Research Review: Child Passengers at Risk in America:

By Dawn Thoma, EMT-B


During February 1999, “Child Passengers at Risk in America: A National Study of Car Seat Misuse” was released by the National Safe Kids Campaign. Restraint use information gathered from over 17,500 children and their parents at the Safe Kids Buckle Up Program inspection clinics since July 1997 was compiled. It is apparent that despite restraint use laws in all 50 states, and public awareness programs, preventable child morbidity and mortality from vehicle collisions remains at unacceptable rates.

This study demonstrated that four out of five child car seats are installed or used improperly, minimizing their potential effectiveness. It is known that infant deaths can be reduced by 71% with proper installation and use. Many factors contribute to this dilemma, such as various age and size requirements, incompatibility between car seat and vehicle design, improper seating position, and gaps in child occupant protection laws.

Study Methodology

The GM Corporation and National Safe Kids formed a partnership called the Safe Kids Buckle Up Program in 1996. The National Highway Traffic Safety Administration has trained 1,200 GM Dealership employees and 6000 community members as Child Passenger Safety Specialists through State and Local Safe Kids coalitions.

Hundreds of car seat checks up events were held nationally at dealerships and other participating sponsor locations. These events attracted thousands of concerned parents and children to receive a free inspection of their restraint devices, and instruction on proper use. The car seat inspections utilized a formal protocol to evaluate proper installation and use of participating families. Parents were surprised to find that they were incorrectly or improperly securing their children.


The findings reflected that 80% of installations or use were found deficient. A significant number of serious errors were found such as “Infants placed rear-facing in front of an active air bag” (0.2%), and “children turned forward-facing before reaching one year of age and 20 pounds” (11%). This is notable, when one considers the “self-selecting” nature of the study population would suggest concerned and attentive parents.

“In 1997, 1791 U.S. children aged less than 15 years were killed and 282,000 were injured while riding in motor vehicles.”[1] Children who are too large for child safety seats often are restrained improperly or not at all. A recent study of four states found that of children weighing 40-60 lbs., 75% were improperly restrained, and 19% were unrestrained.[2] Of passengers between five and nine years of age in fatal crashes in 1997, 46% were unrestrained.

The four to nine year old children are particularly in need of attention. Booster seats are essential for correct seat belt fit for children in this age group weighing 40-80 pounds. Many studies have shown that these children are frequently placed in seat belts without booster seats. A 1995 National Highway and Transportation Safety Administration Study of observed child restraint use found only 6% of these children in booster seats, while 75% were in seat belts.


In the last 20 years, with implementation of mandatory restraint-use laws, overall death and injury rates have decreased. However, non-use remains the major risk factor for death and injury to children. Non-use increases with the increasing age of the child. Driver use is the strongest predictor of child restraint use. Even adults, who are conscientious about using restraints, may be unaware of the dangers posed by improperly secured restraints.


The best child safety seat for each child is that which is easy to use, fits the vehicle seats and seat belt system, and is appropriate for the child’s size and development. Given the variety of available child safety seats, potential incompatibilities between the seat and the vehicle, and recommendations for children by age, size, and developmental characteristics, selecting the proper child safety seat has become a highly specialized technical field. Certified child Safety Seat Specialists, similar to those utilized in the Safe Kids Study, have the special expertise to advise and assist parents in selecting and properly using child restraint systems.

The American Academy of Pediatrics guidelines recommend that the child should be placed in the belt-positioning booster seat as long as he/she fits. After 8 years of age and 60-80 pounds, a child can use the adult lap/shoulder belt only if it fits properly, but it is preferable to use a booster seat as long as possible. The back seat is the safest location for children of any age. A particular concern is the placing of a rear-facing child safety seat in the front seat of an airbag-equipped vehicle. This should never be allowed to occur. Small adults or children are also at risk in front passenger seats of airbag-equipped cars.

Several specific recommendations are made as a result of the Buckle Up America Program:

  1. Infants should ride in rear-facing child safety seats until they have reached both 20 pounds AND one year of age. Never place a rear-facing child safety seat in front of an airbag.
  2. Children who weigh more than 20 pounds AND who are older than one year of age should ride in forward facing child safety seats for as long as the child fits well (e.g. ears below the top of the back of the seat and shoulders below the seat strap slots).
  3. Children who have outgrown their child safety seats but are too small to wear seat belts properly should ride in booster seats.
  4. Seat belts fit properly when they can be worn with the lap portion of the belt low and tight across the hips, and the shoulder portion across the shoulder without cutting across the face or neck.[3]

The goal of this campaign is to increase the seat belt use rate to 90 percent and reduce child fatalities by 25 percent by the year 2005. If this goal can be reached, $8.8 Billion will be saved, and more than 5500 deaths and 132,000 injuries will be prevented.


Several initiatives are directed at reducing the impact of this preventable environmental hazard. The association of seat belt compliant adults and their attention to restraint concerns of children has been well documented. According to the Airbag and Seatbelt Safety Campaign, an organization financed by insurers, auto companies and the Federal Government, in cars in which the driver is buckled, 87 percent of the children are appropriately restrained; if the driver is unbuckled, only 24 percent of the children are buckled in.[4] In every state, police can stop a car when an unbelted child is observed, although in 35 states an unbelted adult is not considered probable cause to stop and summons a driver. Efforts are underway in Florida, and elsewhere to mandate adult compliance through enforcement as a methodology to ultimately secure more kids.

President Clinton announced in February 1999, a new law, which will standardize child car seat mounting design. This effort will provide predictable mounting brackets that will reduce the incompatibilities found today, and create a platform for better seat design in the future. Unfortunately, cars without this modification will remain on the road for another twenty years.

An effort to obtain more immediate results is the National Transportation Safety Boards call for nationwide car seat fitting stations. Australia and Canada have programs that provide for the inspection and proper installation of child safety seats when regular auto inspections or registrations are renewed. In Australia, 90 percent of child safety seats are found to be properly installed and correctly used as a result. Kiwanis International, The American Automobile Association, Ford Motor, DaimlerChrysler, GM and the National Safe Kids Campaign have all expressed an interest in bringing permanent car seat clinics to the United States.


The improper use and installation of child car restraints represents a preventable safety hazard to children, particularly between 4 and 9 years of age. Through a combination of legislation, enforcement, and education, the impact can be significantly reduced. The attached “Fact Sheet” of the “Insurance Institute For Highway Safety” illustrates the unacceptable cost in lives. Impressive reductions in death and injury rates have already been achieved with nationwide restraint laws and awareness programs. The commitment to continue and expand these initiatives is required to obtain continued reductions in death and injury rates of children from improper restraint use.

[1] US Department of Transportation, National Highway Traffic Safety Administration. Children: Traffic Safety Facts 1997. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1998

[2] Decina LE, Knoebel KY. Child Safety Seat Misuse Patterns in Four States. Accid Anal Prev 1997; 29:125-32.

[3] Buckle Up America, American Academy of Pediatrics,

[4] Wald, Mathew L, “Keeping Children Out Of Danger”, The New York Times, February 26,1999 Autos on Friday/Safety.

About the Author

Phil is currently an active career Captain with the City of Stamford Fire & Rescue Department. He spent more than 20 years with Stamfords' Rescue 1 and has experience as a former Paramedic, EMS Instructor, Rescue Diver and Fire Officer. Before moving to Connecticut to join the Stamford Fire & Rescue Department, he spent many several years as a paramedic in Southern Westchester County, NY. Phil is also experienced with graphic design, multimedia development, digital video and audio. Phil brings both vision and implementation experiences of internet technology solutions and is critical in developing the web-strategy plans and operational infrastructure to Sirius Innovations and the Village sites.

Author Archive Page