by Amy Spangler
February 10, 2010

Motor vehicle accidents are the leading cause of death in children 1–14 years of age, accounting for nearly 1,400 deaths and 193,000 injuries a year. All states have enacted laws that require the use of child safety seats for children 0–4 years of age, but only 25 states require booster seats for children up to the age of 8.

In 2003, investigators compared the effectiveness of belt-positioning booster seats with the use of seat belts alone in children 4–7 years of age and found that children restrained with only a standard issue seat belt were 59 percent more likely to be injured in a crash compared to those restrained in a child booster seat.

Since most of the children in the earlier study were 4–5 years old, those same researchers conducted a second study in 2009 to examine the effectiveness of booster seat use in older children.

Research
Data from crashes involving at least one child younger than the age of 15 and seated in the rear seat of the vehicle was examined. Prior to inclusion, the researchers contacted the parent/driver to determine the location of the child in the vehicle, the location of the impact on the vehicle, and the degree of injury suffered or medical care sought for the children in the vehicles. Data was ultimately obtained on 52 percent of the crashes that met the inclusion criteria.

Injuries were classified as none, minor, or major. For the purpose of analysis, uninjured children and children suffering minor injuries such as cuts, scrapes, or bruises were classified in one category. A second category consisted of children suffering major injuries including internal organ injuries, concussions, spinal cord injuries, and fractures of the arms or legs. A total of 6,591 crashes involving 7,151 children ages 4–8 years were included in the final analysis. Seventy percent of the children were restrained by seat belts, and 30 percent were in child booster seats.

Results
Only 1.15 percent of the children experienced a major injury. Those restrained in child booster seats were much less likely to experience a major injury (0.67 percent) compared with those restrained by seat belts (1.36 percent). After adjusting for the child’s age, weight, and placement in vehicle, severity of the crash, vehicle model year, and other driver and crash characteristics, the investigators found that children restrained in child booster seats were 45 percent less likely to experience a severe injury compared with seat belt-restrained children. Approximately 60 percent of the children were in booster seats with high backs, and 40 percent were in backless booster seats. The risk for injury was not significantly different between the two types of booster seats. The investigators concluded that placing a child in a booster seat reduces the risk for severe injury by nearly 50 percent, and that both types of booster seats provide comparable protection.

Recommendations
Despite evidence that prevent serious injury and may even save lives, only 30 percent of the 4- to 8-year-olds in the study were using belt-positioning booster seats at the time of the accident. Making parents aware of the importance of belt-positioning booster seats is the responsibility of all those concerned about the health and safety of children.

Safety tips

• Belt-positioning booster seats are designed for children through 8 years of age who have outgrown a forward-facing car seat.

• Children should be restrained in a booster seat until a seat belt fits properly (usually when a child reaches about 4′ 9″ in height and is between 8 and 12 years of age). You can be assured of a proper fit if the lap-and-shoulder belt is snug but comfortable and crosses the child’s shoulder and thighs, rather than the neck, face, or stomach.

• Booster seats should be placed in the rear seat of the vehicle only.

• Backless booster seats are designed for use in rear seats with a high seat back or head rest and a lap-and-shoulder belt.

• Never place a shoulder belt behind the shoulder or under the arm.

• All children under the age of 13 should ride in the rear seats of vehicles.

As noted in the AAP’s revised Child Passenger Safety policy statement, it is important for parents to understand that every transition from one restraining device to another is associated with some decrease in protection and increased risk of injury; therefore, parents should be encouraged to delay these transitions for as long as possible.