether anchorage system has been designed to better stabilize the seat and reduce the potential for head injury. A top tether is an adjustable strap attached to the upper back of a car seat. It has a hook attachment that secures to an attachment mounting in the rear shelf of the car. Most new passenger cars should be equipped with a corresponding attachment to secure the top tether strap.
The use of the tether for forward-facing seats and boosters reduces forward head excursion by 4-6 inches in the event of a crash. With convertible seats, the tether strap should be removed when the seat is placed in the rear-facing position to eliminate the potential for injury from a flying strap or buckle in the event of a crash. General Motors will install one tether anchor per car for any of their models without a fee.
Conclusion
In summary, health care professionals and most parents universally accept the value of child restraints. However, the task of properly restraining children in automobiles is not as simple as it might seem. Health care professionals must be knowledgeable about child restraints so that they can offer guidance to new parents about the many challenges they may encounter as they attempt to properly restrain their children.
See related Patient Textbooks about Pediatrics.
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See related Provider Topics Child and Teen Health, Food, Nutrition and Metabolism, General, Pediatrics or Safety.
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