Child safety seat counseling: three keys to safety
The number one cause of death for children younger than 14 years is vehicular injury. Child safety seats and automobile safety belts protect children in a crash if they are used correctly, but if a child does not fit in the restraint correctly, it can lead to injury. A child safety seat should be used until the child correctly fits into an adult seat belt. It is important for physicians caring for children to know what child safety seats are available and which types of seats are safest. Three memory keys will help guide appropriate child safety seat choice: (1) Backwards is Best; (2) 20-40-80; and (3) Boost Until Big Enough. “Backwards is Best” cues the physician that infants are safest in a head-on crash when they are facing backward. “20-40-80” reminds the physician that children may need to transition to a different seat when they reach 20, 40, or 80 lb. “Boost Until Big Enough” emphasizes that children need to use booster seats until they are big enough to fit properly into an adult safety belt.
Automobile crashes are the leading cause of death for children younger than 14 years, but safety seats reduce childhood injury and death. (1-4) Child safety seat use is increasing, especially in children younger than four years. (5) However, 11 percent of children still ride unrestrained, and safety device misuses that could cause a fatality may be as high as 72.6 percent. (5) Evidence-based ways to increase child safety seat use include laws, community education, (6,7) and counseling by family physicians. (8) Comprehensive resources (4,9,10) have been published to aid physicians in this counseling, but details may be difficult to remember. Fortunately, there are simple principles for counseling on appropriate child safety seat selection and use.
Correct Safety Belt Fit
Automobile safety belts are designed for adults, and they must fit correctly to work properly for children. Until a child fits correctly in the safety belt, a child safety seat should be used. The safety belt fit is correct when (1) the lap belt portion is low and tight across the hips or upper thighs; (2) the shoulder portion crosses the midsternum and the midclavicle; and (3) the child can sit back against the seat back with legs bent over the front of the seat. (11)
Usually, the adult safety belt fits correctly when a child is 4ft 9in (145 cm) tall. (12) However, this marker may not apply for all children; therefore, the above criteria should be used to determine a safe fit.
Correct Child Safety Seat Installation
Installing a child safety seat securely can be difficult because child safety seats, automobiles, and safety belt systems differ. The Lower Anchors and Tethers for Children (LATCH) restraint system, a feature of all safety seats in automobiles manufactured since September 1, 2001, has made it easier to install seats (Figure 1). Caregivers should be encouraged to read the safety seat manual, but it may be written at a grade level higher than the average person can read. (13) Parents can ensure that they have installed the seat correctly by having it checked at a child safety seat inspection station or by a certified child passenger safety technician. Stations and technicians can be located through the National Highway Traffic Safety Administration (NHTSA) online at http:// www.nhtsa.dot.gov/portal/site/nhtsa/menu item.9f8c7d6359e0e9bbbf30811060008a0c or by calling 888-DASH-2-DOT; or through SeatCheck online at http://www.seatcheck. org or by calling 866-SEAT-CHECK.
Types of Child Safety Seats
Children need different types of child safety seats as they grow. There are four main types of seats: infant seats, convertible seats, forward-facing or combination seats, and booster seats (Table 1 and Figures 2 through 5 (14)). Children with special health care needs may require different restraints. Information about safety seats for children with special needs can be found on the Web site of the American Academy of Pediatrics (AAP) at http://www.aap.org/healthtopics/carseat safety.cfm.
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Individual child safety seats are designed to fit children of specific heights and weights. If the child is too big, the seat could fail (e.g., harness system ripping, buckle breaking, plastic shattering). Federal Motor Vehicle Safety Standard 213 requires that all child safety seats be labeled with height and weight limits. (15) Parents should be instructed to look for this label and change the seat when the child outgrows it. If the label is no longer readable, the parent can call the manufacturer or check the instruction manual. Patient information about safety seat use and recalls can be found on the Web sites of the AAP (http://www.aap.org), the American Academy of Family Physicians, (http://familydoctor.org), and the NHTSA (http://www.nhtsa.gov).
Three Keys to Safety
Physicians not only need to know the types of child safety seats, but also the principles on how to choose which seat is best. Three memory cues help guide parental counseling: (1) Backwards is Best; (2) 20-40-80; and (3) Boost Until Big Enough.
BACKWARDS IS BEST
An infant should ride backwards (rear facing) as long as possible. Facing the rear minimizes the risk of head and neck injury in the event of a crash. In a frontal crash, the back of the safety seat supports the child’s head and neck. If an infant is facing forward, the harness restrains the body, but the head and neck remain unrestrained and whip forward in rapid flexion, potentially causing injury.
To reduce the risk of cervical spine injury in a crash, the AAP recommends children ride backwards, at least until they are both one year of age and weigh 20 lb (9 kg). Children who weigh more than 20 lb but are younger than one year need a safety seat that accommodates facing backward for heavier weights. For optimal protection, infants should continue to ride backward until they reach the seat’s height and weight limits. (4) The AAP recommendations for counseling parents about choosing the appropriate safety seat for their child can be found online at http://aap policy.aappublications.org/cgi /reprint/ pediatrics;109/3/550.pdf.
There are three weights at which children most likely need to transition from one child safety seat to another: 20 lb (9kg), 40 lb (18 kg), and 80 lb (36 kg). Most infant seats have a size limit of 20 lb or 26 inches (66 cm). Most forward-facing seats and convertible seats have limits of 40 lb or 40 inches (102 cm). Most adult safety belt systems do not fit children who weigh less than 80 lb or are shorter than 57 inches, necessitating a booster seat until the child fits into the safety belt.
Height limits are as important as weight limits when determining if a child safety seat is appropriate. For example, tall, thin children usually exceed the height limit before the weight limit. So the “20-40-80” memory key only reminds physicians of usual transition times for when a child may need a new seat. At these times, parents should be advised to look for specific height and weight limits on the label and use these limits to decide when to transition to a new seat.
BOOST UNTIL BIG ENOUGH
A booster seat should be used until children are big enough to fit in an adult safety belt. Booster seats raise a child up in the seat so that the safety belt fits correctly, better protecting the child from crash and safety belt injury. In a crash, if a child who is too small uses a safety belt alone, injury may result. (3) For example, the child can slip out of an incorrectly fitting belt during a crash; or, if the shoulder belt is on the neck, it can cause neck injury. The child also can slip under the lap belt, and this can lead to abdominal injuries such as liver laceration or splenic rupture. (11)
State laws vary regarding when to use a booster seat. For example, in Oregon there is a “6 and 60” law (16) that requires children younger than six years and lighter than 60 lb (27 kg) to ride in a child safety seat. NHTSA lists state child restraint laws online at http:// www.nhtsa.dot.gov/people/injury/airbags/ OccupantProtectionFacts/appendixc.htm. It is important to realize that laws may not represent the safest practice. Physicians should be aware of pertinent laws and be prepared to educate parents on why it may be unsafe to use an adult safety belt alone before it fits.
Many parents incorrectly believe that their child is too old for a child seat or a booster seat. (17) Physicians must remember there is no specific age, weight, or height at which it is safe for all children to use an adult safety belt system. Education should be directed toward teaching parents when their child can transition to a safety belt.
After the Child Safety Seat
Once the child is large enough for the safety belt to fit correctly, a belt system with a shoulder and lap belt is ideal. Lap belts alone are better than no restraint, but because they offer no upper body protection, they are inferior to those with a shoulder and lap belt. Shoulder and lap safety belts are designed to work as a system. The shoulder belt should not be placed behind the back because the upper body will not be restrained, and the belt may not work in this configuration. The shoulder belt portion should never be placed under the arm because the force of a crash could cause the belt to fracture ribs, cause brachial plexus injury, or result in other chest wall and upper extremity injury. To reduce safety belt injury, parents should be instructed to avoid these common misuses of adult safety belts.
(1.) U.S. National Highway Traffic Safety Administration. Buckle up America–the presidential initiative for increasing seat belt use nationwide: House and Senate Appropriations, Committees requested biannual report: first report to Congress. Washington, D.C.: U.S. Department of Transportation, National Highway Traffic Safety Administration, 1998.
(2.) Durbin Dr, Elliott MR, Winston FK. Belt-positioning booster seats
and reduction in risk of injury among children in vehicle crashes. JAMA 2003;289:2835-40.
(3.) Winston FK, Durbin Dr, Kallan MJ, Moll EK. The danger of premature graduation to safety belts for young children. Pediatrics 2000;105:1179-83.
(4.) Committee on Injury and Poison Prevention; American Academy of Pediatrics. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics 2002;109:550-3.
(5.) U.S. National Highway Traffic Safety Administration. Misuse of child restraints. Washington D.C.: 2004. Accessed online July 8, 2005, at: http://www.nhtsa. dot.gov/people/injury/research/Misuse/index.html.
(6.) Zaza S, Sleet DA, Thompson RS, Sosin DM, Bolen JC, for the Task Force on Community Preventive Services. reviews of evidence regarding interventions to increase use of child safety seats. Am J Prev Med 2001;21 (4 suppl):31-47.
(7.) Task Force on Community Preventive Services. recommendations to reduce injuries to motor vehicle occupants: increasing child safety seat use, increasing safety belt use, and reducing alcohol-impaired driving. Am J Prev Med 2001;21(4 suppl):16-22.
(8.) U.S. Preventive Services Task Force. Counseling to prevent motor vehicle injuries. In: guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Balitmore: Williams & Wilkins, 1996. Accessed online July 8, 2005, at: http://www.ahrq. gov/clinic/2ndcps/vehicle.pdf.
(9.) Bull MJ, Sheese J. Update for the pediatrician on child passenger safety: five principles for safer travel. Pediatrics 2000;106:1113-6.
(10.) Biagioli F. Proper use of child safety seats. Am Fam Physician 2002;65:2085-90.
(11.) Weber K. Child passenger protection. In: Nahum AM, Melvin J, eds. Accidental injury: biomechanics and prevention. 2d ed. New York: Springer, 2002:523-49.
(12.) U.S. Department of Transportation, National Highway Traffic Safety Administration. Improving the safety of child restraints. Booster seat study. report to Congress, 2002. Accessed online July 8, 2005, at: http://wwwnrd. nhtsa.dot.gov/departments/nrd-11/childsafety/toc. htm.
(13.) Wegner MV, Girasek DC. How readable are child safety seat installation instructions? Pediatrics 2003;111: 588-91.
(14.) Breitenbach RJ, Carnes JB, Hammond JA, Saunders Z. Baby seats, safety belts, and you! 3d ed. Virginia Department of Motor Vehicles Transportation and Safety Services. Richmond, Va.: Virginia Commonwealth University, 1999.
(15.) U.S. National Highway Traffic Safety Administration. Standardized child passenger safety training program. Participant manual. 2004 ed. Accessed online July 8, 2005 at: http://www.cpsboard.org/pdf/techmanual/ TechnicianStudentManual_rev0504.pdf.
(16.) 71st Oregon Legislative Assembly–2001 regular Session. House Bill 3155. Accessed online July 8, 2005, at: http://www.leg.state.or.us/01reg/measures/hb3100. dir/hb3155.en.html.
(17.) Ebel Be, Koepsell TD, Bennett EE, Rivara FP. Too small for a seatbelt: predictors of booster seat use by child passengers. Pediatrics 2003;111(4 pt 1):e323-7.
Types of Child Safety Seats and Restraint Systems
Intended occupant Restraint
Type of restraint size * characteristics
Infant seat For children weighing Faces rearward only;
(see Figure 2) up to 20 to 22 lb (9 to comes with or without
10 kg) and up to 26 to a base; relatively
29 in (66 to 74 cm) inexpensive and
tall; infants outgrow lightweight; portable,
this seat when they are can be used as a baby
over the seat’s weight carrier weight
maximum or when their
heads are within one
inch of the top.
Convertible seat Most accommodate Faces rearward for
(see Figure 3) infants and toddlers infants and forward for
weighing 20 to 40 lb toddlers; accommodates
(9 to 18 kg) and up to a larger age range;
40 in (102 cm) tall child needs to be
(some seats are removed from the seat
designed for larger to exit the automobile
children, check the
label); for infants
younger than one year
but heavier than 20 lb,
select a seat with a
high enough rear-facing
Forward-facing seat Most are for children Forward-facing seats
or combination weighing 30 to 40 lb can only face forward;
seat (see Figure 4) (14 to 18 kg) (some combination seats have
allow for 20 to 40 lb); a removable harness
the height limits vary system so the seat can
from 50 to 57 in (127 be used later as a
to 145 cm). booster seat
Booster seat, Used when child no Used with an adult lap
high-back longer fits in other and shoulder belt; are
booster, and child safety seats but not attached to the
backless booster is not big enough for automobile
(see Figure 5) the safety belt; should
be used until the
safety belt fits
Lap and shoulder Used when the child A safety belt with a
automobile safety fits correctly in them shoulder belt offers
belt (usually when child is better protection than
4ft. 9in. in tall); the lap belt alone; if
correctly fits when the safety belt is
the child is tall uncomfortable, it may
enough to have legs not fit correctly, so a
bent over the seat when booster seat may be
back is against the needed.
seat, shoulder belt
fits across the
midsternum, and lap
belt is low and tight
across the thighs
Type of restraint Usage warnings
Infant seat Never use a rear-facing seat in
(see Figure 2) a front seat where there is an
airbag; harness straps should
be flat and snug on the child;
seat needs to be secured maximum or when
tightly with the safety belt or
LATCH restraint system.
Convertible seat Never use a rear-facing seat in
(see Figure 3) a front seat where there is an
airbag; harness straps should
be flat and snug on the
child; seat needs to be tightly
secured with the safety belt
or LATCH restraint system.
Forward-facing seat Harness straps should be
or combination flat and snug on the child;
seat (see Figure 4) harness system should not be
used past the
limit; convertible seat needs
to be secured tightly to the
automobile with the safety
belt or LATCH restraint system.
Booster seat, Should only be used in a
high-back seating position where there
booster, and is a shoulder and lap belt;
backless booster high-back seats and backless
(see Figure 5) seats are good in most
situations; if the back of the
automobile seat or headrest
is below the ears of the child,
use a high-back booster.
Lap and shoulder Incorrectly fitting safety belts
automobile safety can cause injury, or the child
belt can slip out of the safety belt;
the shoulder belt should not
be put behind the back or
under the arm.
LATCH = Lower Anchors and Tethers for CHildren (see Figure 1).
*–See child safety seat instruction manual or seat labels for exact
details of the seat’s height and weight limits.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation rating References
Children who do not fit in a safety A 1, 2, 3, 7
belt should use child safety seats
when riding in a vehicle.
Children should use a booster seat B 2, 3
until the adult safety belt fits
Physicians should counsel parents C 7
about child safety seats.
Infants should face the rear of the C 8
car as long as possible.
Clinical recommendation Comments
Children who do not fit in a safety Child safety seats reduce injury
belt should use child safety seats and death.
when riding in a vehicle.
Children should use a booster seat Cross-sectional study and crash
until the adult safety belt fits report review and survey study
correctly. comparing injuries in children
using booster seats with safety
Physicians should counsel parents
about child safety seats.
Infants should face the rear of the American Academy of Pediatrics
car as long as possible. recommendation based on
studies from crash testing and
A = consistent, good-quality patient-oriented evidence; B =
inconsistent or limited-quality patient-oriented evidence;
C = consensus, disease-oriented evidence, usual practice, expert
opinion, or case series. For information about the SORT evidence
rating system, see page 363 or http://www.aafp.org/afpsort.xml.
FRANCES BIAGIOLI, M.D., is assistant professor of family medicine at Oregon Health & Science University, Portland, Ore. Dr. Biagioli received her medical degree from the Medical College of Ohio, Toledo, and completed a family practice residency at Oregon Heath & Science University. She completed the National Highway Traffic Safety Administration Standardized Child Passenger Safety Training Program in 2000 and has since been a volunteer child safety seat technician.
Address correspondence to Frances Biagioli, M.D., Oregon Health & Science University, 4411 SW Vermont St., Portland OR 97219 (e-mail: biagioli@ohsu. edu). Reprints are not available from the author.
Author disclosure: Nothing to disclose
COPYRIGHT 2005 American Academy of Family Physicians
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