Despite the massive improvement in vehicle safety standards across the country, and more awareness brought to keeping kids safe while riding down the road, car accidents continue to be a top killer of children. And, according to the American Academy of Pediatrics, they remain the leading cause of death for children over three[1]. But, child car accident deaths really are only the tip of the iceberg, “for every fatality, approximately 18 children are hospitalized and more than 400 receive medical treatment“. Many times (about 7 out of 10), says the CDC, these can be prevented by proper car seat use[2]. And yet, most parents are simply never taught how to keep their kids safe in the car. In fact, one study examining the car seats used by newborns at hospital discharge found that approximately 95% of all car safety seats were misused[3]. Frequent misuses included harness and chest clip errors, incorrect recline angle, and seat belt/lower anchor use errors. 

So, how do you know if your child is safe in the car?

Is Your Child in the Safest Seat?

Rear Facing Car Seat

Birth until at least 2 years, but ideally until they reach the highest weight or height allowed by the manufacturer. 

With the recommended standard, in most states, of turning your child’s car seat to the forward facing position being a milestone of ‘1 year or 20 lbs’, parents can commonly be found turning their children around long before they are ready. A study published in Injury Prevention in 2007 determined that children up to 24 months of age are actually 500 times safer in the rear-facing position[4]. Because infants and young toddlers have larger head/body ratios, coupled with the fact that their skeletons are composed primarily of stretchy cartilage, they remain at the greatest risk when facing forward in a vehicle. Children like Joel and Jaxon are proving to researchers and medical professionals the necessity of protecting young children in the car[5, 6]. Both toddlers, aged 16 and 18 months, were facing forward when their family was involved in a collision. And both toddlers suffered an extremely serious, and often fatal, injury known as internal decapitation. This injury happens when the ligaments holding the head onto the spine are severed, and is three times more common in children than adults[7]. Because of cases like these, and more research that has gone into the subject, in 2011 the American Academy of Pediatrics updated its recommendation on car seats, advising parents to keep their toddlers “in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by the seat’s manufacturer”[8]

And two years really is the bare minimum. In the World Health Organization’s Seat Belt Manual, it was recognized that the process of forming bone isn’t quite complete in children until around 6 or 7 years of age[9]. Because of this, kids 4 and under remain safest in a seat that limits ‘forward head movement.’ Last year, a 4-year-old boy’s internal decapitation sent shudders down the spines of parents across the nation, showing that rear-facing truly is beneficial for as long as possible[10]. Killian was involved in a serious accident with his mom that left his skull detached from the spine. The main reason these injuries happen, according to a study published in The BMJ, is because of a child’s “relatively large head mass, and differences in anatomy of the cervical spine.”[11] These differences “can lead to excessive stretching or even transection of the spinal cord if the child is involved in a frontal crash while in a forward facing seat.” It is for this reason that rear facing seats are safer than forward facing seats for children under 4 years old.”‘

Some of my favorite extended rear-facing carseats are:

 

 

 

 

 

Forward Facing Car Seat with a Harness

Children who have outgrown the rear-facing weight/height limit should use the harness until they reach the highest weight or height limit allowed by the manufacturer. 

As children grow older, and more independent, many parents begin to wonder how much safer their child really is in a baby seat versus a booster. Because of this, many 3 and 4 year olds can be seen sitting in booster seats with a seatbelt, but the truth of the matter is: this really isn’t safe at all. At a minimum, children should be restrained in a five-point harness until 5-years-old, but many children remain significantly safer sitting this way for much longer. A study published in Pediatrics examined the riding habits of nearly 14,000 children between ages 2 and 5 and discovered, that while the vast majority were restrained, 40% of them were using only a seatbelt[12]. This is especially concerning because the study also determined that children of this age group were 3.5 times more likely to suffer a significant injury (most likely a head injury) if they were in a seat belt instead of a harness. This is because, at this age, harnesses are highly effective in preventing serious injury and hospitalization. A study published in Accident Analysis & Prevention found that when a child was restrained by a harness, instead of a seatbelt, their chances of sustaining serious injury or being hospitalized were reduced by nearly 80%[13].

One main reason that harnesses consistently test safer than seatbelts with young children is because they keep the child in place. Now, this may seem like a no-brainer, but when you really think about it, keeping a child restrained in a safe position in a moving vehicle is vital to their safety. Kids are wiggly little creatures, especially when they sleep. I often find myself scratching my head at the positions I find my son sleeping in – they just wouldn’t be comfortable for me! A wiggly child with the freedom of a seatbelt can be a recipe for disaster. After 5 years old, by gauging a child’s maturity level (and likelihood to remain in a seated position while sleeping), a parent is able to decide when their child is ready for moving into a booster. It’s important to remember that there is no rush. Every child will end up in a seatbelt one day, and it doesn’t matter who got there first. The National Highway Traffic Safety Administration (NHTSA) recommends leaving your child in the harness “until he or she reaches the top height or weight limit allowed by your car seat’s manufacturer.”[14]

Some of my favorite forward-facing seats are:

 

Belt Positioning Booster Seat

Children who have outgrown the forward-facing weight/height limit should use the belt positioning booster until 4’9″ or ability to pass 5-step test.

Kids who have outgrown their carseats still aren’t quite big enough, and lack the proper bone development, to ride in a seat with a belt alone. This is where the happy middle comes in: the belt positioning booster. These seats help give the child the boost they need, so that the seat belt is sitting properly on their body. In children too small to be properly positioned in a seat alone, the belt often sits on their neck (instead of the collarbone, where it does in an adult), and over the soft organs of the abdomen (instead of the pelvic bones). So, even in children big enough to not be ejected during an accident, when it come the seat belt may do more harm than good. Booster seats have proven the ability to reduce the chance of injuries commonly seen in children whose seatbelt fit improperly: abdominal, neck/spine/back, and lower extremity[15]. In fact, the odds of sustaining any type of injury were reduced by nearly 60% when the child was sitting in a booster seat. The biggest problem with booster seats? Most people aren’t using them. One study that examined booster seat use among children deemed too small to safely sit in a seat belt alone, and found that nearly 80% of the children were improperly restrained. Only 21% were sitting in booster seats at all[16].

So, how do you know when your child is ready to graduate from the booster seat? First, they must be at least 8 years old, and at least 4’9″. Many safety councils are now recommending putting your child through the 5-step-test in order to determine their readiness for the seat belt[17]. 

Some of my favorite booster seats are:

 

The 5-Step-Test

1. Is your child able to sit all the way back against the car’s seat without a gap between the lower back and the seat?
2. Without slouching, do your child’s legs bend comfortably at the edge of the seat?
3. Does the shoulder strap sit in the middle of the child’s shoulder, between the neck and arm?
4. Does the lap belt sit low, across the top of the thighs, and not on the tummy?
5. Can the child stay seated like this for the entire trip?

If you answered ‘no’ to any of these questions, your child is not ready to sit without a booster seat.

Is the Car Seat Installed Correctly?

Because each carseat (and vehicle!) is different in its own way, sometimes installing one correctly can become a stressful and confusing task. Thankfully, all car seats come with instruction manuals but, according to the NHTSA as many as 20% of parents don’t even look at it when installing the seat[18]. The first, and probably best, thing you can do to understand the equipment meant to keep your child safe in the vehicle is to read the manual. If you run into trouble or confusion, the vehicle’s manual can also come in extremely handy. 

Is the Seat Tight Enough?

Sometimes called the ‘Inch Test’, this is the best way to determine whether the seat is installed tightly enough. Once you feel confident in its installation, grab the base at the belt path and give it a good shake. The seat should not move more than one inch in either direction (side to side, or front to back). If it does, it’s not secure enough.

LATCH or Seatbelt?

As a way to make things easier for parents and families with young children, most vehicles manufactured after 2002 included the Lower Anchors and Tethers for CHildren, or LATCH, system as an alternative installation method to the seatbelt. According to the NHTSA, the LATCH system is comprised of a minimum of two LATCH-equipped seating positions (tether anchors between the seat back and seat cushion designed for the lower attachments located on the child safety seat) in the rear of the vehicle, as well as a minimum of three anchors for the top tether straps[19]. Your vehicle’s manual is the best resource for correctly locating these anchors. A large number of parents seem to look at the LATCH system as an added safety measure to the seat belt, but it is not. While both the LATCH and the seatbelt installations are equally as safe, as they both must pass federal regulations, most car seat manuals will tell you that the seat has been tested using one or the other, and not both. Because car seats are designed to handle impact forces in specific ways, it is important to use them the way they were created. Installing a seat in a way it was not tested by the manufacturer puts the seat at risk for unevenly distributing the stress, and essentially using your child as a crash test dummy. 

Is the Top Tether Attached?

In forward-facing car seats, all seats that contain the lower LATCH system will also include a top tether. This tether, as its name suggests, comes from the top of the car seat, and attaches to your vehicle’s top tether anchor. Regardless of the installation chosen by the parent (LATCH or seatbelt), the top tether should always be used. According to a research review conducted by the University of Michigan, “attaching the top tether achieves a more secure installation and reduces occupant excursions”. Crash studies examining the top tether’s performance have revealed that children in seats with the top tether attached experience up to 6 inches less forward movement of the head[20]. This reduction in movement makes the child’s head significantly less likely to come into contact with something in the vehicle’s interior (front seat, center console, or even an intruding door), and this is huge because head and facial trauma are some of the most common injuries seen in child car accident victims. Despite this crucial added safety measure, car safety experts have observed that top tether use occurs only about 40% of the time[21]. 

Is Your Child Positioned Correctly?

Unlike car seat installation, which is often done once and then forgotten about (at least for some time), children have to be positioned correctly in their seats for every single car ride. For this reason, it is especially important to give your child a quick glance every time you take a trip in the car.

Are they Within the Limits of the Seat?

It’s no secret: kids grow, and fast. Remaining aware of the limits of the seat (ex: when to turn forward facing) is especially important for keeping your child in the safest position they possibly can be. It’s also important to remember that the LATCH weight limits may differ from the weight limits of the actual seat, so consulting your car seat’s manual (and having it in an easily accessible place) is vital.

Where is the Chest Clip?

If you’ve ever seen car seats available outside of the United States, you will often find that many of them don’t have chest clips at all. Many American parents panic, thinking these kiddos aren’t as safe, because why else would the chest clip exist at all? The chest clip is designed as a pre-crash positioner and is actually supposed to break in an impact. Its purpose is to merely help prevent tiny Houdinis from breaking out of their seat prior to an actual accident. In seats that include the chest clip, the straps are designed to depend on it to remain evenly spaced during the car ride which, in the event of an accident, would ensure proper placement of the straps on the child’s body. It’s important to take the time to check that the chest clip is where it belongs: on the chest at armpit level.

How do the Straps Look?

Most car seats come with strap slots, and parents often don’t pay much attention to these, but they are most definitely important, and the rules are different depending on how your child is sitting. For rear facing children, the straps should be inserted through slots at or below the child’s shoulders. It is imperative that the straps are not above the child’s shoulders because, in a reclined position, the force of an accident can cause the child to slide up the back of the seat increasing their risk of injury. In children who are facing forward, the opposite applies. Having straps that are too low can result in the torso having room to move too far forward in the case of a collision. For forward-facing car seats, straps should be at or above the shoulders. 

When a child is securely buckled into their seat, you also want to conduct a ‘pinch test’. By first inspecting the straps to make sure they are not twisted in any way, tighten your child into the seat. To ensure the straps are tight enough, grab one of the straps on the collarbone and, in an up and down fashion, try to pinch the straps. If you’re able to pinch the material, they are not tight enough. This article has a great visual.

Nothing Between the Child and the Seat/Straps?

Taking just a glance on amazon reveals an entire selection of cute carseat add-ons just asking a parent to buy them. But, the safest add-on to buy is one created by the manufacturer for that seat, like infant inserts, because they have been crash tested for compatibility with the particular seat. Third party products can put the child at risk of not being securely in the seat. These non-regulated items can include inserts, strap covers, custom covers, and seat protectors. They simply haven’t been tested with the seat, and using your child as an experiment is something no parent wants to do. And surprisingly, this doesn’t just stop at aftermarket products. Nothing, except for regular clothing, should come between your child and the seat or straps – this also includes bulky winter jackets. These thick coats just don’t allow the straps to be tightened enough to keep the child positioned in the seat, and crash tests have shown that with enough force, these children can be ejected from their seats altogether[22].

 

Keeping children safe in the car is everyone’s business. With car accidents unnecessarily taking hundreds of young lives each year, remaining up to date on your car safety knowledge can mean life or death for a child in your life. Keep your kid rear-facing as long as possible, ensure both the child and the seat are as snug as possible, and read your manual.

If you ever run into any issues, you can always ask for help in a car seat inspection station near you.

Until next time,
Savannah

 

References:

1. American Academy of Pediatrics Technical Report – Child Passenger Safety
http://pediatrics.aappublications.org/content/pediatrics/early/2011/03/21/peds.2011-0215.full.pdf
2. CDC Child Passenger Safety: Get the Facts
https://www.cdc.gov/motorvehiclesafety/child_passenger_safety/cps-factsheet.html
3. The Journal of Pediatrics Unsafe from the Start: Serious Misuse of Car Safety Seats at Newborn Discharge
https://www.jpeds.com/article/S0022-3476(15)01459-6/fulltext
4. BMJ Journals Car Safety Seats for Children: Rear Facing for Best Protection
https://injuryprevention.bmj.com/content/13/6/398?ijkey=98991b7e67a26e9a498d650dbb2fedc24249bd76&keytype2=tf_ipsecsha
5. Parenting Joel’s Journey: Why Rear-Facing Car Seats are Safer

6. SBS News Toddler has Head Reattached to Spine after ‘Internal Decapitation’
https://www.sbs.com.au/news/toddler-has-head-reattached-to-spine-after-internal-decapitation
7. NCBI Atlanto-Occipital Dislocation
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363805/
8. American Academy of Pediatrics AAP Updates Recommendation on Car Seats
https://www.aafp.org/news/health-of-the-public/20180921kidscarsafety.html
9. World Health Organization The Need for Seat-Belts and Child Restraints 
http://www.who.int/roadsafety/projects/manuals/seatbelt/seat_belt_manual_module_1.pdf
10. CBS News What is Internal Decapitation and how did Child Survive?
https://www.cbsnews.com/news/what-is-internal-decapitation-how-did-boy-survive/
11. The BMJ Advise Use of Rear Facing Child Car Seats for Children Under 4 Years Old
https://www.bmj.com/content/338/bmj.b1994.full
12. AAP News & Journals The Danger of Premature Graduation to Seat Belts for Young Children
http://pediatrics.aappublications.org/content/105/6/1179.short?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
13. Science Direct An Evaluation of the Effectiveness of Forward Facing Child Restraint Systems 
https://www.sciencedirect.com/science/article/abs/pii/S0001457503000654
14. NHTSA Car Seats and Booster Seats
https://www.nhtsa.gov/equipment/car-seats-and-booster-seats
15. JAMA Network Belt-Positioning Booster Seats and Reduction of Risk of Injury Among Children in Vehicle Crashes
https://jamanetwork.com/journals/jama/fullarticle/196677
16. NCBI Booster Seat Use in an Inner-City Day Care Population 
https://www.ncbi.nlm.nih.gov/pubmed/18570146/
17. National Safety Council Booster Seat 5-Step Test
https://www.safenebraska.org/application/files/9815/3617/4912/5_step_test.pdf
18. NHTSA Drivers’ Mistakes When Installing Child Seats
https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/811234.pdf
19. NHTSA Lower Anchors and Tethers for Children (LATCH) Restraint System
https://one.nhtsa.gov/Driving-Safety/Child-Safety-at-Parents-Central/Child-Passenger-Safety-%28CPS%29-%E2%80%93-LATCH
20. University of Michigan Transportation Research Institute Research Review
https://sites.google.com/a/umich.edu/cpsbestpraci/resources/forward-facing-child-restraints
21. BMJ Journals Observed Use of Tethers in Forward-Facing Child Restraint Systems
https://injuryprevention.bmj.com/content/17/6/371
22. Today Car Seat Alert: The Winter Coat Mistake that can Endanger Your Child
https://www.today.com/parents/car-seat-alert-could-wearing-winter-coat-endanger-your-child-t61206