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Objective: Current guidelines for optimal restraint of children in motor vehicles recommend the center rear seating location for installing a child-restraint system. However, recent research on child occupants in child-restraint system has brought this into question. The objective of this study was to describe seating position patterns among appropriately restrained child occupants aged 0 to 3 years in the rear row of vehicles. In addition, we determined the association between rear row seating location and risk of injury., Methods: We studied data collected on child occupants from December 1, 1998, to December 31, 2006, via insurance claim records and a validated telephone survey. The study sample included child occupants aged 0 to 3 years seated in a child-restraint system in the rear row of the vehicle, model year 1990 or newer, involved in a crash in 16 states. Children were classified as injured if a parent or driver reported an injury corresponding with Abbreviated Injury Scale scores of > or = 2., Results: Seating position distribution for child occupants was as follows: left outboard (31%), center (28%), and right outboard (41%). There was an inverse relationship between the center position and increasing child age (39% for occupants < 1 year old versus 18% for occupants 3 years old), independent of the number of additional row occupants. Child occupants seated in the center had an injury risk 43% less than children seated in either of the rear outboard positions., Conclusions: The most common seating position for appropriately restrained child occupants in a child-restraint system is the right rear outboard. The center rear seating position is used less often by children restrained by a child-restraint system as they get older. Children seated in the center rear have a 43% lower risk of injury compared with children in a rear outboard position.

Objective: To quantify the independent contribution of recently enacted booster seat laws on appropriate restraint use by child passengers in motor vehicles., Design: Longitudinal study of children involved in crashes with data collected via insurance claims records and a validated telephone survey., Setting: Sixteen states and Washington, DC, from December 1, 1998, through December 31, 2004., Participants: Probability sample of 5198 vehicles in crashes involving 6102 children aged 4 to 7 years, representing 78 159 vehicles and 91 752 children., Main Exposures: Booster seat law provisions, child age, state, and secular trends., Main Outcome Measure: Reported appropriate restraint use for this age group, including forward-facing child safety seats, belt-positioning booster seats, and combination seats., Results: Children aged 4 to 7 years in states with booster seat laws were 39% more likely to be reported as appropriately restrained than were children in other states (prevalence ratio [PR], 1.39; 95% confidence interval [CI], 1.14-1.70). Children aged 4 to 5 years were 23% more likely (PR,1.23; 95% CI, 0.80-1.42) and children 6 to 7 years twice as likely (PR, 2.09; 95% CI, 1.46-2.99) to be reported as appropriately restrained. For children aged 6 to 7 years, when compared with no law, laws through age 7 years were most effective (PR, 3.71; 95% CI, 2.49-5.42), followed by laws through age 4 or 5 years (PR, 1.43; 95% CI, 0.89-2.24)., Conclusion: Given the higher current use of age-appropriate restraints among children 4 to 5 years compared with older children, future upgrades to child restraint laws should include children through at least age 7 years to maximize the number of children properly restrained for their age.

Objective: To provide an estimate of benefit, if any, of child restraint systems over seat belts alone for children aged from 2 through 6 years., Design: Cohort study., Setting: A sample of children in US passenger vehicle crashes was obtained from the National Highway Transportation Safety Administration by combining cases involving a fatality from the US Department of Transportation Fatality Analysis Reporting System with a probability sample of cases without a fatality from the National Automotive Sampling System., Participants: Children in tow-away [corrected] crashes occurring between 1998 and 2003., Main Exposure: Use of child restraint systems (rear-facing and forward-facing car seats, and shield and belt-positioning booster seats) vs seat belts. Potentially confounding variables included seating position, vehicle type, model year, driver and passenger ages, and driver survival status., Main Outcomes Measure: Death of child passengers from injuries incurred during the crash., Results: Compared with seat belts, child restraints, when not seriously misused (eg, unattached restraint, child restraint system harness not used, 2 children restrained with 1 seat belt) were associated with a 28% reduction in risk for death (relative risk, 0.72; 95% confidence interval, 0.54-0.97) in children aged 2 through 6 years after adjusting for seating position, vehicle type, model year, driver and passenger ages, and driver survival status. When including cases of serious misuse, the effectiveness estimate was slightly lower (21%) (relative risk, 0.79; 95% confidence interval, 0.59-1.05)., Conclusion: Based on these findings as well as previous epidemiological and biomechanical evidence for child restraint system effectiveness in reducing nonfatal injury risk, efforts should continue to promote use of child restraint systems through improved laws and with education and disbursement programs.

Background: Currently, many states are upgrading their child restraint laws to include provisions for the use of age-appropriate restraints through 6 to 8 years of age, with some also requiring rear seating for children, enabling the laws to be in closer alignment with best-practice recommendations., Objective: To evaluate the relationships of seating position and restraint status to the risk of injury among children in passenger vehicle crashes., Methods: This was a cross-sectional study of children <16 years of age who were involved in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 17980 children in 11506 crashes, representing 229106 children in 146613 crashes, was collected between December 1, 1998, and November 30, 2002. Parent reports were used to define restraint status, seating position, and occurrence of clinically significant injuries, with the use of a previously validated instrument., Results: Approximately 62% of the children used seat belts, 35% used child restraints, and 3% used no restraint. Nearly 4 of 5 children sat in the rear seat, with one half of all children being restrained appropriately for their age in the rear, although this varied according to the age of the child. Overall, 1.6% of children suffered serious injuries, 13.5% had minor injuries, and 84.9% did not have any injury. Unrestrained children in the front were at the highest risk of injury and appropriately restrained children in the rear were at the lowest risk, for all age groups. Inappropriately restrained children were at nearly twice the risk of injury, compared with appropriately restrained children (odds ratio [OR]: 1.8; 95% confidence interval [CI]: 1.4-2.3), whereas unrestrained children were at >3 times the risk (OR: 3.2; 95% CI: 2.5-4.1). The effect of seating row was smaller than the effect of restraint status; children in the front seat were at 40% greater risk of injury, compared with children in the rear seat (OR: 1.4; 95% CI: 1.2-1.7). Had all children in the study population been appropriately restrained in the rear seat, 1014 serious injuries (95% CI: 675-1353 injuries) would have been prevented (with the assumption that restraint effectiveness does not depend on a variety of other driver-related, child-related, crash-related, vehicle-related, and environmental factors)., Conclusions: Age-appropriate restraint confers relatively more safety benefit than rear seating, but the 2 work synergistically to provide the best protection for children in crashes. These results support the current focus on age-appropriate restraint in recently upgraded state child restraint laws. However, it is important to note that considerable added benefit would be realized with additional requirements for rear seating.

Previous work quantified a 59% reduction in injury risk for children in belt positioning booster seats (BPB) compared to those restrained in seat belts using a sample of crashes of all directions of impact. Experimental sled tests have highlighted the potential for extreme occupant excursion out of the BPB in side impact crash conditions. Using data from a large child specific crash surveillance system, the present study built upon these previous studies and quantified the relative effectiveness of BPB as compared to seat belts in reducing the risk of injury among 4-8 year olds in side impact crashes. Children in BPB were at a 58% reduction in risk of injury than those in seat belts in side impact crashes. This result varied by booster seat type: those in high back BPB were at a 70% reduction in injury risk while those in backless BPB did not experience a statistically significant reduction in injury risk compared to those in seat belts. This differential performance of the two types of BPB provides direction for future research into the design and performance of these restraints.

The objective of this study was to determine the effectiveness of forward facing child restraint systems (FFCRS) in preventing serious injury and hospitalization to children 12-47 months of age as compared with similar age children in seat belts. Data were obtained from a cross-sectional study of children aged 12-47 months in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. Effectiveness estimates were limited to those children between 12 and 47 months of age seated in the back row(s) of vehicles, restrained in FFCRS, regardless of misuse, or seat belts of all types and usage. Completed survey information was obtained on 1207 children, representing 12632 children in 11619 crashes between 1 December 1998 and 31 May 2002. Serious injuries occurred to 0.47% of all 12-47-month olds studied, including 1.72% of those in seat belts and 0.39% of those in child restraint systems. The risk of serious injury was 78% lower for children in FFCRS than in seat belts (odds ratio (OR) = 0.22, 95% confidence interval (CI) = 0.11-0.45, P = 0.001). The risk of hospitalization was 79% lower for children in FFCRS than in seat belts (OR = 0.21, 95% CI = 0.09-050, P = 0.001). There was no difference between the restraint types in preventing minor injuries. As compared with seat belts, CRS are very highly effective in preventing serious injuries and hospitalization, respectively. This effectiveness estimate is substantially higher than older estimates, demonstrating the benefits of current CRS designs. These results provide those educating parents and caregivers population-based data on the importance of child restraint use.

Objective: To assess the success of recent outreach activities to promote appropriate child restraint in motor vehicles by examining trends in restraint types used by children under age 9 in 3 large regions of the United States., Methods: Cross-sectional study was conducted of children who were under age 9 and in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 8730 crashes involving 10,195 children, representing 128 291 crashes involving 149,820 children, was collected between December 1, 1998, and November 30, 2002. Parent report was used to determine restraint type used in the crash. Logistic regression models were used to analyze the secular trend of restraint type use., Results: Overall, for children under age 9, seat belt use decreased significantly from 49% to 36% between 1998 and 2002; for 7- and 8-year-olds, from 97% to 92%; and for 3- to 6-year-olds, from 63% to 34%. Concurrently, gains were achieved in overall child restraint use from 49% to 63%, for 7- and 8-year-olds, from 2% to 5%; and for 3- to 6-year-olds, from 35% to 65%. Child restraint use remains stable for children from birth to 2 years of age (from 97% in 1998 to 98% in 2002). Both the use of child safety seat and belt positioning booster seat increased significantly, whereas shield booster seat use decreased significantly., Conclusion: Although considerable achievements have been realized over a short period of time, substantial inappropriate restraint still remains: 62% of children aged 4 to 8 remain inappropriately restrained in adult seat belts. Parents hear safety messages when they are relevant to their children. As a result, sustained efforts about appropriate restraint must continue to maintain and improve the gains achieved in appropriate child restraint use. The additional benefits realized by recent changes in child restraint laws remain to be evaluated.

Background: The American Academy of Pediatrics has established guidelines for optimal, age-appropriate child occupant restraint. While optimal restraint has been shown to reduce the risk of injuries overall, its effect on specific types of injuries, in particular abdominal injuries, has not been demonstrated., Methods: Cross-sectional study of children aged younger than 16 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 10927 crashes involving 17132 restrained children, representing 210926 children in 136734 crashes was collected between December 1, 1998 and May 31, 2002. Restraint use was categorized as optimal or suboptimal based on current American Academy of Pediatrics guidelines. The outcome of interest, abdominal injury, was defined as any reported injury to an intra-abdominal organ of Abbreviated Injury Scale >or=2 severity., Results: Among all restrained children, optimal was noted in 59% (n = 120473) and suboptimal in 41% (n = 83555). An associated abdominal organ injury was noted in 0.05% (n = 62) of the optimal restrained group and 0.17% (n = 140) of the suboptimal group. After adjusting for age and seating position (front vs. rear), optimally restrained children were more than 3 times less likely [odds ratio 3.51 (95% confidence interval, 1.87-6.60, P < 0.001)] as suboptimally restrained children to suffer an abdominal injury. Of note, there were no abdominal injuries reported among optimally restrained 4- to 8-year-olds., Conclusions: Optimally restrained children are at a significantly lower risk of abdominal injury than children suboptimally restrained for age. This disparity emphasizes the need for aggressive education efforts aimed not only at getting children into restraint systems, but also the importance of optimal, age-appropriate restraint.

Context: Although more than a dozen states have ratified laws that require booster seats for children older than 4 years, most states continue to have child restraint laws that only cover children through age 4 years. Lack of booster seat effectiveness data may be a barrier to passage of stronger child restraint laws., Objectives: To quantify the association of belt-positioning booster seats compared with seat belts alone and risk of injury among 4- to 7-year-old children and to assess patterns of injury among children in booster seats vs seat belts., Design, Setting, and Population: Cross-sectional study of children aged 4 to 7 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 3616 crashes involving 4243 children, weighted to represent 56 593 children in 48 257 crashes was collected between December 1, 1998, and May 31, 2002., Main Outcome Measure: Parent report of clinically significant injuries., Results: Injuries occurred among 1.81% of all 4- to 7-year-olds, including 1.95% of those in seat belts and 0.77% of those in belt-positioning booster seats. The odds of injury, adjusting for child, driver, crash, and vehicle characteristics, were 59% lower for children aged 4 to 7 years in belt-positioning boosters than in seat belts (odds ratio, 0.41; 95% confidence interval, 0.20-0.86). Children in belt-positioning booster seats had no injuries to the abdomen, neck/spine/back, or lower extremities, while children in seat belts alone had injuries to all body regions., Conclusion: Belt-positioning booster seats were associated with added safety benefits compared with seat belts to children through age 7 years, including reduction of injuries classically associated with improper seat belt fit in children.

From 1999 to 2002, 32% fewer US children between 9 and 36.4 kg (20-80 lb) were restrained inappropriately in seat belts and the most prevalent form of restraint shifted from seat belts to child restraints with harnesses. There was a significant increase in the use of combination child restraint/booster seats with harnesses by children 9.1-18.1 kg (20-40 lb). Among children weighing 14.1-18.1 kg (31-40 lb), the inappropriate use of seat belts and shield boosters decreased. Among children weighing 18.6-27.2 kg (41-60 lb), the use of belt-positioning booster seats increased while the inappropriate use of seat belts decreased. Of note, by the end of 2002, 27% of children weighing between 18.6 and 22.7 kg (41-50 lb) were restrained in child restraints with harnesses. These children were of weights typically above the manufacturer's recommended limit. Despite progress, substantial inappropriate restraint still remains and continued investment in outreach efforts is necessary. The risk of injury for heavier children in child restraints with harnesses should be monitored.

The objective of this study was to quantify the relationship between harness type and the prevalence of child restraint system (CRS) misuse. Data were collected at 21 child safety seat clinics between August, 1997 and November, 1998 in southeastern Pennsylvania and southern New Jersey. The main outcome measured was the prevalence of CRS misuse for each of the three most common harness types. Of the 438 convertible CRS evaluated, 89% demonstrated at least one form of misuse. This rate of misuse did not vary by harness type: 5-points (89%), T-shields (87%), and tray-shields (93%). However specific misuses were more common for specific harness types. Having marked/ twisted harness straps was more common among five-point harnesses. T-shields were more commonly recalled, due mainly to the high market share of a particular T-shield CRS recalled for defects with the shield buckle and harness retractor mechanism. Although not statistically significant, there was a trend towards not using a chest clip when necessary in both tray-shields and T-shields when compared to five-point harnesses. This study confirmed a high prevalence of CRS misuse and extended previous results by demonstrating that this misuse is consistent across CRS harness designs. The data further suggest specific design improvements for each harness design based on the particular pattern of misuse.

The applicability of the federal safety standard that governs child restraints (FMVSS 213) has recently been called into question. Population- based estimates of the risk of injury to children in child restraints and a description of the patterns and mechanisms of injury are necessary to evaluate this standard and identify areas of needed improvement. A probability sample of children 12 to 47 months in crashes was identified in an on-going crash surveillance system (1998-2002) which links insurance claims data to telephone survey and crash investigation data. The risk of injury in forward facing child restraints (FFCRS) was estimated and a series of cases was examined using in-depth crash investigation to identify the mechanisms of these injuries. Although children in FFCRS are well protected in crashes, further reductions in serious injuries might be achieved by reducing head, neck, and extremity injury risks. These results have implications for the current efforts to upgrade the current FMVSS 213 and better protect child passengers.